interviews
Managing The Unavoidable
by Michael Brumage
April 1, 2020
This interview with Michael Brumage, the Medical Director of Cabin Creek Health System and Program Director of Public Health/General Preventive Medicine Residency at WVU School of Public Health, was conducted and condensed by frank news.
frank: Thank you for speaking with us Michael. Will you tell us about your background?
Michael Brumage: My name is Michael Brumage, I'm an MD and I have a master's in public health. Currently I'm the medical director for Cabin Creek Health Systems. I'm also the program director for the general preventive medicine residency at West Virginia University in the school of public health.
I am a native West Virginian. I went to undergraduate and medical school at West Virginia University.
How did you get your start working on pandemics?
I started by working in internal medicine for the United States Army and later became a preventive medicine physician. From 2005 to 2007, I was the chief of preventive medicine at Tripler Army Medical Center in Honolulu. While I was in that job, I wore two other hats, one as the public health emergency officer, PHEO, for the Pacific Regional Medical Command, and PHEO for Joint Task Force-Homeland Defense, which covered all the U.S.-affiliated islands in the Pacific. I was up to my neck in pandemic planning.
At the time we were planning for Influenza A H5N1, the “bird flu”, the highly pathogenic avian influenza we worried would become the next pandemic virus. Fortunately, it never acquired the characteristics to spread easily from person to person. While it had a very high mortality rate, it didn’t spread easily. I understood what was at stake from the very beginning of this current pandemic.
This has transpired, largely as I hoped it would not.
How so?
I had hoped that our government would have been more proactive in seeing the danger and expressing that to the American people, and that did not happen. Now we have to make really hard decisions about what price we're going to pay. In places like New York City, Seattle, Boston, we are reaching the capacity of our healthcare system and may soon overrun it.
How will this affect rural communities, like yours in West Virginia?
We have to consider how we can prevent the spread to rural areas of the United States. Where we are in West Virginia, we serve people from all walks of life, but are primarily in underserved areas. We have clinics in formerly very heavy coal producing areas, and we deal with a lot of chronic illnesses like heart disease, lung diseases, and diabetes.
The Kaiser Family Foundation recently did a study evaluating at-risk populations for a pandemic.
West Virginia had 51% of its population over the age of 20 at risk for complications. The national average is 41%.
We are not only dealing with individual human beings that have chronic medical illnesses, but also Hepatitis B and C, and HIV cases related to intravenous drug use. In addition to these problems we now have to address a pandemic that strains our own internal capacity. What's most concerning to me is that we are working with very high-risk populations for complications from coronavirus.
How do you prepare for a pandemic in the face of that reality?
As the medical director, my effort in the last couple of weeks has been almost solely focused on preparing Cabin Creek Health Systems for a pandemic, which includes 11 sites in Kanawha County. We've been preparing to try to segregate people with respiratory symptoms away from other patients, moving toward deferring visits that do not require an in person visit, and trying to shift more to telephone and telemedicine to care for patients. We will still need to see patients in person for a variety of issues.
Yesterday I was in clinic for the first time in a while and actually swabbed someone for COVID-19. He had been on a cruise with two other family members with upper respiratory symptoms. I tested him for COVID-19 after donning personal protective equipment and administered the nasopharyngeal swab. We will find out the results in a few days.
This has been the pressing issue for me: worrying about a pandemic with the background of people in a state that ranks first in almost every bad category of health indicators, and usually bottom three for every good category of health outcomes.
It's a real challenge because our population is sicker than most.
If it hits here the way it does in other places, we're soon going to be out of ICU capacity and hospital bed capacity. There may be difficult triage decisions made for people to access care.
One advantage I think we have is that we are rural. People either live on ridge tops or they live in the hollows and that tends to create its own capability for social distancing. Whether you're in rural America or urban America, you're going to do pretty well if you practice social distancing. The question is whether or not we have the discipline to maintain social distancing, and biting the bullet on economic damage that it is going to do.
The case number is currently low in West Virginia. How are people responding in a place that is not visibly taken by the virus?
https://dhhr.wv.gov/COVID-19/Pages/default. | 39 Total Positive Cases as of 11:47PM PST 3.24.20
First of all, we don't really know how many cases there are. This is a huge blind spot everywhere in the United States, and here in West Virginia as well. While we know we have eight cases [on 3.21.20], I think everybody in public health understands that the real number of cases out there is much, much higher.
We are really like soldiers on a battlefield in a fog. We know the enemy is out there, but we don't know their strength in numbers.
I think many people here, from what I can gather from social media, are still in disbelief that this is as bad as it was because of messaging that came from some conservative media sources and the message that was coming from the White House for some time. I think the lingering effect of that is that there are many people who don't take it seriously. Two days ago, I went to a supermarket and I still saw people walking out with rolls of toilet paper under each arm, which I can't comprehend because there is no toilet paper shortage. And instead of just getting in and out with their toilet paper, I saw people congregating in the parking lot having discussions, which is an anathema to what we should be doing right at the moment.
Right. There is something strange about going to a store right now, without knowing what the future looks like – even with all the information I have, I pause and think, do I need more stuff?
Definitely. That attitude can be very contagious.
When we look to countries ahead of us chronologically, how can we use their experiences as a model?
If we stop and take a look around the world and how different people handled it, we're going to find success stories that could help lead us to a better place. One is China.
China of course, made the fatal flaw of suppressing the information on the virus, and we're all suffering because of it.
Because they have much more authority to enforce disciplined public health measures than we do in Western democracies, they were able to clamp down very rigidly on their population. This sort of radical social distancing and enforcement of quarantine seems to have worked in China. I think they may be out of the woods, depending on how they manage the subsequent waves of disease that are inevitably coming. While there may be no more new domestic cases, China is very connected to the rest of the world and can import cases.
Then you have South Korea. South Korea was an early leader in terms of number of cases and number of deaths. The Korean CDC is a capable and intelligent organization. They rapidly deployed testing kits and identified the people at risk and tested them. Whoever was positive, was isolated immediately. This is very widespread, population-based testing, an aggressive management of the disease seems to be flattening the curve in South Korea. They seem to be a model we can follow. In general, South Korea looks a lot more like Western countries politically, than they do a rigid, authoritarian country like the People’s Republic of China.
If we want to really get a hold of this, we have to expand testing radically.
Part of this is buying time everyday so we can slow the spread and allow industry to catch up, to allow research to catch up, and to implement widespread testing. This will really make a major difference in our response.
What can we expect given our current reality?
My concern is what frequently happens when you start to get success is that you become complacent. I anticipate we will eventually succeed in controlling this in some manner or another. The reality of the situation is going to hit home, even for the people who are still out there in denial. I anticipate that over the summer months, the disease will wane and give us the sense of security that we've kind of got this thing under control.
I really worry about what's going to happen in the fall if we let universities reconvene and schools reconvene.
People from all over the country are going to descend on campuses and share their viruses, which happens every year. This could reignite the whole situation. That’s why we really need to have a much tighter testing regimen in place by fall. We can buy time through the summer months and become very aggressive about developing testing, including point of care testing. There's a difference between what we're doing now with testing, which is the nasopharyngeal swabs and sending it off to a lab for evaluation, and things like the rapid flu test, which we can do in an office setting in about 30-45 minutes. We have a similar test already for influenza. In those cases we test, keep the patient in the office and tell them whether or not they have influenza. A similar test for coronavirus would be ideal. I believe it could be a prerequisite that the student body and the faculty would have to be tested and be certain they were negative before returning to campus.
Coronaviruses are not new to the United States. There are at least three other coronaviruses that show up in our communities and present like a common cold. What we are concerned about here is the more pathogenic and dangerous COVID-19 virus. We need a test that could be easily administered, and then we need to be able to isolate the positive cases that do come back away from the population.
In some ways, it's like when you think you've put out the forest fire, but those smoldering embers lying in wait can help reignite the fire all over again. My greater concern over the long term is that we become complacent and that this disease makes a resurgence in the fall months.
Data is finally emerging, but I feel like data is only as useful as the person interpreting it. How are you reading what comes out of China, Italy, or South Korea?
Data is also only as good as the people collecting it, and what they are collecting.
The Chinese data and the South Korean data especially, are the best gauges for what the real case fatality rate is.
There's a lot that comes into play here. So again, South Korea has done much broader testing, they're identifying the less symptomatic cases, as well as the extremely ill cases. The last time I looked, the fatality rate was 0.8%.
Italy on the other hand, is not doing the broad-based testing. It could be that their case fatality rate is in fact higher because they can't deliver the level of care required to every person coming in because they're making triage decisions – literally who's going to live and die. Because they are in this dire situation where they have outstripped their capacity, people who might have survived previously are no longer given that opportunity because there's not enough intensive care unit beds, ventilators, and intensive care unit staff. We have to look at all the data from a wide variety of angles.
What is the real number? I'm looking at the South Korean model as the most accurate, even though it's probably not perfect. If we can drive the case fatality rate down to 0.8% that means: a), we're doing enough testing and b), we're maintaining our capacity to care for those who are extremely ill.
What else do we need to pay attention to right now?
One is that we have to plan ahead for vaccine distribution. We know when this vaccine is finally produced, we are not going to have enough for everybody, and it's going to be available gradually as production increases. People like health care workers and first responders are going to be among the first in line. People at highest risk of disease are going to be next in line. We have to begin to communicate those priorities well in advance, in order to prevent public panic.
Think about people trying to get vaccine when you see people hoarding toilet paper.
The communication has to be clear.
One of the most touching things I saw in relation to pandemic preparedness was a mass vaccination on Saipan in the Commonwealth of the Northern Mariana Islands. In 2007 and 2008, the Department of Defense received an excess of flu vaccine they were planning on paying a company to destroy. At the same time there were people in places like the Pacific US territories that weren't getting enough. I thought, we have this need in the Western Pacific, so why not use it? I was able to get it shipped out and used as part of the community's pandemic planning.
How do we plan for a mass vaccination?
Ultimately, that's going to come down to planning at the local level. That means local health departments and hospitals and other health organizations will have to collaborate with law enforcement to set up mass vaccination sites that may include drive-through vaccination clinics where you are.
Got it.
I wanted to mention that at the end of this, we have to ask ourselves, “How could we let our public health system fail the way it did?”
When it comes to a pandemic, you see how the system has failed because it was underfunded and under-resourced at the federal, state, and local levels for many years. We often boast that we have the best healthcare system in the world. That myth is busted if we are failing even the doctors, nurses, and other staff on the front lines of this pandemic without adequate personal protective equipment. How could this be allowed to happen when we knew that a pandemic would eventually hit?
I was just listening to NPR on the way to talk to you and I heard somebody talking about how a pandemic bears a similarity to earthquakes, another periodic natural event. If you live in Los Angeles, you know that the big one is coming sooner or later. We knew pandemics were coming. It was inevitable. And yet we were so ill prepared for this.
This is a societal failing to undervalue public health.
We have to reimagine how we view health. We have typically viewed health through the lens of health care, when we know about factors called the social determinants of health that account for 80% of a population’s health. I'm talking about things like employment, economy, education, housing, transportation. All of these things play together in the health of people. The growing homeless problem you have in Los Angeles, in San Francisco, and even here in Charleston, West Virginia is a nationwide phenomenon, and these are people who are at high risk for all kinds of bad health outcomes. We are together only as healthy as the least healthy among us. They are the weak links in the chain of health. We have to have the view that we are interconnected.
We need to be prepared for the next pandemic that will inevitably come, and look at health from a holistic perspective. At the social services, at education. All of these things are crucial determinants of health for our nation and for our planet. If we fail to do that, then we have fundamentally failed to learn the lessons of this pandemic.
You’re so right about LA – it's cognitive dissonance. It's too big to wrap your head around. Right now there’s no looking away. Hopefully we use the opportunity as you suggest.
You nailed it. This cognitive dissonance is so true. We can't ignore it, and we're all paying the price for all of the weaknesses in our chain of health, in our chain of healthcare, and in our failure to plan for the inevitable. I think it's just such a profound quote from Tom Friedman who said, “We have to manage the unavoidable to avoid the unmanageable.”
And I thought, wow, that's really the whole pandemic in a nutshell. We have to face what's clearly in front of us. We can no longer look away, otherwise, we are setting up future generations for a failure on the scale that we see today.
interviews
We're Teaching Our Kids Too Late
by frank
April 19, 2019
This interview was originally published on November 18, 2018 in our Civics issue.
This interview with the students of The Young Women's Leadership School of East Harlem was conducted and condensed by frank news.
From left to right: LaShay Fernandez, Morgan Carter, Javeria Amir, and Fargana Alden.
Morgan: Right now, we're learning about how to take an issue that we feel passionate about and see how we can impact our local government - legislative, the mayors, governors. To see how we can change the issue, or see if we can get more engagement so people will pay attention. The issue we all picked was sexual assault in schools, from colleges, middle schools, high schools...
Why did you choose that?
Morgan: At first, it was separated for a week. Some people wanted to do education and the other side wanted to do sexual assault. We were debating for a week or two and none of us wanted to do it together, and then eventually we just had to decide - why don't we just put them together? Now we're doing sexual assault in schools. And how education and money affects why we don't have sex ed.
That's amazing.
Javeria: There's this thing that there's enough about raising awareness for it. It's time for us to take action and the way we can take action is contacting our local office members rather than just going for the governor or the president. We're saying oh my god the President's doing this and what are we doing? We know we can't directly affect what the President is doing himself, but we can work at a local level which is what we're going to do now.
Who are your local officials?
Javeria: Our mayor and our city council members. We would start contacting them rather than the governor.
LaShay: We did a whole thing where we sat down with people in our neighborhood or district to look up all our local members and see what they're doing and see if they're good. We looked them up and really tried to see if our representatives are everyman or superman. To see how much of our representation is actually what we want, or actually accurately depicts the people that are there - us.
What's the conversation around sexual assault? What are the things you want to see done and what are the sort of modes of getting those things done?
Morgan: Today we learned about root causes and systemic causes. We're starting in elementary schools and high schools. People have sex ed, but we realized that a lot of the problem is that people don't actually know what counts as sexual assault. No one has consent classes. You can't just start at high school, because by that time a lot of people are already having sex. We said that maybe we could start with 7th and 8th graders and give them sexual education - maybe not assault, but basic knowledge so that later on they can know - this is what we do, this is how this works.
LaShay: It's very hard because since people are so young and it's such a fragile thing even though yeah, you should learn about it, we're also talking about different ways to tackle the situation. Instead of just saying "consent" and just straight talking about sex with 12 year olds, it's using different methods. There's this video that a college made about tea and offering people tea and it's really weird, but it really pushes the message of consent and not forcing people to do what they don't want to do.
Fargana: To add on, some parents don't have a lot of knowledge on sexual assault or how to to keep safe, or they feel uncomfortable talking about it. For us to teach kids at a young age about safe sex and just making sure everyone's using protection, what no means if someone is saying no to sexual intercourse. It's very important for us, and also since we are young teens, it'll be easier to talk to students because we're in the same generation in a way. We would just be considered like their older sister, we'll have that bond if they ever need something, we can help them out.
Are you learning about how to communicate with your representatives directly? How can you make sure your voice is heard outside of the classroom?
Javeria: We haven't gotten to that point yet. We're trying to figure out what part of the issues are we focusing on, what are the factors that are leading to such issues, and once we have those down, then we can go and be like this is what's wrong with our system, and this is what we have to fix. Once we get that correctly done, then we'll be approaching them, but we haven't learned how to do that yet.
Morgan: It's hard because sex ed is like - a lot of parents don't want their kids learning about that and it's not just girls, it's boys that have to learn about it, too. It's kind of hard knowing exactly what we want them to do because it's often a societal thing. It's hard for them to say, oh we want a rule against this. You have to make something specific.
Do you guys feel empowered by the class?
LaShay: Yes, I was just talking to a friend about it today because I think a lot of times we sit in our class, and especially going to TWYLS, we talk about this stuff, like since freshman year we've been talking about this stuff, and it's such a big issue and we always talk about it, but we never talk about what we're going to do about it. And I think sometimes when you're just in your little city, you think this is huge and this is happening in the government and I can't do anything about it.
Even if you're starting small, it's a ripple effect. I think that's what the class has really done for me. I can do stuff, even if it's really small, it's important.
Javeria: People talk a lot and they don't do anything about it. We have a social justice club and I feel like that has empowered us in general and then having Generation Citizen - being able to take action now, instead of just talking about it. What should we do? I feel like it's a wonderful opportunity for us to have.
Fargana: In addition, compared to other schools, TYWLS really prepares you. We're really thankful to be offered Generation Citizen because in other schools, again, they would talk about it - or not even, the topic wouldn't even come up in their conversations - it would just be ignored rather than at least being talked about it and seeing different ways how we can help. For us to talk about it and see how we can fight as young teens, it really impacts us.
Can you tell us more about the social justice club?
Javeria: The social justice club is led by Jessica Taylor, our 10th grade global history teacher. In that club, anyone - I think it's mostly high schoolers - can come in the beginning of the year, we focus on an issue and advocate for the issue we think is affecting our community right now. We're in 10th grade and we raised some funds for the Syrian refugees, that was around $500 by doing food sales. It's just the little things we're doing. We're seeing what current issues are affecting the people around us. It's giving back and even though our school doesn't have that much, we're trying to take initiative.
Fargana: We donated a bunch of toiletries to a women's shelter as well. Every year we would do something - I think of it as a main project and then a mini project. So the mini things are some local things - like donate toiletries, donate money, and then our main project is what all of us are mainly focused on and how we can help.
That's amazing. Have you guys learned about civics anywhere other than Generation Citizen?
Morgan: I think some of us learn it at home, but in school, other than government or AP US History, not a lot. I think as a whole, they always push us to change something or if you feel something, talk about it, try to change it so not directly, but I think that we all get encouraged throughout our years of being here to try to change something.
Javeria: Our government class is coming senior year, it's important, but other than that we're not used to having that - what policies are, how they're made. It's senior year and Generation Citizen. For me, even if we're in AP Government, you're getting that in senior year which is a little late, but.
How early do you think civics should start?
Javeria: I feel like middle school. They're going into that 9th grade year where they're like we're going to be like high school, and they're already empowered so you might as well give them another boost.
Fargana: Yeah, it would really impact a person if you're starting in middle school. It would be perfect to teach them about the government issues and who's your local representative, what does it mean? Then when you're in high school, as the years go by, you'll have more knowledge. Each grade, we can all come together and create a bond within us and be able to go out and do something. For seniors, since we're capable of doing it, we can continue it in college and teach others that really didn't have this opportunity when we were in high school.
Are any of you about to be 18?
Yes, yes.
Are you planning on voting?
Javeria: Yes! I was going to say that. Us turning 18 - I feel like this is encouraging me at least to vote. That's one of the ways my voice can be heard, so why not? I feel like that's part of the issue. We need to tell them - yeah, voting may seem like your voice is not heard at all, but we're the people and you're one person so we need all the people to make that voice be heard, so vote, please.
Are you excited to vote?
Javeria: Yes, I'm really excited. I've been waiting. I've been waiting to turn 18 so I can vote.
LaShay: I think it's so funny that she's acting like that because my parents don't vote and it's really weird. I'm always like why don't you vote? "Well it's not gonna matter." I'm really glad I took this class because you're influenced by your political socialization - you're influenced by the people that you're around, and you inherit these ideas and you're kind of conditioned to believe this one thing and I think before I came to TYWLS, I kind of did have that mindset of well, I can't make a change, I'm one person. I'm so excited to vote now and it's so weird because before I didn't think it would matter.
Fargana: I don't turn 18 until another year, my parents are immigrants - they're both US citizens - so it's for them, the only main election they worry about is presidential because that's the big one, but I feel like now that I have more knowledge on this, I'm literally waking my mom up early so she can come with me to go vote. Well, for her to vote, I'm just gonna be there making sure she's there.
Morgan: I'm the exact opposite. It's weird because my mom has always been - my mom is the kind of person, even if she doesn't like anybody on the ballot, she'll still vote. She's always told me to pay attention to what's going on and vote. And I was always just like, I don't really care, but I think Generation Citizen has made me really want to do something now because every single thing counts. I kind of wish, like a lot of things, that we would've learned it in middle school.
I think the problem is we underestimate young people. They think they're not old enough to understand it. When a lot of times, the middle schoolers know more than you think they do. Like a lot more. And I think that they need to start encouraging them and teaching them because I feel like 11th graders and 12th graders, we're about to leave, there's no point. I feel like if I would've heard it in 8th grade, maybe I would want to vote more. I can change a lot more things than I thought I could have.
Never underestimate the youth.