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
Working at the Supranational Level
by Daniel Naujoks
July 31, 2019
This interview with Daniel Naujoks was conducted and condensed by frank news. It is part two of our conversation on The Mobility Mandala.
frank: Today, we often hear about a crisis of cooperation at the international level. It seems that many countries are reluctant to work together and many wonder about the place of the United Nations in today’s world. This is broad – but what influence does the UN have on nations today?
Daniel Naujoks: When we think about the influence of the UN it’s important to recognize that the UN isn't one entity. What we call “the UN” includes many different ways in which states interact with each other, often mitigated or moderated by certain entities of the UN. You have the General Assembly, which, for many people is the quintessential UN. And the Security Council – a highly political body and the only UN organ that has the power to take decisions infringing on states’ sovereignty. On the other hand, there is the UN of the many programs and agencies that have specific mandates and that work with governments and non-state actors to achieve something, like the UN Development Programme, the International Labour Organization, or the UN Environment Programme, to name a few.
When it comes to migration and displacement, we actually had several discussions on these topics at the General Assembly. In 2006, the UN organized the first high level dialogue on international migration and development, for which I was part of the organization team at the UN Population Division. In 2013, we had another high-level dialogue at the UN General Assembly. And after preparing and negotiating for two years, in December 2018, the global community adopted two new compacts. The UN adopted the UN Global Compact for Migration, for safe, orderly and regular migration, and the UN Global Compact on Refugees. These are non-binding agreements but the entire process of drafting these compacts was influential for spurring discussions among countries, between countries and civil society at the international level, and, even more importantly, at the national level.
Often we think of UN issues as matters at the supranational level, happening at the UN General Assembly hall here in New York or in Geneva. And that's true, that is an important venue. But, when we have a UN event or UN treaty, or in this case, a compact, there are also national stakeholders, human rights commissions, NGO networks, ministries at the national level, who have an interest in promoting certain issues. And they have consultations, the press picks up issues. Each country is a little different and it depends on the strength of certain stakeholders and their interests. For example, the U.S. government was largely absent from the process of the UN Global Compact for Migration.
The risk of somewhat being held accountable would actually be low. And remaining in the discussions would have given the US a way to influence the content. But I think it was more about sending a political message to certain local constituents than an actual policy move in the international sphere.
What is remarkable is that even though the national government withdrew from the process, many U.S. cities said, "Can we be part of that?" New York, Chicago,and other cities really stepped in. Thus, in the end, there was a lot of participation in the U.S., even though the national government declared they don't want to have anything to do with it. So, sometimes, how the UN works is a little more complex than just what the official state department position is on an issue. And there are many venues. There are bilateral consultations, there are regional consultations on human trafficking, on labor migration and so on. There is a Global Forum on Migration and Development, the GFMD, which, since 2007, takes place every year. Governments come, they exchange notes on good policies, and on what can be done, mostly at the working level. At the working level, government officials cooperate and learn from each other. Again, it's non-binding. And the UN provides inputs, they chair sessions, they write background papers, they present case studies.
This is to exemplify that there are systems where policy learning happens in a much more informal setting, than through rigid rules-setting and treaty-making. This is something students in the UN Studies specialization here at Columbia’s School of International and Public Affairs, that I direct, focus on when studying global governance. There are many different ways in which local and national governments, countries’ specific ministries, institutions, and agencies, international organizations, NGOs, and other groups negotiate and collaborate.
And then in the developing world, of course, the UN has a different role, because they are not just advising, they're working with local partners and in actual programs, like funding. And they're advising governments directly on how to do things.
So, when Kenya says that they want to close the refugee camps for Somalia refugees, UNHCR can plead, "Oh, please, refugees have rights and camps are bad." But, unless the Kenyan government gives UNHCR authority to work on certain programs, and provides UNDP consent to implement initiatives on livelihood strategies targeting refugees, these agencies can't do much. This being said, because of certain power asymmetries and donor interests, the so-called technical assistance from UN agencies in the Global South has the potential to influence policy decisions and exemplifies how the work of the UN can have an impact. But the political leverage of many agencies is not as large as is often seen. Which is why there's a lot of bargaining in the background. The things that you don't see that are not official.
Can you give an example?
DN: An example for the fact that the UN has to always ask for permission to work on certain issues is the persistence of the use of refugee camps. For the last 15 to 20 years, we know that refugee camps are not good for refugees. In the very short term, in the immediate aftermath of an atrocity, of a civil war, of a calamity, in the case of a sudden influx, camps may make sense to provide shelter and food and medical services to a large number of people. But, even in the medium term, they're very bad for the human development outcomes of people.
Camps generally don't provide sufficient economic opportunities for people, et cetera. That's why for some time now, we know that limited humanitarian responses to large refugee and IDP movements are not good for development. Definitely not for those people who are displaced, but mostly equally for surrounding communities. I actually developed a role-play simulation on the reasons for and against refugee camps and participants understand quite clearly the mix of international development and human rights logic with local politics and interests.
Addressing the shortcomings of classic humanitarian approaches, different UN agencies have been very strong in advocating for a more development-based strategy. For example, in the Syrian context, there has been the 3RP, the regional refugee and resilience plan, which is headed by UNDP and UNHCR, with I think, about 270 partners. It’s implemented in Syria’s neighboring countries, Jordan, Turkey, Lebanon, Iraq, and Egypt. In addition to each country’s national plan there's a regional plan, which focuses not only on the humanitarian side but also development side. UNDP has been leading these efforts to provide livelihood support, skills, training, et cetera. But even there, we see that the implementation is hampered by a lot of challenges. Take Jordan. In the 2013 donor conference in London, Jordan pledged to give work permits to 200,000 Syrian refugees. They were very committed at the highest level of government.
But, a year later, there were almost no permits for refugees, and everyone asked why. We did a project with Better Work Jordan, which is a collaboration between the International Labour Organization and the World Bank. BetterWork Jordan published a report that my students drafted on why Syrian refugees did not get more official work permits. There are many reasons why employers couldn't employ refugees or couldn't expand their production. The refugees could only work in the export-oriented zones, mostly in the garment sector. They couldn't work in other areas. There was a distance they had to travel. Refugees often didn't want these jobs for a variety of reasons. There were many bottlenecks in the bureaucratic procedure to get work permits. In brief, there were many challenges at the supply side, the demand side, as well as on the bureaucratic transaction side.
These issues combined led to a situation in which this great policy that was mediated by the UN and other donors to actually empower refugees to be economic actors, didn't have the impact people had hoped for. While much of what the UN does can have important impacts, this shows that what can be done at the national level depends a lot on national priorities and politics. How politicians are afraid of negative impacts for the local voting populations. And then, of course, it has also to do with the commitment of the international donors to actually put in money to say, "Yes, we will not only give you minor funds to warehouse refugees but we will partner with you to empower them and your populations." Part of the agreement with Jordan that I mentioned was a pact with the EU. The EU said, "If refugees are employed you can export garments and other goods from export-oriented zones to us duty free." The idea was to use trade and the increase in production in the Jordanian garment sector as a way to increase employment opportunities for refugees. A great idea.
But, you probably need to do more to help Jordanian products to be competitive on the EU market. There's also a time lag. Even if you open up the market right away, these products may not satisfy the EU standards for garments. So, there are many things that the partners need to do to support these endeavors and to really make sure that local leaders are not afraid that if they open the labor market, if they open chances for local integration, that in two years, donors will pull out. And then, they will get stuck with the additional population without the support financial community. So, that's where the UN can help a lot. But, without real commitments from large donor countries or any countries to resettle and share the responsibility for refugees, there's only that much the UN can do.
Thank you so much for your time.