A Conversation With Dr. Millard
April 15, 2020
Looking ahead and self improvement.
Before a viral outbreak in China became an epidemic, before that epidemic spread across the world and became a pandemic, and before it was even considered likely that the novel coronavirus, that causes COVID-19, would even appear in Valley County, the County Health Officer Dr. Anne Millard was already preparing for such a scenario.
That is because Dr. Millard had seen a need in the community over two years ago and filled her already sparse spare time with earning a master's degree in public health at the University of Montana in Missoula. She has taken the classes online, which have included public health administration-like issuing health orders and managing government affairs-epidemiology and environmental and rural public health.
"Actually, interestingly enough, I'm currently doing environmental and rural public health, and we just finished our disaster chapter," said Millard, laughing at the irony. "It's kind of like okay." She added that the real-world scenario was a serious way to learn the realities of pandemic diseases in rural communities.
Viewed from a health officer lens, Millard's foresight has better prepared her to take on the challenges faced by a potential outbreak of COVID-19 in Valley County. At press time, there have been no reported cases of COVID-19 inside the county borders and the county board of health is working to keep it that way.
Asked how the degree program has better prepared her for this real-world disaster, Millard responded, "Well some of it is more about a different way of thinking about this [outbreak]. It's thinking about the population and not individuals. What I do [in medicine] on a day-to-day basis is so individualized, but this is more about what's best for the many instead of best for the one. And that has been an eye opener."
Millard says she has had to consider so many different facets of life in Valley County, from the town of Glasgow to the rural and remote farmers and ranchers, when she makes decisions. Considerations like how they get food and water to how they deal with refuse and human waste have all factored in her public health decisions and directives.
"It also makes me feel much more responsible for everyone who lives in the county than I used to," explained Millard. "I used to feel responsible for my patients and the things that are going on with them, but now it doesn't matter, you live in my county, you're my responsibility."
The degree has also prepared her for what to do in this scenario. In every disaster there are methods and procedures for dealing with the health and medical fallout. Millard said the classes have made her aware of those methods and how to put them into action. She says she would not have had the tools or even known about them without her graduate training.
She pointed out that a degree in public health is not a requirement to be the health officer. In fact, she says, it's not even a requirement to be a medical doctor, and some health officers around Montana are veterinarians. Millard implied that without the tools she has learned in grad school, she would have been worse off in responding to the pandemic and limiting the public's risk of exposure.
Since taking over as county health officer in July 2018, there have been some events on Millard's watch, like a "rabies thing with the baseball team" and "a few other quirky things" but that this pandemic "wins as the biggest and busiest" she has ever had to be as county health officer.
Asked what the differences are between managing a disease outbreak in a rural community versus a city, Millard said managing a pandemic in a rural area is easier. Mostly because everyone is already spread out from each other, she said. Diseases are spread in a few ways by human-to-human interaction-touching, coughing, sneezing, etc.-or it is spread by animal or insect vectors-mosquitos, rabies and so on-or through other environmental factors like tainted water. COVID-19 is spread by human-to-human contact through respiratory secretions and, as a result, that spread out population makes it easier to limit personal contact.
She caveated saying, "The bigger issue here, is our access to testing is a little bit less, because of the way it has to be done. We just don't have the equipment here yet." The hospital has been looking into acquiring a polymerase chain reaction (PCR) device that can detect COVID-19 by looking for the virus' RNA. Millard hopes to have the machine in place and working by fall. That way, in case the virus is still around then, testing can be done more quickly and locally.
With a PCR, the hospital could perform tests without the need for special swabs and media for keeping the virus alive while it awaits testing at the state lab, which would cut down on sparse resources and speed up testing results. The device could also test for the flu, strep and other diseases, adding to the hospital's overall capabilities.
Early Action Likely Helped.
As a result of her training, Millard was placing health orders in Valley County before the governor had implemented similar orders for the entire state. So, as the virus was spreading in the state's more populated regions, many people here had already cut back on social engagements, congregating in public spaces and close social contact. Millard hopes those early interferences with the virus' spread will prevent widespread infection in the community. She is optimistic with the county's situation even though she knows it appears to be spreading in neighboring Roosevelt County.
Another benefit of the training has been key in convincing the county government-like the Commissioners, Sheriff and others-to accept public health measures and buy-in to their implementation and enforcement.
"It's really easy right now," said Millard, referring to the county's acquiescence to the orders. "I can sit here, and I can put out an order for health, but that doesn't mean that everyone agrees with it or supports it, and if you don't have the support for it, they don't work."
Millard stressed that she has had to convince others to come together and agree on measures that would be both effective and acceptable to those involved before putting out the orders. In fact, Millard says, she prefers to have a voluntary compliance from the public instead of mandating and enforcing measures with legal action.
"I will say that I always believe, if I have options, in using carrots instead of sticks," said Millard. It was that mentality that led Millard to put out health recommendations in the beginning of the county's response, but she quickly upgraded those measures to directives when it became apparent that large groups were not taking heed of the guidelines. Since then Millard has turned more quickly to health orders but has still relied mostly on "good-faith" compliance among community members.
Is the End in Sight?
When she spoke to the Courier, world leaders had two opposite opinions. President Donald Trump was hoping to return the country to normal as soon as possible, while the Prime Minister of Canada Justin Trudeau cautioned that things would not entirely return to normal until a vaccine was available.
In regard to the opinion that this pandemic could continue for months up to a year and a half, Millard stated, "I really hate that idea."
Millard does not think people can manage with an open-ended restriction until a vaccine can be created. She said she thinks it would be "very, very hard" to keep the strict restrictions in place that long. Instead, she expects things will loosen up some by then, allowing work and non-essential businesses to restart. She does expect social distancing and masks to be in place for some time though until a vaccine or treatments are created.
"A vaccine will mostly solve the problem, as will adequate preventative treatments," said Millard. A vaccine could be over a year away, she said but a treatment could be more readily available. Experiments with the plasma of recovered patients are being conducted now and Millard said, in the past, elements of plasma have been used to artificially introduce antibodies into sick patients for other diseases.
"That's certainly another thing," said Millard. "I don't know if they'll get anywhere, I certainly hope they do."
People should plan on fabric masks and social distancing to be around for some time in the United States. Especially as those measures continue to be effective in preventing the spread of the virus, at least until other control measures become available. Currently, the Center for Disease Control says that social distancing is the best method for preventing coronavirus spread and that masks are most effective in preventing a sick person from spreading the disease to others. In other words, masks only work if everyone uses them.
The President and Governor Steve Bullock have recommended people wear masks when out in public and in settings where social distancing is difficult to maintain, like the grocery store or other confined space containing multiple people.
Why Not Test More?
A contentious issue has been testing numbers. At press time, the last available numbers said 34 tests have been returned to Frances Mahon Deaconess from the state lab. All of those tests have come back negative. Still the low number has upset some who think the county should do more to detect the virus early.
Millard does not view those numbers as a problem, and she said the debate on whether to test more has been occurring among the county's health care providers. In the end, the county has weighed their options and decided not to increase testing for a myriad reasons.
"There are reasons to do it and reasons to not do it," said Millard, "and right now the not doing it reasons kind of override the doing it reasons."
One of the reasons not to test more, is a limited supply of the required swabs to collect the samples and prepare them to ship. Millard said she was grateful that the requirement for a specific kind of transport media, which keeps the virus alive until testing, was replaced with a more accessible alternative. But the issue of having enough swabs persists as hospitals across the globe seek out the specific and limited type of supply needed.
The other issue is what to do about detection. Even if testing identifies community spread, she said, nothing would change. Basically, if people are found to have the virus, then they would be sent home to treat their symptoms and isolate themselves from others. The only change to anyone's daily life would be if they had close contact with the infected person or if their symptoms became so severe, they required hospitalization. Otherwise, Millard said, social distancing, quarantining, washing hands and avoiding crowds would still be the norm for Valley County residents, so testing to detect would not be necessary.
"What you do for symptomatic people is you treat them symptomatically, we're not going to hospitalize them. We've already told everybody to stay home and the only way to prevent it from spreading that way is to stay home," stressed Millard.
Besides, she said, to detect it you would have to test almost everyone in the community, and you would have to do it weekly for it to be guaranteed. That would be impractical and would burn through already scant resources with little to no benefit.
The other hurdle to widespread testing is the state's priority testing queue. Once the sample gets to the state lab, it is prioritized. Priority one being hospitalized patients and symptomatic health care workers; two being those with symptoms and in long-term care, over 65, have an underlying condition or are first responders; priority three are symptomatic critical infrastructure workers, anybody with symptoms not already listed and non-symptomatic healthcare workers and first responders. Non-priority samples are those regular citizens without symptoms or direct contact.
Millard added that a priority-three sample sent off by FMDH had taken over a week and a half to return from the lab. Once that amount of time has lapsed the test is irrelevant because the patient may have contracted the virus since the test was administered or they may already be recovering from the infection. A negative test does not mean a person will never contract the virus; it merely means they did not have it before the test was administered.
"I understand why everybody wants to test," said Millard. "I understand it and I'd love to do it, if I just had a way to do it."
Once a case is detected in Valley County, the health department would be testing primary contacts and monitoring secondary contacts for symptoms, she said. She added that any of those close contacts could be ordered to quarantine if needed, but that until there is a case, testing randomly to detect spread is not possible.
Millard did say that it would make sense to test groups of people that are in contact with or members of a vulnerable population group, even if they were not symptomatic but have been exposed to someone who had tested positive. Places like assisted living facilities and nursing homes would be among those populations.
People begin to get sick, four to six days after exposure explained Millard. That timeline can be as fast as 48 hours or could take as long as two weeks. For that reason, slow testing can be irrelevant and, Millard says, you can also make a case for monitor and watchful waiting by looking for symptoms and checking temperatures and then testing if people get sick. That is especially true for those close to already confirmed cases.
According to Millard, a person becomes contagious about 12 to 18 hours before symptoms manifest and even then, they can be relatively mild for three days before increasing in severity over the course of days. The short contagious period with none to mild symptoms makes the period of spread before people get tested a fateful part of the virus' pandemic status.
While discussing testing, Millard noted that few people had arrived at the clinic to be tested for COVID-19 and that they had screened more than just the 30 that were tested, but she does worry that people may be mildly symptomatic and just not reporting to be tested for any number of reasons. That scenario could have implications for controlling the outbreak in the county.
Along that same line of thought, Millard does think the virus could be kept out of Valley County if everyone does the right things all the time. Millard stressed that in order for that outcome to become a reality it would require everyone, to include those traveling through and arriving for work, to adhere to every single directive, recommendation and guideline.
Millard said so far, contractors, pipeline workers and other crews have been very responsive to isolating and quarantining measures, but that shutting down the highway or checking everyone entering the county is near impossible.
"If you can do all these things that we ask you to do, and-I mean, it has to be everybody and with Easter I know that makes it really hard because everybody wants to be with their families, I know that-but if you don't do these things you risk your family," said Millard. "You risk losing those members of your family before you are supposed to lose them."