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
Wargaming: An interview with ICONS director Devin Hayes Ellis
by Devin Hayes Ellis
April 10, 2018
This interview with Devin Hayes Ellis, the director of The ICONS Project, was conducted and condensed by Tatti Ribeiro for frank news.
Bottom line is, I know nothing about gaming, and I would like to know more.
Works for me. So the ICONS project is 36 years old now. It was founded by my predecessor, as director, Jonathan Wilkenfeld, and a couple of academics who thought it would be intriguing to see if they could use the Internet to connect classrooms and teach political science back when that was you know, cool and new, and it worked. In the last decade or so the organization has evolved from being mostly an education mission, which you know, it's had throughout its history, which we still do have, providing classroom simulations for starters, into also having a strong presence providing what is essentially wargaming. Although we often use the phrase simulation or human driven simulation.
Is there a difference between those words and definitions or are they all interchangeable?
They're interchangeable to an extent. I think it depends a little bit on who you're talking to and what the disciplinary background is. In the military context I usually say wargaming because that means something to military folks. And it usually means something pretty close to what I mean, which is,
I think we all would consider the pope of war gaming to Peter Perla, who wrote a book called The Art of Wargaming that remains one of the definitive studies of the practice. It's not really a discipline right. You know, people come from a lot of different backgrounds, a lot of them in the professional military community who do this are from an operations research analysis background, but that's a very specific set of academic disciplinary things.
How seriously do they take gaming in government and in the military?
It depends a lot on where you're talking about. So the law says, well, Title 10 mandates service level wargames. And so these are gigantic exercises and they take place annually. They are these gigantic efforts, where often people in the planning staffs of major commands and services whole time in that part of the planning staff, will be spent designing and executing Title 10 games. They also have these sort of cute permanent names. So for example, the Special Operations Command Title 10 game is called, Shadow Warrior, and that's what it's called every year. So it'll be you know, “what is Shadow Warrior 2018 gonna be about?, oh X, Y, or Z". And that's sort of how they handle that at the highest level. But those games tend to be very driven by a sort of a combination of three major factors. The long term institutional priorities of the commander of the service. So, you do not want a game that's going to undermine what you're telling Congress you should get money appropriated for. Right? The specific intent of whoever the commander there is. So if it's a service game then you know the service chief is going to have significant input on what the priorities are. What he, or hopefully a future she as well, wants exercised in that annual game. And then the third thing of course is, what are the national security priorities that are being set by the president's national security strategy, and then, the secretary's national defense strategy.
Games happen all over the place at various levels. I was recently in Europe for a small-ish tabletop exercise that involved about 60 folks from our particular command and we were very focused on one very, very specific problem and that took a couple of days and —
What problem was it?
I can’t really talk about that. But let me say this. There are only so many problems that the military’s worried about in Europe. And some of them I think we thought were from the past, and now they are back in fashion again.
On a military level, when there's time, is gaming something that usually contributes to the decision making?
Not always no. In fact you know, wargaming has sort of had peaks and valleys of fashionable-ness, I guess. You know, we talk about sort of high points in the history of war gaming within the U.S. military establishment. I think most people who study the issue would point to wargaming that the Navy did prior to World War II. Which is often talked about as an excellent example of a service really spending a lot of time and effort thinking through what could be a plausible strategic problem for them. And then gaming it on various different levels, to the extent that you know, I can’t remember if it was Halsey or Cane, but one of them said after the war, that they had worked the Pacific theater so many times prior to World War II, that the only thing with the Japanese that actually surprised them was kamikazes. That was the only thing they hadn't thought of.
Wow. And today, how is gaming used in comparison?
So I would say they are on the rise right now. For a couple of reasons. First of all I think in the last 15 years or so the community of war game professionals has really sort of coalesced in a away that didn't exist before, thanks to maybe about, a half a dozen individual people honestly, who have been crusading on this their whole careers. And you know, we now have an interdisciplinary community of interest conferences that are even international. I go to one annually in London. There's one in Australia, Canada, and the Netherlands, and here in the U.S. And you know, it's really I think…that the strengthening of that community of practice and the popularity, the rising popularity, of the methodology with some parts of the U.S. defense establishment especially, has been able to promote its utility, and has seen a sort of a resurgence in wargaming. And then a couple of years ago the deputy secretary of defense at the time got involved in the work. He was a big fan. He actually put out a memo ordering the reinvigoration of wargaming in the Department of Defense.
Has that enthusiasm continued from the previous administration to our current administration?
Secretary Mattis has not actively reversed that directive in any way. So I mean, I would say it doesn't have quite the momentum it had at the moment, when Secretary Work said make it happen. But it's not you know, I wouldn't say it's been shunted aside either, because the life cycle of reinvigorating something in the Defense Department, if people actually take it seriously and put resources behind it, we could be in the next presidential administration before they've even done the things that they said they wanted to do four years ago. So I think there's a lot of good wargaming taking place in a lot of places in the defense establishment. To be perfectly honest there's also a lot of very bad wargaming taking place all over the place, mostly because when something like that happens and everybody says, “get me a wargame”, you know part of it is box checking.
Obviously I'm a proponent of this as an analytic tool, as a decision support tool, as a training tool, because it's what I do.
A lot of us think the professional conscience of wargaming is a gentleman named Steven Downes Martin, who was on the faculty at the Naval War College for many, many years, and is a professional game designer. He likes to joke that the three questions he always asks his sponsor are, what is it that you need to know that you don't have right now? Why do you think a wargame the right tool to get that? And, when do you rotate?
What are the other options in terms of analysis and running through scenarios? Gaming seems like the obvious choice if you’re looking at complex levels of decision making.
Right. I would say that if what you have is a decision making problem, then gaming is a great tool. If what you have is not a decision making problem, then it might not be the best tool for you. If what you have is a big data empirical analysis problem, wargaming is not going to help you. I try very hard not to sell this as a one stop solution for all decision issues for leaders and organizations. I also know we try to call out things, if you have a chance, when they’re not really living up to what this technique is valuable for. Because then it reduces people's interest in the technique. Right? You go to a couple of wargames that you feel were a total waste of time, and you're not going to go back to a wargame for your problem. Half the time that's because it was either a problem that should have been addressed in a different light, or it was a really badly designed game.
But I should say there is also a slightly more insidious potential problem, where maybe you have a really nicely executed game about an interesting topic, but it turns out what you got out of it, the relevance, or the utility, or how much did you really learn from that, is less than maybe you would have wanted.
Right.
Okay, so the sort of a pinnacle of the wargaming system is an outfit in the Joint Staff, in the J8 directorate, which you know, sort of studies and special plans at the Pentagon, as opposed to the J5 who are the people who actually write war plans. The J8 has a unit called SAGD which stands for…oh look it up.
[Studies, Analysis, and Gaming Division]
But that unit is charged with doing very high level, what we call Pol-Mil games, which is short for political military gaming. It’s potentially about inter-agency decision making. So it's not just a military or a defense problem, it's something that would involve state, the intelligence community, Treasury, Homeland Security, whomever else has an equity in that problem. And so that's why we call it political military because you're bringing in political leaders and other interagency leaders, in addition to defense establishment leaders. And the Pol-Mil gaming that they do in the J8 at the Pentagon is usually at the very highest level. So at the national command authority level, even where the players who are there representing their departments activities, are playing the members of the national security units. Tom Allen, who is now retired, ran that organization for many years and is in that Pantheon of wargaming greats in my opinion.
He, you know, at one time said to me, “I’ve never seen a bunch of people walk away from a weeklong TTX junket, where they all got to leave their jobs behind and band together, and pretend to be fighting the Russians, and say, oh that sucked. I didn't get anything out of that. Everybody always says it was so cool, that was important.
What is the most essential thing to understand about gaming as it applies to our military and our national security right now?
Right. So I mean, I know it said it a trillion times, but I'll say it again,
Do you work with Special Operations frequently? Do they involve you?
So, special operations, I think the special operations, the SOF community, has been called on in the last 15-20 years to do a tremendous number of very varied missions in support of U.S. national security policy. They’ve had to tackle a lot of issues and problems that are not…that are like, way divergent from what the original SF mission was back in the 70s. That's fine. So the answer to your question is yes. Because the leadership in that community has been conscientious about trying to apply whatever techniques they can to understand the dimensions of the thornier parts of their mission better.
As a result of the wars in Iraq and Afghanistan, the defense establishment, and we’re speaking about defense with a big D, spent a massive amount of energy and resources trying to tame the problem of complex operating environments, especially around insurgency, counterinsurgency, dealing with human populations, and all the attendant problems, trying to jam that problem set into an engineering framework. If only we can build a better, faster, stronger systems dynamics model, it will eventually spit out an algorithm where all the commander has to do is say, here's the details of my population, and the details of my mission, and it will tell you what to do to be successful.
In part because a lot of the complex environmental modeling techniques that come out of engineering and hard sciences could be an amazing analytic tool to deal with problems in those domains, when you try to apply them to social science settings, to human terrain settings, they rely for their validity and their strength in their original homes, on having a really high degree of certainty about the causal relationships between different variables.
That was a very long way of saying, I think much more quickly than the big D establishment over all,
You talk about SOCOM, well you know a four star commander, whose mission is to prepare and equip all of the SOF community, has a very different level of concerns about these things than a two star commanding general of a theater of Special Operations Command, who's sending guys out to do very specific missions. And so you just, you know, you want to make sure that the way you're calibrating your game addresses the level of the question. That's really, really important.
Right. Thank you. I think that answers most of my questions. Do you have anything else you’d like to add?
You know, not to be unpatriotic, but I think the best short introduction to how, or why to wargame, and how to do it, is the very brief manuals that the UK Ministry of Defense of wargaming has written very recently. I will send that to you because that's just a great resource for anybody who's like, while that sounds good, I want to be able to go and read about it.
Thank you! That’d be great. Thank you so much for your time.
Thank you very much. Have a good day.