Editor's note: Second Wave is fostering discussions between people working on issues affecting both rural and urban Kalamazoo County. This is the fifth part in the series and focuses on the challenges of what local health officials call "preventable suffering" the onset of COVID-19 among those who have not been vaccinated.
For our latest "Let's Talk" discussion on issues that impact both rural and urban Kalamazoo County, we're taking on the virus that's brought about a two-year emergency situation, COVID-19.
With every wave of cases, the pandemic has had a huge impact on both Bronson and Borgess, from their main hospitals to the small-town clinics. In the past few months, there's been a two-part spike in hospitalizations, first from the Delta variant, then Omicron.
Two phrases popped up during these interviews: "preventable misery" and "preventable suffering." Most of those hospitalized with the virus have been unvaccinated.
We spoke with three figures in Kalamazoo public health about the pandemic and where it stands now:
Dr. William Fales, Medical Director, Kalamazoo County Medical Control Authority; State Medical Director, Michigan Bureau of EMS, Trauma, and Preparedness.
Jim Rutherford, Kalamazoo County Health Officer.
Dr. William Nettleton, Medical Director of Kalamazoo County Health and Community Services; Medical Director of Calhoun County Public Health Department.
We spoke with the three during the height of the Omicron wave in January. Case rates are now dropping in Michigan, but are still at the
levels of early January.
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Jim Rutherford, Kalamazoo County Health Officer.These were separate interviews -- we were unable to arrange a discussion among them in the way previous Let's Talk discussions have taken place because they've got extremely busy schedules.
Are there any differences in how this illness is impacting rural versus urban Kalamazoo?
Rutherford says that there's no data that he knows of to show if COVID is hitting rural Kalamazoo harder than urban Kalamazoo, or vice-versa. There is a 33% positivity rate throughout the county, (for the week of Jan. 17) which is a good indication that "it's pretty universal. We know that it's everywhere."
"Communicable diseases don't pick and choose (who they infect). Their objective is to replicate. If they're given the opportunity to do that and flourish, then that's what they're going to do," Rutherford says. With "vaccination and wearing a mask, we're trying to avoid the spread of that disease. It's pretty much that simple."
As of Jan. 19,
Kalamazoo County Health shows that some rural townships have vaccination rates below 50%, as well as some sections of urban Kalamazoo.
Nettleton says, when it comes to vaccination rates, racial disparities and lack of access to vaccination and information should be taken into consideration, as well as vaccine-hesitancy. "In general, Kalamazoo county has done very well (in vaccination rates), compared to others, respectably in the state of Michigan. Other places in the United States have higher vaccination rates," he says.
A busy, stressful time in public health
How have these three public health officials been holding up over these long two years?
"Things that should not be hard, are exceptionally hard. It's just a really difficult time," Fales says.
He says that for all health care providers, "on the front line or in administration, I think everyone has experienced unimaginable disruption of both personal and professional lives." Everyone "taking care of COVID patients is simply tired, they're hardened in ways that we've never imagined, and I think everyone is just well past the point that it needs to be over. We're just kinda continuing to go forward, and that's what's hard on everyone."
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Dr. William Nettleton, Medical Director of Kalamazoo County Health and Community Services; Medical Director of Calhoun County Public Health Department gets vaccinations in both arms.Rutherford says for him, "It's been a rollercoaster. And it's been like nothing I've ever done professionally before."
Rutherford has been in public health for about 32 years and was health officer for Calhoun County before joining Kalamazoo's department. He was part of the
Enbridge oil spill response, when "a million gallons of oil spilled into the Kalamazoo River that impacted about a 32 mile stretch of waterway, and that was pretty significant. But I've got to say that this is more significant than that."
Nettleton says with a slight laugh when asked how he's held up in the past two years, "That's a loaded question to ask someone who's in public health right now.... I've been doing alright. There are ups and downs.... The hardest part as a physician, and as a public health doc, is seeing preventable suffering."
Speaking further, Fales sighs with genuine stress. "In my life, a part of every day, over the last two years now has involved COVID. That's aside from working in the ER, which I obviously don't do every day, but just administratively, with the state and with Kalamazoo County EMS, every day involves spending part of that day thinking about COVID."
Fales says, "You need kind of a COVID holiday. That would be nice."
Done with COVID -- but COVID is not done with us
It would be nice for everyone to have a COVID holiday, but as of late January, the virus has been killing Americans at the highest level since early 2021, when the vaccines were still new and not available for all age groups 5 and over. The Wall Street Journal
reports Jan. 25 that death rates in the U.S. reached 2,100 a day.
Yet, some -- at least in opinion pieces and on politically-oriented talk shows -- are deciding the pandemic is over for them.
In December, somewhere around the peak of hospitalizations for the Delta variant and the beginning wave of the Omicron variant, conservative commentator Matthew Walther wrote
"Where I Live, No One Cares About COVID" for the Atlantic.
Walther lives in Three Rivers, south of Kalamazoo in rural St. Joseph County. In his piece, he acknowledges that "no one cares" sounds "flippant," that at the time the average of positive test rates in the county were high, and the virus had killed 136 county residents since June 2020.
Then he goes on to say that he and his family have avoided wearing masks since 2020, and his children "are distinctly uncomfortable on the rare occasions when they see them...." Also, he writes, "I do not know a single person who has received (a booster shot)."
Because of fatigue with it all, or disinformation, or just honest confusion with the changing recommendations, people are thinking they are done with this. But the virus doesn't seem to be done.
"That's what's hard," Fales says. "We can't wish this away, no matter how hard we try, it doesn't work. It's not done with us yet."
Are people getting too relaxed about the pandemic?
Nettleton says, "I think it depends on your own individual risk. We still must be vigilant, for sure. Everyone in Kalamazoo County should be wearing a mask when they're indoors and in public.... So we still must be vigilant, for sure."
The best way for most to reduce risk is to be vaccinated and boosted, he says. "I recommend everyone five years and older should receive all their vaccines that they are eligible for."
Nettleton emphasizes, "We know more about the virus (than we did in 2020), we know that we have tools to reduce risk. But people just aren't using those tools.... We have tools now, so it's a different situation, but people really need to use the tools."
Getting the message across that COVID is hitting communities hard becomes complicated when some people will need hospitalization, while others go through a mild illness, Nettleton says.
"It's challenging to communicate risk on a population level, versus risk on an individual level."
For individuals, "There's a spectrum of disease," mild-to-severe, he says.
Some will face severe sickness if infected. The elderly, immunocompromised, people with certain medical conditions, those who can't get vaccinated, and those who won't get vaccinated, tend to have a greater risk of severe illness, hospitalization, and death.
The vaccines are shown to lower that risk. "Booster shots, for example. If you are above the age of 50, your additional booster shot clearly reduces your risk of being hospitalized. We've talked to our local hospital -- and this is true for CDC national data -- people who are boosted are not being hospitalized. The overwhelming majority of people being hospitalized right now are unvaccinated, are un-boosted."
Some groups and individuals are in a better spot but aren't in the clear. For example, "We know kids are at low-risk for severe disease with coronavirus. But there's still a spectrum within that age group, kids who are obese, kids with a lot of medical conditions, are at higher risk for hospitalizations. Nearly 99% of kids who are hospitalized are unvaccinated."
Nettleton adds that recently two children under 18 died in Kalamazoo County because of COVID. "And those are vaccine-preventable deaths."
That this virus is still a real danger for those who are unprotected is not an easy message to get out to people who haven't seen family, friends, acquaintances get sent to the ICU thanks to COVID.
"What I'm attempting to do is communicate on a population level of rare outcomes of severe hospitalization and death, but they can happen. But for people who are at higher risk, most often. And that those are preventable with safe and effective vaccines," Nettleton says.
"It's understandable that people are tired. I tell you what, health care leaders are tired, public health professionals are tired. We're exhausted. But we'll continue to do what we're called to do."
How have the county's medical systems been holding up?
"Kalamazoo County is blessed with (medical) resources," Rutherford says.
"We've got a regional health system that's a hub for a multi-county region through both Borgess and Bronson," he says. But when hit with the waves of COVID patients, "we have struggled."
Is there not enough room, or equipment, for Kalamazoo hospitals to handle the pandemic?
"We don't have people," Fales says.
There are few solutions that he can see. What if we send in medical staff from the National Guard? "At the end of the day what that comes down to is robbing Peter to pay Paul," he says. Doctors and nurses in the National Guard work at other hospitals, so their health care systems suffer when they're helping out at ours, Fales says.
Regulations could be eased, "other health care providers to come in and practice in Michigan that aren't licensed here, things like that."
But the problem is nationwide. "The hospitals are trying everything they can to retain their current workforce and to recruit new providers new health care providers to the community, but everyone is competing with one another," Fales says.
Staff are leaving for higher wages in other states, "they go from Michigan to Pennsylvania and fill the gaps in hospitals that were created when the nurses from Pennsylvania went to Texas, and then we end up having to pay really high wages to get the nurses from Texas to come up to Michigan. We're kind of cannibalizing one another and with the system we have, there's no easy way to stop that. Which is really tough," he says.
"The hospitals are doing everything reasonably possible to provide the kind of care we all strive for with limited resources, but at the end of the day you can't instantly make a nurse or respiratory therapist or a paramedic."
Rutherford says, "Quite honestly, someone could offer me a million-dollar grant, and it wouldn't change much, because I can't hire nurses if I wanted to. I can't attract them, I can't retain them. I'm competing with the private sector, I'm competing with hospitals, I'm competing with WMed. We're at the end of our rope when it comes to staffing. That's the case with both hospitals."
Everyone in health, Rutherford says, "is forced to work more hours than they should, there's just no relief, and it catches up to everybody after a while."
Medical staff will continue to do their best, but ultimately the fatigue and lack of staff affect everyone who might need their services. "That's part of the frustration... this impacts all of us, as a community." Rutherford says that waits for elective surgeries have been "doubled or tripled because of where we're at."
"It hasn't let up. Normally an incident that's critical like this, it comes and goes... For something to go on for two years, that's pretty overwhelming to any system," he says. "It has a significant impact on morale, impact on being able to retain people."
Fales says, "What's been amazing to observe, for the most part as frustrated as many health care workers have become -- and it's understandable caring for patients that are unvaccinated -- that to their credit, they are taking care of patients the best way that they can. Regardless of your vaccination status, the men and women who provide health care are taking care of you no matter what. It really is rewarding to see health care workers taking care of people who are sick because they need taking care of, and not being judgmental."
He adds, "we're seeing less of that now, and some of it is (health care staff) being hardened and desensitized....
Yet, "regardless of whatever decisions you made in life, whether you're ill or injured, you're going to get the health care system doing their very best to help you."
Medical science politicized
Rutherford was recently selected, in a 6-4 vote of Kalamazoo County Commissioners, to become Interim County Administrator. He expects to serve a short term during the search for a replacement.
Some commissioners, like John Gisler,
opposed his placement due to Rutherford's masking and other public health decisions.
"I'm pretty thick-skinned, in regards to that. A lot of people curse my name as a result of some of the decisions I've made. But at the end of it all, I'm just doing my job as a public health official, and I have to rely on the expertise that exists on the national and state associations, the American Medical Association, the CDC, the Michigan Department of Health and Human Services. Those are the sources that I have to rely on," Rutherford says.
"I would've been derelict in my responsibilities as a health officer had I not made those decisions, or had I've let politics cloud my decision-making. Did it make me enemies? You bet. Did it hurt me? Some may say that, but I don't take any of that personally. Even the comments, 'he's a dictator, he's tainted goods,'" he says with a chuckle. "At my age, as long as I've been doing this, those things don't keep me up at night."
Rutherford says COVID hasn't had as much of a differing impact on rural and urban Kalamazoo as it has had on politics. "I don't know if I would divide it by a person's address so much, as I think more of a prevalent division element is politics." The division is evident in the county commissioners, he says.
"And that is what I think is terribly unfortunate and has been for quite some time. Particularly in the second year of this when people just got tired of it. That's when we went down the road of conspiracies.... And then the offshoot of that is, you get people who are fighting about wearing a mask, fighting about vaccinations, fighting about allowing people in or not allowing people in, fighting about required mitigation strategies. I think you have politics just about everywhere," he says.
"At some point in time as a country we have to rely on scientists, the public health specialists, the physicians, the nurses, this is what they do.... If we're not going to rely on the experts, then I think we're not able to respond to a pandemic of this nature."
Rutherford pictures what would happen if a more-deadly pandemic happened, "and we approached it the way we've approached it... with false information and lack of trust, lack of coordination, I just can't imagine that we'd be very successful. You'd see a lot more death, unfortunately, because we're not able to respond the way that we should be able to respond."
"The core of public health practice, the core of practicing medicine, is trust. And right now we don't trust one another," Nettleton says.
He and colleagues in the regional medical system spoke about this in an early December
WMed press conference.
"That was the time of our Delta surge when our hospitals were really overwhelmed." Nettleton felt there was a need to plead with all to help slow the spread, "because the health care system was threatened, and the entire community's health was in jeopardy. We live here, our children go to school here, we see patients here, we are your local physicians, and we're asking for your help."
"If you can't hear messages from your local doctors, who can you hear it from?"
Nettleton says that it's difficult to build that trust since science, by its nature, changes as new data come about. Throughout the entire pandemic recommendations evolved and changed with new data.
"So, to the general public, there is this constantly changing information, and then (add the public's) distrust in institutions and government. So the challenge for public health professionals and medical professionals has been -- we make decisions based oftentimes on evidence, but also on our own experience and expertise," Nettleton says. "And oftentimes in public health, it's in the background of a significant amount of uncertainty."
Facts arise, but those come up against people's personal, sometimes deeply-held, opinions. "When our personal opinions are tied to our identity, when things change, then that questions that person's identity at that point. That's been a real challenge," he says.
"How can we rebuild that trust? I think that's going to be a huge challenge for medicine and public health over the next couple years. How can public health professionals, medical professionals, communicate better, how do we build communication competency?"
"And then, how do we, I hope, divorce this idea that my personal opinion is always married to my identity? Because all of a sudden, if the evidence changes or the situation changes, in science our recommendation or practices should change, too. Just the situation has changed, instead of it being an identity crisis at that point."
It's hard to say where the most mistrust is -- rural, urban, or everywhere. Nettleton brings up what he suspects was a purposeful targeting of vaccination clinics for 5-to-11-year-olds in November.
When vaccinations were approved for young children, he oversaw these clinics in both Kalamazoo and Calhoun Counties. "A joyful occasion -- very joyful, parents happy to bring in their kids to get vaccinated," he says.
"Moms and dads gave permission to post pictures online at the health department. We got a very good social media response in Kalamazoo. We did the same thing in Calhoun County and got trolled, very hard. From people just haranguing about this effort to vaccinate children, 5-to-11-years-old, to the point where parents asked us to take down the posts. That's the type of differences that occurs even regionally within southwest Michigan."
How can we get more people to protect themselves and their communities?
All three agree that vaccination greatly reduces the risk of severe illness, hospitalization, and death. That commitment to masking in public, indoors, among others, and being mindful of other social distancing recommendations, help reduce the spread of the virus. And that Kalamazoo hospitals have been overwhelmed with people ill from COVID.
They also agree that they've seemed to have hit a wall with people who have yet to be vaccinated, who wish to go out and mingle without the inconvenience of a mask.
So, what's the solution, other than find some way to persuade people to protect themselves and those around them?
"If they haven't done it (get vaccinated) by now, I don't know how to get them there," Rutherford says.
He has members of his family who refuse to get vaccinated. "I talk to them, I love them, they're just in a different place, and I respect that. I've done everything I can to convince them, but I'm not successful."
Fales responds, "Maybe you should be asking that question to a psychiatrist or a clergy, someone like that. How do you modify behavior when behavior doesn't want to be modified?"
Maybe it can be done through empathy, a one-on-one connection, personal stories, not just through repeated medical messaging and lecturing?
Fales says, "We all have plenty of anecdotes," in the medical world of witnessing people unvaccinated, going through a terrible illness, sometimes ending in death.
He says, "It's not a good way to die. Some of the absolute sickest patients I've seen in my long career have been these patients. Gasping for breath, in your final moments, is an absolutely awful, awful way for anyone to die."
Fales recalls an emergency room scene: A woman in her 80s from a nearby rural county, and her five unvaccinated adult children who'd "talked Mom into not getting vaccinated, or certainly influenced that decision." He suspects she would've been fine with getting the shot, but her family convinced her otherwise. "The opinions and beliefs of her children impacted her opinion on getting vaccinated, and she, unfortunately, ended up dying from COVID."
He treated another older woman brought to the ER, "and as I'm talking with her... she said she'd made a huge mistake in not getting vaccinated. And if she survives this she's going to make that her cause, try to get her friends and family who aren't vaccinated to get it."
The decision to stay unvaccinated doesn't just impact the individual, Fales says. "It has far-reaching impacts on friends and family, everyone else."
Fales then recalls how, when the trucks loaded with vaccine had just started rolling out of Pfizer, he had concerns that Kalamazoo first responders might be vaccine-reluctant. He was in contact with a retired public safety lieutenant, "an anti-vaxer since before the vaccine," who'd been hospitalized for a month at the end of 2020, "sick as can be."
"He was a cops' cop, he was on the SWAT team, a super physically fit kind of guy." Fales spoke with him, and it was obvious the disease left him physically and emotionally depleted.
Fales helped put together a video to encourage Kalamazoo first responders to get the shot. For part of it, they interviewed the retired officer. "He was in his hospital bed, and he just gave this really impassioned plea to get vaccinated," he says. The former officer delivered a straight message of, "I thought this was all hyped-up. I thought it was political. I had no intention to get the vaccine. And then I got (sick), and let me tell you how bad this thing was," Fales says. In the video, the man was breathing with difficulty from his hospital bed.
Seeing this known fellow officer going through his struggle, and changing his mind about vaccines, helped others change theirs, Fales says.
When changing minds about COVID, "The messenger matters. I think we've learned that over and over again," Nettleton says. The message needs to come from, "Someone who that person trusts."
Nettleton adds, "I also think that calling out people with misinformation in a public manner that may embarrass that individual is counter-productive. There may be times when that is productive, but we've talked about when we've seen our friend post something on social media that is just flatly false or misguiding. It's tempting for me to respond to that, to call out that individual."
"A better approach would be reaching out to that person privately and having a genuine authentic conversation. 'Hey, this concerns me, this is what I'm hearing you say, this is my background, the information you're sharing is false, and here's why, and what my recommendation is for you and your family.' I think that's a better approach."
He points to Surgeon General Dr. Vivek Murthy's
recent guidelines for talking with others about health misinformation: "Listen. Empathize. Point to credible sources. Don't publicly shame. Use inclusive language."
What will the future bring?
During these interviews, new case rates were peaking. As of
Jan. 31, case rates are dropping in Michigan.
Nettleton says during the peak, "We are still at a very high case rate with Omicron. We are still evaluating its effect on hospitalizations and death. That's to be determined. Likely less so than Delta. Delta, we had our highest surge, highest hospitalizations, highest deaths, in October, November, December."
Nettleton reminds us that what happens in Kalamazoo is determined by the rest of the world. New variants may arise somewhere on the globe. "Where we are going will depend on several factors. The less that people are vaccinated or who have had prior infections (leading to some immunity), the more risk for another variant to emerge."
We may see the pandemic transition to an endemic phase when the virus is always present. "For me, that's when morbidity and mortality related to the disease is no longer above an expected level," Nettleton says.
Surges that health systems aren't ready for don't happen when a virus is endemic. "Seasonal influenza, for example -- every season our cases go up and down, people get hospitalized, people do die from influenza, but it's predictable... and there are flu vaccines to prevent that. We're not there yet at all with COVID-19, but we may be heading in that direction. It's just harder to predict when new variants emerge."
Nettleton has some optimism for the summer. People won't be indoors as much, and combined immunity from people who are vaccinated and people who've caught the virus and survived, will lead to "overall immunity that we'll have as a county and as a state, and hopefully, that engenders enough protection where we don't have these spikes in hospitalizations and deaths."
Fales wonders if "this awful term, 'herd immunity,'" could arise thanks to the rapid spread of Omicron, that if people refuse to get vaccinated they'll at least have some immunity after the illness.
Of course, everyone should avoid the virus, don't seek it out. "I wouldn't want to suggest that's even an option.... The old chickenpox parties, get all the kids exposed at once," Fales says, is definitely a bad idea in the case of COVID.
He points out that two years of this pandemic have led to many treatments for those who get ill from COVID. "But it requires you to take action, and with some of these (therapies), you have to start treatment within days in order for it to work."
A fully-boosted vaccination is a person's best bet. No one should think, "'Oh, I'm not getting vaccinated because I know there are good therapies out there.' The therapies are the fire extinguisher, so why don't we try to prevent the fire," Fales says.
Rutherford seems a bit more pessimistic after seeing the response to this global emergency, even if cases drop.
"It just seems to be the nature of human beings to just think, okay, everything's better, and we just go back to our normal ways. Which most of us want," he says.
"This is going on all over the world -- as a species or as a culture, we're just not prepared for a pandemic with a very high rate of fatality. Based on what I've seen, and again I don't want to sound pessimistic about human nature, but based on what I've seen with politics and lack of (societal) cohesiveness, it doesn't give me a whole lot of hope that we can handle a mass epidemic or pandemic unless we change some things."
Change what?
"I don't know. I mean a lot of it is the timing, where we're at politically, the polarization that exists, I think is a big part of that."
Rutherford adds, "This isn't just a public health issue, it's a human issue in terms of how we interact and how we go about our business, our politics."