Thomas Weiser - Session 2

Q: It is Friday, October 21st, 2022, and this is Mary Hilpertshauser for the COVID Memory Archive History Project. I’m in Los Angeles and I am talking with Dr. Weiser, who is still in Portland. Correct?

WEISER: Yes.

Q: This is our second session.

WEISER: Yes.

Q: We left off talking about Native Boost [Boost Oregon], which is a program to get people to trust vaccines. Is that correct?

WEISER: Yes.

Q: So, let’s start off with when the pandemic hit and the first iterations you saw of the pandemic.

WEISER: Sure. I had been kind of paying attention to some reports from December and early part of January about this novel virus in China. And so far, we didn’t have any cases here. I was already feeling nervous and a little scared because it sounded a lot like SARS-CoV original, which we only had one at the time. And now I call it SARS-CoV-1 but I think I’m the only person who calls it that. It’s still called SARS-CoV. In any case, I was kind of paying attention to that and wondering when we would need to make any kind of a response or you know, what clinicians in my region would need to know about that particular outbreak. I had been doing this for quite a while so our clinicians, we have a face-to-face meeting twice a year, and my spiel is to give the epi update. In that I talk about the things that are of emerging importance in our area. Then I also will focus a little bit more internationally. For example, I’ve talked about MERS [Middle Eastern Respiratory Syndrome] to this group. I’ve talked about Ebola to this group. Things that, you know, we never really dealt with, but I just thought these are the things that I’m watching. That was kind of usually the title slide. We had our last face to face meeting with them in November of 2019. We would have monthly updates by way of a web call, and I think I had already been thinking about, it’s time to start talking about this with them.

The first entry in my notebooks about this was on January 27th – Oh I need to turn that off, let me just turn off this real quick. So, the first entry in my notebooks about SARS-CoV-2 was on January 27th. You know, I didn’t look at the details of why I made those notes. I’m sure it was an update of a webinar or something like that, that we were getting information from. Then on January 30th is when I began what I thought would just be a series of weekly updates to my area clinicians, and I’ll read an excerpt from that because it’s probably kind of helpful. It starts off, “Welcome to the first weekly update from the Portland area IHS [Indian Health Service] regarding the novel— 2019 coronavirus outbreak. Our goal is to distill information for you on a weekly basis to minimize some of the email traffic you receive, allowing you to focus on information that is most relevant to your clinical operations.” Well, one problem with that paragraph is it says we but it’s just me. [laughter] I don’t have a team necessarily. Then I have a couple paragraphs giving the background, and then in each of the subsequent issues of this little newsletter I keep all of that at the front. Then I have a bunch of links from our state health departments, and then each week as there’s something new added I would add those in and highlight them so you had all the old information plus what was new. It could be readily gleaned from looking at the highlighted information. One thing I noticed is that we have three states that we work with. Oregon, Idaho, and Washington.

Each week there were more entries under Oregon and Washington. I don’t know if I didn’t pay close enough attention to Idaho or if I did— I don’t recall if I did due diligence to look every week at what Idaho’s updates were. In my newsletters there were no updates from Idaho after the first one, which was just a health alert. Idaho, you know, unlike Oregon or Washington doesn’t have a port necessarily so it was less affected by I think any risks of international transmission or people coming into the country. Maybe they felt like they were not quite as affected early on. We tried to mostly link our clinicians to the updates that were coming from the states because our clinicians are going to be reporting cases to the state or to the local health jurisdiction if they happen to have any kind of case. They need to really know what to do and how to do it in their context, their local context. Fast forward to March, where we had the stay-at-home orders and all of that stuff, one of the issues that became a struggle for me personally and for us in our area was sort of a top-down directive that we were only going to share information from CDC [Centers for Disease Control and Prevention]. CDC was putting out the best information, I believe, that they had access to and available to them. As I said, our clinicians also need to know about the local situation and what to do locally. Because that’s where they’re going to be reporting cases. That’s where any help is going to come to them. It’s going to be from the state or from local health jurisdictions. We had some heated discussions, let’s say, [laughs] about whether we could only provide information that was from CDC or whether we had some latitude or discretion to provide information from these other sources. I argued pretty strongly that we needed to do both. There was no reason for us to limit it. There was distinct reasoning – a distinct need for us to have local information. Officially we were kind of bound. We could only repeat what CDC was telling us we could say or was happening. I looked for unofficial channels to be able to put information out. I think these newsletters stopped on February 28th. That was the last one that I could find on my computer, I think it’s the last one I issued. Because by then it became impossible for me to distill all the information and share it with everybody once a week. Things started to move so much faster.

I was talking earlier about Idaho. One of the things that Idaho and Washington were doing early on and making available was, they began reviewing newsfeeds and the latest literature and things like that and putting out, initially daily and then eventually weekly, distillations of that information. That was immensely helpful. I think under the direction of the CEFO, the Career Epidemiology Field Officer, in Idaho, these weekly or daily initially, kind of updates on information from published articles, from various news sources and reputable websites, became really valuable. Because that was a place, like a little digest every evening, I could get the digest and then kind of look through it and maybe learn something for the next day that I could then share with others.

Q: Who prepared these? I mean, how did this information get shared? Also, when you say we and they, who are you referring to?

WEISER: Okay.

Q: Let’s start with we and they.

WEISER: Okay, give me just a second. Because I always have trouble with names. [laughter] Can you pause for a second?

(pause)

Q: Alright. Go ahead.

WEISER: Kris Carter. K-R-I-S Carter, she’s the Career Epidemiology Field Officer so she’s the CDC assignee to the Idaho Department of Health and Welfare. She and Michelle Griffin was the other person that was working with her I think, they would send out these daily digests. And those were tremendously valuable because that would come as an email right to my inbox and I could click on it and then I could just scroll through and look at it. For Washington and I think Oregon was doing this too, it was a place on their website you had to navigate to. [laughs] It wasn’t as readily available. You would have to go search for it. But this was something that would show up in my email box that was really helpful. I have to admit, I didn’t read all of them. Maybe only about ten percent, but when I did read them, I always learned really useful information. There’s just so much out there. I think maybe they were working with some other site too, to put those together. Maybe they were just passing on information from another source. I’m not sure. Wherever they got it from, it was extremely helpful.

Q: So, besides CDC giving you information, you got information from these sources.

WEISER: Yes.

Q: These are more local sources?

WEISER: Well, what was produced on the digest from Idaho was actually, you know, the latest research. So not just local stuff. It was national and international research. You know, links to articles and JAMA New England Journal and other places, MMWR’s [Morbidity and Mortality Weekly Report]— they always gave a little synopsis of it too. The one takeaway from all that was each synopsis would always have at the second or third last line, “The authors opined,” [laughs] about something and nobody uses the word opined really that much. Every single one of those always said the authors opined about what this means, and I thought that was interesting.

Q: How long did those last?

WEISER: They’re still coming out I think about once a week now. So less often but still available. We recognize, and I say “we”— we, was myself and our Chief Medical Officer at the time, Andrew [J.] Terranella, and Andrew now works for CDC in their opioid prevention on the pediatric opioid response. So, Andrew was our chief medical officer. I was the medical epidemiologist. We also had our CDC assignee, Alex [Alexander] Wu, EIS [Epidemic Intelligence Service] officer. So that was mostly the “we” that I refer to. Then the Northwest Portland Area Indian Health Board were, I was still going there every day to work. You know, we also had a team of folks there as well. Mostly Celeste Davis, who was the Environmental Health Lead for the health board at the time. The four of us would share information between ourselves and try and get together and discuss what might be important. This became kind of the way that we got information to the tribes eventually. Once there was a total declaration of emergency and, which I think was March 13th, then we had our incident command set up. That was for the Portland Area Indian Health Service.

In the weeks leading up to that, I did approach our area director to see if we could have a combined incident command structure that would include myself and our counterparts. Plus, my colleagues at the Northwest Portland Area Indian Health Board as well. Because I thought that would be the best way if we combined into a single incident command, that we could have, you know, a better way of communicating information and keeping everyone up to speed. I don’t know if it was an internal decision or if it was directed from a higher level like IHS headquarters, but we were not able to have a combined incident command. The area office had its incident command and then the health board had its own incident command. I was on both [laughs] so I had my own combined incident command, but [laughs] we weren’t always acting together. Part of the difference for that is that Indian Health Service, the area office has its first and foremost responsibilities for the six facilities that we directly operate. Then secondly, to support the rest of the tribes as much as they can with whatever resources and funding was left to the area to distribute or to manage for those tribes. Many of the tribes have taken portions of their funding to operate, for example, behavioral health services or diabetes programs or other programs, and so those funds don’t exist at the area. We don’t have any ability to manage or direct any of that funding or those programs. Those are up to the tribes then. The health board then, the Northwest Portland Area Indian Health Board, represents all forty-three tribes. Including those that have their operations directed directly by IHS. The tribal representatives, tribal delegates from each of those tribes are on the Northwest Portland Area Indian Health Board and so the board is responsive to all of the tribes and has an obligation to provide information, funding, direction, to all of the tribes. Now when I say direction, I use that term loosely because each of the tribes is a sovereign nation. They determine their own priorities and how they’re going to respond to whether it’s a public health emergency or an ongoing program like the diabetes program. It’s up to them to determine how that’s going to be operated and how they’re going to use the funds that they’ve received for those operations. In my role as the medical epidemiologist, in general my role is more as a consultant to the tribes and to the Northwest Portland Area Indian Health Board.

For our six directly operated clinical sites, I don’t really have a direct line of authority but under the ICS [Incident Command System] structure I guess and with the backing of our chief medical officer, then I could say things that people would have to do. I don’t generally give orders, which [laughs] some might expect since I have the rank of captain on my collar. If they see me in public they think, well a captain (equivalent of Colonel in the land services) would command an entire military installation in the Army or the Air Force. I do not [laughs] and I don’t have any staff that I direct other than my CDC assignee, my EIS officer. Which I’m extremely grateful for because having the EIS officer with me and available to me gave me like, it was a way to double my capacity. I really appreciate having those colleagues.

Q: So, after those first couple of weeks and months, how did the rest of COVID play out for you? One more question. Having so many incident command structures, did that create challenges in how you got your messaging out or —

WEISER: Yes. I’ll come to that in a bit. I’m going to start with what else I was doing in February. So, I was putting out these weekly, or I had kind of slowed already to like biweekly because I couldn’t keep up [laughs], updates to the clinicians. In mid part of February, February 11th, I traveled to Sacramento to join the California Rural Indian Health Board, another board like ours to meet and have a discussion for a couple of days about maternal mortality review committees. This is the kind of work that I was doing when all this happened. Then later in the month on February 25th I was at the ACIP [Advisory Committee on Immunization Practices] meeting, which I think was Nancy Messonnier’s last public appearance, or maybe the weekend after that. At that meeting, there were two things that happened and one of the things was Nancy gave us the straight talk about what we were facing. I think everyone in the room appreciated that and was already recognizing that that was the case. That we were in for a major pandemic that we weren’t going to be able to readily control. The entire room stood and applauded her presentation.

Q: They did?

WEISER: Well, here’s why I’m not a great historian because yes, I think it was at that meeting. I’ll have to double check, but yes. I think they all appreciated her giving us the straight talk. That standing ovation may have happened later, but I think it was at that meeting. It must have been because we hadn’t met face to face since and I haven’t been to a face-to-face meeting. It was at that meeting.

Q: So, at the ACIP meeting?

WEISER: At the ACIP meeting after she gave her statement, everyone stood and appreciated her. It was kind of a moving moment because it was like, you know, okay it wasn’t as dramatic as Henry the Fifth’s St. Crispin’s Day speech [laughter] but it was maybe the closest you get in public health to that. It was like, okay we’re hearing what is coming and what we’re going to be in for. What’s that?

Q: How did people react to that? I mean, in the room?

WEISER: I think we all listened attentively, and I think the main thing we appreciated was hearing the truth. Which we were all suspecting was the truth but hearing it from her. You know, most folks in the room are vaccine experts but they’re also public health experts and many of them are epidemiologists. This is the kind of thing that we’re all kind of prepared for. We know that vaccines are going to be probably the most important tool that we get. I think at this time it wasn’t clear like how quickly a vaccine could be developed but one of the things, you know, is that within just like ten days of identifying the virus we had it sequenced. That was a kind of a world record, because for SARS-CoV, that happened in 2003. It took three months to do that.

Q: Why was it so quick?

WEISER: Well, I think the technology has improved in the period of time and so it was sequenced and shared within ten days. I think that was a real key thing about being able to then take that sequence and be able to make vaccines using that sequence and recognizing which of the areas that we need to focus on. The science moved really fast. I know there’s a lot of debacle and you know, complaining about CDC’s first tests not working properly. You know, at the time it was a huge setback and it really affected trust I think in CDC. But when you look now, two and a half years later, those first tests were so small compared to all the tests that we’re doing now. I mean, the millions and millions of tests that happened. While it would have been really critical to have more testing earlier on, I’m not sure how much of a role that goof up made in the overall ability to get testing developed and rolled out.

I think there were for whatever reason— the supply chain issues began early on too and I think that was in my weekly updates. By the second or third one, I had already been communicating to our clinicians that PPE [personal protective equipment] is hard to find. They hadn’t released the national stockpile until later on but for our sites to be able to get updated PPE, N-95’s and things like that, it was already becoming hard to find in early February. Testing supplies, we began to have difficulty with getting the swabs and the transport medium and that kind of thing. To be able to do the testing, which all had to be sent to the state. The process for getting a test, in Idaho you actually had to call the state first before you sent any test because they were prioritizing testing. So, you had to get it cleared that this was a priority patient and then you could send the test to them. And the other states didn’t require a call but they did require this form or two forms to accompany each sample. Those would be reviewed, and if the patient met the criteria, then they would run the test. If they didn’t meet the criteria, they wouldn’t run the test. Early on there was very restrictive testing because it was an asset that we had in short supply. In hindsight, you know, it was that approach that really made all the difference in allowing the virus to spread unchecked. Because we were missing so many people that could have been tested and might have been positive asymptomatically or pre-symptomatically. The focus on only testing symptomatic people was one of those things that really, if we could do it all over again that’s the thing that I think we would want to do differently. Is have our tests developed faster and not run into shortages of swabs and either the liquid viral transport medium that’s required for the swab to reach the lab. Eventually we got permission to use just saline, which that was available. That was a game changer because it allowed us to test more people and get around that supply chain issue.

Q: Testing was important because— why?

WEISER: Our only tools in the first months of the outbreak were to identify cases and make sure that we got back to that case, found that case, and had them isolate so they would stop spreading the disease. If they were indeed not that sick or not symptomatic at all, we needed to communicate that their test was positive and they needed to isolate. And then we needed to get the interview process going so we could interview them, find out who their contacts were, and monitor them. Put them in quarantine where we could monitor them for signs and symptoms. If they developed signs or symptoms, then we would test them. Our early tools were identifying cases, isolating them, doing contact tracing, quarantining those contacts, and all that depended on that test. That was the first thing that we needed to have happen. Then for folks who may have been around someone, there were masking and social distancing recommendations that came out. You know, about mid-March or so is when that really took on a greater importance. We had the different stay-at-home orders from the different states and that sort of thing. It was in early March, I think a couple days before that, maybe March 10th, I was planning to go on vacation with my family. We had a spring break planned. We had tickets to go see my wife’s family in Japan and it became quite apparent to me that I was not going. [laughs] It also became apparent to me, I think, that the best thing for my daughter and my wife to go. And my daughter’s a senior in high school at this time and I just had to tell her pretty frankly that, “Honey, your senior year is toast. Take everything with you. You’re going to Japan with Mom. And I don’t expect you guys back very soon.” They left around March 10th and my daughter was gone until the summer, so until I think it was July when she came back. My wife stayed there even longer. She came back after eight months. It was later in the fall that she came back. Yes. That was an added hardship for me in some ways to not have my family with me. It was also a relief because I didn’t have to worry about them or you know, I could focus full time on what we were doing. What I was trying to do. I could go to bed when I wanted to [laughs] and that sort of thing. I just didn’t have the support of someone who could help with cooking and you know, things like that. So, I was on my own for some of the daily essentials. I also didn’t have the interruptions that I would have probably normally had and probably welcomed and maybe even benefitted from [laughs] by not having my family there. But also, Japan is a completely different case study. In Japan it’s not controversial at all to wear masks. It’s always been common if someone either feels ill or feels like they might get something from somebody, they’ll wear a mask to protect themselves or to protect others. There is no stigma about wearing a mask at all. In Japan when, for the most part, when the government would declare a lockdown or a quarantine or stay-at-home orders, at the beginning especially there was ready 100% compliance. Everyone did what they were supposed to do. That’s pretty common in Japanese society in general. There wasn’t protesting and that kind of thing. Even though Japan had cases, they also had I think more testing than we had earlier on. They and South Korea and other countries in Asia learned from the first SARS outbreak how important testing was and isolation and quarantine and rapid response to that. I think they did a better job in the early days of doing that.

Q: So, did you feel a little isolated though?

WEISER: Yes, absolutely. Absolutely. Emotionally, it was difficult because yes, I didn’t have much social interaction. I will say however, I live in a co-housing community, which means that we’re like a condominium but we’re self-managed. I was also getting asked to provide guidance for my neighbors [laughs] as well. Like, can we use the common house? Are we still going to have our potlucks? Are we still going to have our once or twice a week community meals? Things like that. One of the worst was telling them masks are still not recommended, we don’t know if it helps or not. Then like an hour or two later, “Everyone make masks.” [laughs] “Go buy fabric, go buy elastic bands. Start making masks. Here’s designs.” Then you know, maybe an hour or two later, “Well, it might not work that well.” [laughs] Whereas my wife in Japan is like, “You guys are so dumb.” [laughs] “Masks work. And even if they don’t work that well, they don’t hurt anybody. Why aren’t you wearing masks?” I was like, yes. Like always, my wife is always right. [laughs] Okay, yes, everybody just make masks. We had people who were, in the early days, were staying at home. We’re complying with the orders. We want to do something, and so making masks for ourselves, part of it was making masks for healthcare workers who were running out of PPE. It was like, should we be doing that for people at the hospital that’s down the road from us? Or people always want to help the tribes and so they wanted to make masks that I could then send out to people. Actually, some of the best masks were made by some of the folks in tribal communities who also were making masks and are great at sewing. There’s a lot of traditional sewing that takes place and so I think some of the best masks came from those communities anyway. There was that confusion about what works, what doesn’t work, what should we do, what shouldn’t we do, you know? As individual citizens and officially as federal employees and that kind of thing.

Q: Why do you think there was so much confusion in the very beginning of the masking? Not masking, masking— yes, we’re masking, well maybe some masking?

WEISER: Well, there were conflicting messages coming from CDC. Since that was our only source of information that we were allowed to share, you know, it was kind of like a lot of people felt like yes, masking makes sense. We should do that. It doesn’t hurt. But CDC hasn’t said it yet officially. Then you know, it was sort of a lukewarm recommendation of you could wear a mask if you wanted to. People may wear masks, rather than should wear masks. In our healthcare settings, that was different. That was a little bit more— well we weren’t wearing masks in the healthcare setting initially, everyone. Only in the area where we were seeing potential COVID patients, so seeing respiratory patients. Then it was, a mask or an N-95. Then OSHA [Occupational Safety and Health Administration] regulates N-95 use for employees in healthcare settings and other employment settings. There are rules and regulations about wearing an N-95, it’s not a mask it’s a respirator and it’s regulated by OSHA. Our employees who were asking to wear N-95s all had to be fit tested to demonstrate that they are wearing the right size respirator, that it has a good seal, and that it’s actually providing the protection that it’s supposed to. That’s why they have these regulations. Because if you wear an N-95 that’s too big or too small or doesn’t fit properly, it’s not providing you the protection that it’s supposed to.

The protection comes from filtering through the face mask, or the filtering part of this respirator. If it’s got gaps on the side or over the nose then the pathogens are going to follow the path of least resistance and they’re going to come in through those gaps, and you’re no longer protected. But we hadn’t done a mass fit testing for our staff. We found that there are two ways to do it. Many large hospital systems have a qualitative, testing systems and CDC has this, they have a machine, you hook up a tube to the N-95 and you breathe through it. It tells you, quantitatively, I’m sorry, how much of a seal you have and what the pressures are and things like that. Most places, most small healthcare places, which we are, use qualitative testing. That means you wear the mask, you put on a hood, and you spray something and see if you can taste or smell it. We usually use saccharin spray, which will taste sweet if it gets into your mouth. Well very quickly, there was a shortage of those sprays that are used for fit testing. We had [laughs] that constraint as well. We had one of our six service units had an extra set of sprays, and so we then mailed those around to the different sites. You know, sent it to one site, when they’re done with it, they sent it to the next site, send it to the next site. Trying to rapidly get all of our staff fit tested that would need to be fit tested to wear N-95s.

We had a lot of N-95s in a stockpile from H1N1 [H1N1pdm09 virus] and these had variously gotten extensions of their shelf life for being still functional. They were kind of running low [laughs] on their shelf life but the ones we had were still valid to be used. Those were what we were able to use initially, and we were able to use our— IHS runs a national supply service center located in Oklahoma City. That’s kind of our main clearing house for supplies and medications and vaccines and things like that. We were able to get some things from them. Once stuff started coming out from the national stockpile, we could either get them through that source or through our states. Both of them were getting allocations [from the stockpile], and so that was helpful. In short time we had boxes and boxes of N-95s and one of the things I remember thinking was, yes, we need these for our staff but we’re not doing critical care for very sick patients. We stopped doing any aerosol generating procedures within our clinics so the need of having to wear an N-95 to avoid any kind of aerosolization was really low. At that time, hospitals and things like that were really in need. I felt like, I wonder if we should redistribute some of these to our local hospitals. You know, we didn’t do that because if we gave those away, we wouldn’t know when we would get more back. We continued to use what we had for staff.

Q: You never experienced a shortage?

WEISER: No, I don’t think we ever experienced a severe shortage of N-95s, masks, or gowns. We were impacted by the shortages of vaccine transport medium for a short time until they said, well you could just use saline if you have to. That allowed us to be able to do that. I think we did have short term shortages of the swabs as well, but the folks in Oklahoma City at that center were able to reach out. We had additional spending authorities to engage in contracts that allowed us to reach out to other vendors that we hadn’t normally worked with. Sometimes paying through the nose and then of course there were a lot of allegations of fraud from some of those vendors that jacked up the prices of things in order to make them available to us. You know, we didn’t have much of a choice. If we really needed something and there was only one or two sources to get it from, we just had to pay the price.

One of the other things that I spent a lot of time thinking about and not knowing really whether we could or how we could do something, was we were seeing the pictures from China initially and then from New York City that these patients were being put into these temporary facilities. Temporary hospitals. Field hospitals, if you will. In China, it was if you were exposed then you were put into these quarantine, mass quarantine centers, right? We didn’t have anything like that. In some of our pandemic planning there was allusion to being able to do that, but nobody really had concrete plans on how that might work. Once we had the emergency declarations and FEMA [Federal Emergency Management Agency] was brought on board, we quickly learned that FEMA would be the resource that we would turn to, to help us plan for setting up any kind of structure like that and would provide the material and the funding for putting it together. But they didn’t have a staffing package for it. That became, for me, the critical question. Like I think we could probably build this if we needed to in a tribe or at one of our facilities, but who’s going to staff it? Who’s going to be there twenty-four hours if someone is there and gets sick and needs to be seen by a provider? Needs to be transported somewhere? I mean, there were so many questions about that, and we didn’t have any experience or resource at that time to think through that. So, one of our—go ahead.

Q: In April, end of April, President Trump launches Operation Warp Speed and that is creating a vaccine.

WEISER: Right.

Q: Which is pretty early on, for April.

WEISER: Yes. Yes, I was part of that because I was on the ACIP representing IHS at the time. With that effort there were a lot more meetings that suddenly came onto my schedule. There was the COVID-19 work group for ACIP and I joined that. In addition, I was on other work groups, those other work groups really slowed their cadence, the pneumococcal vaccine work group and some of the other work groups kind of took a backseat to the COVID-19 work group. Because we were meeting like every week for a while and then every two weeks at some times. Then just before any new change or considerations were coming, then we were meeting sometimes twice in a week. We had the ability to have presentations from Pfizer, from Moderna, directly to the work group so that we could learn what they were doing. All of that was held in the strictest confidence. It was a challenge to hear what they were working on and not be able to talk about it outside of the work group. You know, I could only say that we heard from, maybe I could mention that we heard from them about the developments. But I couldn’t say anything really about any of the details. Being on the work group allowed me to be able to listen to all of the CDC experts that were also on the work group and be privy to their thinking. You know, what they were thinking about. What their considerations were.

Early on, discussions about equity were an important part of what the COVID-19 work group worked on. I really appreciated that because as we were by then seeing in April and May, how the Navajo nation was impacted early on by COVID and how it just rapidly spread through those communities. Which frankly was a bit surprising, because you know, I haven’t worked on Navajo but I’ve been around there and there’s large distances between the population centers on the reservation. Then many of the people live quite a ways from their neighbors. I mean, miles apart sometimes. But the challenge is they don’t have running water. They don’t have electricity. Communication is a challenge. They don’t have the internet in many of these places. There’s such a challenge of getting information to folks in those regions. If you can’t wash your hands, if you don’t have a ready water supply, you can’t wash your hands, then a disease like this is going to spread really easily. Even though there’s a large distance between houses out on Navajo, the houses are small and the families are large. There are many people living under the same roof. That’s not unique to Navajo, that’s true throughout Indian country and in our region too. I think that’s one of the issues that we faced early on with cases. That you know, sometimes we would have outbreak clusters that were related to an event like a funeral or some other social gathering. Usually, it was related to household clusters, because there were ten people in that household. When one person got it, it very quickly spread to the other people. On some level I thought, well I would have thought that maybe Navajo would have been more protected because of these large distances. It wasn’t really too much of a surprise how heavily they were impacted.

There were other stories we were hearing from other parts of Indian country. Where I started my public health service career with the White River service unit in Arizona, White Mountain Apache actually stood up their incident command and their response. They actually had some really early on great success stories. A big part of that was being able to mobilize a team to be able to go out and visit people in their homes. They had an article in, I think it was New York Times Magazine, if you haven’t seen that I think I have a copy or a link to that I can send. You know, one of the stories they shared was that they would go to see a patient that they knew had been exposed or had a positive test and they were following up on that person with a positive test to see how they were doing. As they made that home visit, they would look and they would see the elder in the kitchen in the corner who hadn’t come in for testing who looked sicker than the person they came to see. They identified that very ill person, were able to get them into care, and that was a big factor in the success of their home visiting program. Yes, they were able to follow up on the people they intended to follow up, but they found all these other people who were also ill or maybe even sicker than the persons that they were trying to visit. We were all trying to set up some kind of outreach to the communities by partway through March and April.

Our cases were really slow in starting. We had trickling cases in March but then by April we started to have more and more cases. We were trying to get ready for that because we had in our six service units, we have public health nurses in three of them that we manage. In the other three the public health nurses are managed by the tribes themselves. Those three service units that were tribally operated, only one of them really had public health nursing capacity at the time. The other two did not. They had a couple of community health nurses, but community health nurses are different. They’re the people who maybe help make sure someone gets oxygen for their chronic lung disease or wound care supplies or ostomy supplies and things like that. They may be doing home visits to check on people with chronic illnesses. They weren’t in the job of doing contact tracing and case investigation. Our EIS officer, Alex Wu, he got materials together through working with the states and from CDC and from IHS. He went out and he did trainings on contact tracing and case investigation in these communities so that they would be able to have a workforce that was trained and could respond. Early on, the states asked the tribes, do you want the local health jurisdiction to do these case investigations for your patients or do you want to do it yourself? I was a bit surprised that the vast majority of our tribes responded and said no, we want to do it ourselves. This was something they hadn’t been in the habit of doing. Whether it was pertussis cases or sexually transmitted infections or TB [Tuberculosis] or anything else, most of the time those things were being investigated and followed up and contact tracing done by the local health jurisdictions. The county health departments around those tribal lands. In some coordination and consultation, oftentimes the counties are— they don’t feel like they have the ability or the right to just go on the reservation and talk to folks. They always want to try and coordinate and get permission to do that. In this case, the tribes were saying no. I think they probably felt early on that this was an existential threat and they wanted to be the ones to really take care of their people. There’s also some legacy from H1N1 and some of the other past interactions with government that the tribes were understandably reluctant and skeptical the government would be able to take care of their needs.

I mentioned earlier about the ICS and the health board had its ICS and IHS had its ICS. In the health board ICS, they began a data collection of cases, testing and cases from each of the tribes. It was voluntary. Each day the tribes, and this is still ongoing, each day the tribes were asked to fill out like this survey— SurveyMonkey survey that gave the basic information about how many people were tested, how many people were positive, how many were negative, how many were hospitalized, and how many had died. We didn’t have 100% reporting from all of the tribes on that. Not on every day and not on any day. We only collected information when we received it and it was voluntary. We couldn’t compel that information collection. This was to support IHS’s effort to collect the same information. What IHS set up at a national level was a spreadsheet that would be completed every day and then forwarded to headquarters. Well, it’s forwarded to the area and the area person compiles it and then sends that area report or area spreadsheet to national. At the national level I think there was just one person who would receive these national reports and have to collate those national reports into a daily report. The information is only based on testing. It’s only based on the patients who were tested in our facilities. A site could report on tests that were done elsewhere that they knew about. Like, you know, we had three patients who got tested at the hospital this week and this is their results. They could add in that information. It was really about collecting on the testing that we were doing. We don’t know how many of those tests were conducted by us and how many of those tests were conducted outside of our system. Moreover, the tool was designed to be as quick as possible and tried to be as low of a burden as possible. There was no information collected on demographic variables or risk factors or underlying conditions or, when they became available, vaccine status. Those kinds of things. To this day, that’s the only information that IHS has.

Q: Oh, really? They didn’t get updated or adjusted?

WEISER: No. No. In a recent conversation with someone at, you know, one of the highest levels [laughs] in our agency, I confirmed this. I said, “So, if someone asked you for the age breakdown or the sex breakdown of our patients, you couldn’t tell them, could you? If they asked you how many of our patients were hospitalized or died, you couldn’t tell them, could you?” Because we don’t have that information. This is probably, for me, the most vexing part of our response, what hampered me the most as an epidemiologist. CDC and NIH [National Institutes of Health] use a system called REDCap [Research Electronic Data Capture], which is not that different than SurveyMonkey in the sense that you get a link, you open that link, and you have like a survey. You fill in the survey and then it goes to a server. Then there are some tools within REDCap where you can do data analysis or you can export it to SAS [Statistical Analysis System] or [Microsoft] Excel or whatever you want to work in. However, complex you are. You can do more analysis of that. You have certain functionalities. You have fields that are validated. You can only put in information like yes or no, not a mixture of yes, no, plus signs and minus signs. P or N or [laughs] Y or things like that.

There are data quality parameters set for the field so that you get consistent data, so that you don’t have to spend hours and hours cleaning the data before you can actually analyze it. Stop me if I’m getting too deep in the weeds of this stuff. [laughs]

Q: It’s okay.

WEISER: But for an epidemiologist, these are the kinds of things that you know, it’s like talking to a carpenter about the right kind of wood or nail or screw to use. Or the right kind of chisel to use for this particular thing. We need the right tools to do our job. So, NIH uses REDCap, they have used this for a long time for many of their research studies. It’s HIPAA [Health Insurance Portability and Accountability Act] compliant. It’s secure enough for NIH to collect very detailed information about people participating in clinical trials. CDC uses REDCap. Many of our states when their information systems for collecting cases, their usual systems became overwhelmed. There was just no way they could handle the volume that was coming into their usual systems. They turned to REDCap to be a way that they could offset that load and more quickly get the information they needed. If you sign up with REDCap, it’s free. You have to have the server and infrastructure and stuff, but you design your own data collection forms in this system to meet your needs. Then people put in the information, and then you see the information. There were also some other, you know, black box tools that were made available to in different jurisdictions to help with contact tracing and case investigation. None of those could be approved by IHS to be used.

Q: Do we know why?

WEISER: Yes. [laughter]

Q: Are you willing to comment on why?

WEISER: Absolutely. It comes down to, you know, a bureaucratic red tape issue. It may have something to do with interpretation of rules and regulations. It may actually be, they were actually right on some level. When other HHS [Health and Human Services] agencies can use this software to collect HIPAA protected information and we’re in a pandemic, it seems to me that when it comes to security and those kinds of things, better funded agencies than ours have already gone through this and determined that it’s okay. Our agency, which is severely underfunded, determined that they weren’t secure enough for us to use, number one. Number two, they determined that it would actually be considered a system of record. Which is an OMB [Office of Management and Budget] term, or yes, I think OMB. You have to go through certain steps to be able to adopt a new system of record. It has to meet like all the national archives criteria and things like that. It’s a federal system of record and so it has to meet all these specified criteria. You have to, you know, request that or apply for that and demonstrate that you have a need for this and that this meets that criteria and all of that. That probably takes a couple of years [laughs] for most systems, I would imagine. What they determined was that we had an electronic health record, which is our OMB authorized system of record. They felt that, you know, we could not justify requesting a new system of record. Myself and several other people, we tore our hair out time and time again when we had these discussions because we could not make any headway with the folks at headquarters who were making these decisions. You know, our office of technology and it still defies logic for me. That a pandemic of this scale was not justification enough to have a system of record or that we could get some kind of a waiver from OMB to adopt this now and do the paperwork later or something. Of course, bureaucracy can’t operate like that, right? You can’t say let us have it now, we’ll get back to you later with our promise to comply with all the rules and regulations. I understand that on some level, but no one was willing to go to bat for us. No one could look and say—Hey NIH, can we tag on, or CDC can we tag onto your OMB authorization for using this system? If they had one. Or if CDC doesn’t have an OMB authorization for this as a system of record, then why in the hell do we have to have that? Are we being held to a different standard and is it a matter of people’s interpretation of those standards? These are the questions I still have. I don’t know the answers to these.

I tried working with our public health nurses. Particularly one of our service units, the Yakama service unit which serves the Yakama Nation, was being really hard hit. They are the biggest of our service units. They’re user population is around 12,000. I think the enrollment of the tribe is even more than that. They were having a lot of cases when this happened. We only had one of four public health nurses filled, so there were three vacant positions. So, she was working— the one public health nurse, Marie Bastin, was working really hard to try and set things up and put things together. You know, she developed a spreadsheet and that became her system of record for tracking cases and contacts. Eventually we were able to establish an agreement with the tribe, but it took a long time to get this agreement through where the tribe would assist with the contact tracing piece. As a federal employee the public health nurse was primary in charge of the case investigation. She had the information in the electronic health record of a positive test. She had their contact information in that electronic health record. She would reach out by phone if she could and talk to them and do the clinical follow up a little bit. Like, give them guidance if they’re sick, when they need to go to the hospital. Then she would each day provide information to the contact tracers about the contacts that needed to be followed up. She was actually doing the case interviews and then she would collect the names of the people that were contacts, and she would share that with the contact tracers.

The difficulties around HIPAA and interpretation of HIPAA and trust between the tribe and IHS were such that initially, we couldn’t share with them who the case was. I’m not sure how this played out in other jurisdictions. You know, when they’re doing contact tracing, are they saying, “You were exposed to Mary A. last week and we’re calling to follow up and see if you have symptoms or can you get tested or have you been tested?” I mean, usually in case investigation and particularly if it’s a sensitive thing, you’re not going to disclose who the case was. You would just say, “We know that you were exposed to somebody”. So there really wasn’t necessarily a need for the contact tracers to know who this person was. One of the issues was, in the communities everyone knows everyone. If you know who the case was, you know that out of these three contacts you’re given, you know the whole family and there’s ten more [laughs] that should be on this list that aren’t on this list. You would know that if you knew who the case was. There were reasons why I think the contact tracers probably should have had that level of information. Eventually I think we did iron that out where they could have that, but we had to really make sure that they were on board with, you know, HIPAA compliance and not revealing that to other people. Either the people they’re calling or anyone else that they might talk to about their work. Family members, council members, things like that.

There were pressures early on from tribal councils, not just there but other tribal councils, where council members wanted a list every day of who was positive. Especially in the early days. Because you know, if they had one case or two cases, they wanted to know who it was. We had to like push back and say, “We can’t tell you.” [laughs] “We’re not allowed to tell you. It wouldn’t be good for that person, for you to know, for everyone to know that they have COVID.” Right? Try and really explain the nuances of the stigma and everything like that that would quickly arise. On the other hand, when IHS is providing the care and the tribes providing the support, including the home visits, and delivering food boxes and delivering oxygen sensors for family to have at home and thermometers and over the counter medications for someone who might have COVID. They need to know where to go. [laughs] And as soon as they get the address, they’re going to know who lives there. You know, at some level we had to be able to share information and work together. It was a rocky road for many reasons initially.

Q: Has that rocky road gotten a little bit smoother?

WEISER: The road’s closed now. [laughter] Right? We don’t do case investigation or contact tracing anymore. We do case investigation but not contact tracing. Some of the tribes have stopped almost all of their COVID activities.

Q: Really?

WEISER: Yes.

Q: Is that because the vaccine came out and everybody got vaccinated and everybody’s complacent?

WEISER: Part of it I think is that the funding has run out, so they’ve spent all the COVID funding that they received. There isn’t any new or ongoing COVID funding coming, so there’s that. There’s also the desire to get back to normal. You know, schools are opening up. Businesses are opening up. Things like that. And we do have the vaccines and we have treatments available. In many of these communities, like you know, there are still county and local health jurisdictions that are working to still track cases and provide guidance and things like that. Almost everything now is such that, you know, yes, there’s not much of a response left to COVID anymore. Anywhere you go.

Q: Is that due at all the vaccine coming out and the lack of funding, I guess?

WEISER: The response has pretty much stopped because we have vaccines and because we have treatments. Because people are not dying at the rates that they were dying initially. Of course, the economy can’t handle being closed for all that time. As far as masking and some of the other social distancing things, in my opinion those should still be ongoing. Because they work. Because not everyone is vaccinated. Because these variants keep coming out and because like it or not, COVID has an asymptomatic and pre-symptomatic period that that is the, I don’t know what the right term is. The coup de grâce? I don’t speak French [laughter] but I mean, that’s the thing that sets this virus apart from flu or other things is that piece. Because people can be infected, not know it, and spread it. As long as that continues, we really should be wearing masks. Even I have been to gatherings recently where initially I wear my mask. I’m the only person in the room wearing a mask, or one of five or something. I’m like, it feels safe, it could be safe. I’ve got all my boosters. I’ve got my bivalent booster. I think I’m going to take my mask off. You know? Especially if I have to speak and I want to be heard. It’s hard to speak through the mask. I’ll tell you in a week if I got COVID or not. [laughs]

Q: Yes, same here. I’m probably one of the few people wearing a mask when I go to the large gatherings. If ever I’m on a plane, I’m probably the only one on the plane wearing a mask.

WEISER: Yes, yes. Airports I do. Grocery stores I do. Because, you know, I don’t know anybody at the grocery store. They don’t need to see me if I have a mustache or not. [laughter] I’m here to buy stuff, you know? Gosh, especially like Costco or something. Yes. You don’t need to see my face. It’s okay.

Q: Now I want to return back to vaccines, and you’re work. The ACIP and how you were able, you were privy to what was going on and how that felt with that information and not being able to share it. Thank God your family wasn’t there because you probably would have inadvertently said something.

WEISER: Yes. Related to that, IHS headquarters set up a Vaccine Task Force. When Operation Warp Speed was first announced, it was within the first weeks of Operation Warp Speed, IHS set up a Vaccine Task Force to prepare and plan for this. We had staff who were embedded with ASPR [Administration for Strategic Preparedness and Response], the Assistant Secretary for Prevention and Emergency Response. I’m a terrible bureaucrat. I can’t remember acronyms to save my life. We had folks from IHS from, mostly these were pharmacists, from either the Oklahoma City National Service Supply Center or from the Vaccine Task Force, who were pharmacists from different parts of the country who were specifically asked to participate or take on leadership roles within the task force and stepped up to do that. These folks were embedded with folks at ASPR and in Operation Warp Speed, so they were there with them as things were developing. Then they would report back to the Vaccine Task Force about how things were developing. There was this other channel too where some of the information that I was hearing through ACIP, you know, we were hearing it from these folks as well. From the Operation Warp Speed directly. You know, one of the main lessons that we learned from H1N1 was when that vaccine was developed and rolled out, and the nature of H1N1 was such that it really affected younger people and middle-aged people more than older people for whatever reason. We still don’t know why. When the vaccine came available, the priority population was those younger and middle-aged people. Not the elders. And in tribal communities, elders are like the most revered. Those are your traditions, your knowledge keepers, you want to protect those folks. They’re usually the older, more vulnerable part of the population too. It was completely opposite to anything that the tribal communities were used to or expected or planned for when H1N1 came out. There was pushback, because CDC said you have to use this vaccine in the way that its detailed and you can’t deviate from that. They called them deviations. [laughs] If a tribe said, yes, we’ll get the vaccine but we’re going to use it however we want to. You can’t tell us what to do, we’re a sovereign nation. The sparks flew over those issues with H1N1.

The other thing that happened was that as sovereign nations, they expected to deal directly government to government. Like tribe and federal government. That level of government interaction. For tribes, it’s an insult to say, you have to work with your county. They are more and more willing to work with the state in lieu of the federal government, but not the county. We heard this in every after action, every emergency preparedness meeting we had after H1N1, we would have discussions about this particular issue. It was really well known, particularly in Washington state, that if we’re going to have any kind of an asset delivered like this again to tribes, the state has to be the one that delivers it and not the county. Because the state can maintain a certain level of responsibility and interaction with the tribes on a government-to-government basis. It won’t be left up to some county person who might not have a good rapport with the tribe and might not have the same level of respect for tribal needs or tribal wishes. That lesson was learned. I’m thinking particularly Washington state, which is where it came up a lot. When COVID vaccines were being readied for roll out, IHS for the first time was being looked at as a jurisdiction. In H1N1 we weren’t really a jurisdiction. We got a little bit of extra H1N1 vaccine that we could allocate each week for our healthcare workers but we weren’t given a full allotment as a jurisdiction. This time, we were. I think our membership, our embedding of people with Operation Warp Speed, and our Vaccine Task Force and our headquarters incident command and the level of interaction there really made it possible for that to happen. There was a lot of skepticism at first because previously IHS said the central Oklahoma City National Service Supply Center did not have the surge capacity to handle receiving from the Strategic National Stockpile or from any other large federal repository, how to get that back out then to the sites. We don’t have the ability to bring in 100 new warehouse workers to do that work. They never really wanted to do that, but through the discussions and how things were going to work out, you know, they took on a leadership role as well to dispense some SNS [Strategic National Stockpile] supplies. The vaccine was outside of the Strategic National Stockpile. So, the vaccine was going to go to jurisdictions, which included states, territories, and federal entities like DOD [Department of Defense], VA [Veterans Affairs], and Indian Health Service. We were getting our own allotment.

Then we tried to have a— things were moving so fast we couldn’t do our usual tribal consultation with tribes, which requires a certain amount of time of notice that there’s going to be a tribal consultation so they can prepare. Then the tribal consultation occurs. Then the decisions that follow after that tribal consultation are then vetted and happen. That’s how it normally would work out. There just wasn’t time to do that fully so they had tribal listening sessions, I think they were called, convened by HHS and IHS to try and get feedback from the tribes. One of the things was, do you want to get your vaccine from IHS, or do you want to get it from the states? That was kind of the way we determined the best we could do to honor tribes and recognize their level as sovereign nations, and yet not compel the vaccine distributors to have to ship, to make those agreement with all 574 individually recognized federal tribes and all the states. We have to somehow streamline this distribution to larger scales because some tribes are very small. Some tribes are very large. None of them is as large as the state. Well except Navajo nation, it’s probably as large as Montana perhaps. [laughs] That was sort of the decision made through Operation Warp Speed and it took a lot of talking to the generals of Operation Warp Speed, to really explain to them how IHS works, who tribes are, what their status is. Because they had never had to work with tribes before. We really had to fight strongly to get that in place, to say we need to provide this choice to tribes and if it comes to IHS, we’ll manage the orders and help with the distribution. Then if the tribes choose to go with the state, then the state will manage that. In our area, I think overall in IHS about 300, it kept fluctuating so between 330 and 350 or so, of the tribes in IHS of the 574 federally recognized tribes chose to go with IHS as their point of contact for distribution.

Q: And the others picked their states?

WEISER: Yes, they went with their states. You know, and I don’t mean this to be flippant or disrespectful or anything, but it kind of came down for the tribes, it came down to which of these government entities do you trust the most? Which of these has harmed you the least in your recent memory or recent history? Or ever? You know? It was a tough decision I think for tribes because you know, for some tribes, like they don’t trust the state or the national government or IHS. I think it was really tough for them. Some of them still really wanted to have their own distribution and not have to go through state or IHS, but it was the best plan that we could come up with to distribute a scarce resource in as timely a manner as possible in keeping with the goals of Operation Warp Speed. It worked quite well. We got our first vaccine distributed in December along with everyone else. We were part of the first allocation. The challenges of having the ultra-cold freezers to handle the Pfizer vaccine, that was one of the big challenges. Like nobody had those— except one site, and that was the Lummi Nation.

The Lummi Nation is located up near Bellingham, Washington. They were pushing the envelope through many parts of the earlier part of the pandemic. They struck out on their own to try and put together a field hospital on their land. I have to preface this to say, none of our tribes or IHS operate a hospital in our three-state area. They’re all ambulatory care centers. To set up a hospital would be unprecedented. I think in the distant past there were a couple of IHS hospitals, but none exist today. To set up a hospital would be something new and unprecedented. But the Lummi were so adamant about trying to protect their people. They wanted to do everything they could. They were seeing what I was seeing, what we were all seeing on T.V. and stuff where we were like, you know, our local hospital in town might become overwhelmed. When push comes to shove, they felt as Indian people that they would not get fair treatment. They felt like in case that happens, we need to be able to provide for our own. That was what was behind that. I think they purchased a modular building. They started purchasing equipment to put it together and set it up. They were trying to develop policies and procedures. I can put you in touch with folks if you want to learn more about that. They also were participating initially in the AstraZeneca trial in the US. As part of that participation, they had an ultra-cold freezer. That’s why the first vaccines in our area were shipped directly to the Lummi tribe, or Lummi Nation. Nickolaus [D.] Lewis, who is a tribal leader for Lummi, I think he was on the council but not necessarily the chairman. He’s also the chairman of the Northwest Portland Area Indian Health Board. He is the leader of this organization that represents all forty-three tribes. He’s a busy guy [laughter] with all that going on. He personally picked up an allocation, a subset of that first allocation of vaccines, and drove them— first to the Yakama Nation. Then on to the Confederate Tribes of the Umatilla Indian Reservation in Oregon. This week we had the fiftieth anniversary celebration for the health board.

Q: Is this the Indian Health Board?

WEISER: Yes, this is the Northwest Portland Area Indian Health Board. I’m just going to take a moment.

Q: That’s fine.

(Pause)

WEISER: Yes, I may not be able to say everything I want to say but it was a pretty emotional event. You know, because we were meeting at the Confederate Tribes of the Umatilla Indian Reservation so out near Pendleton in eastern Oregon. Nick Lewis, our chairman, was there to celebrate fifty years of being together as a board and to joke that, you know, he wasn’t even born when the board started. [laughs] Which made for some good laughter. I think he actually wasn’t born then. [laughter] He recounted that journey of driving those vaccines. The first vaccines for tribes.

Q: Wow. That’s pretty powerful. I mean, I know it’s like, yes. I mean, getting that first shot I think everybody almost felt that. I asked a lot of people what they felt like right after they received their first shot. So many different emotions that come up. Some people were like, oh I really didn’t have time to really think about it. Then there were people like, it felt like now this is a whole other level of my protection. Then a lot of people felt guilt.

WEISER: For me, because I had been sitting on all of those COVID Vaccine Work Group meetings and all of the ACIP deliberations and the public meetings, and I was also part of the Vaccine Task Force for IHS. My role was in the prioritization sub-team, so we tried to figure out, you know, when we get this vaccine, how are we going to roll it out? Who’s going to be our priority populations? Will we be able to vaccinate the people that we think we need to vaccinate? How to work with tribes to define that. Yes, it had all these other layers as well and it was more meaningful, I think to see the roll out of those first vaccines for me than even my own vaccine. I mean it just really overshadowed it. You know, Chairman Lewis said that he’d never drove as carefully [laughs] in his whole life as he did then. I was sitting next to our now area director, he was in a different role during that day, but now he’s our area director. He just became our area director about a month ago. His name is (CAPT) Marcus Martinez, he’s a Spokane tribal member. I was sitting next to him as we were hearing this talk from Chairman Lewis and CAPT Martinez told me that he was the one who picked it up from Yakama and then drove it to Warm Springs, [Oregon].” Which is one of our federal service units. That one box of vaccine, and you know, we got the one shipping case of 144 vials or whatever, that got distributed up between I think these four clinics and service units. Two tribal and two IHS, and these were some of our biggest tribes and IHS facilities (in the Northwest) that received the first shipments.

Q: Was it easy for a lot of tribal members to get an appointment? Because I feel like in the community where my parents were, there was a lot of ageism on how you would sign up for your vaccine. So much so that they’re not internet savvy but they’re not internet, they’re in their nineties so it’s hard for them. It was kind of an ageist way of rolling out the vaccine. They had no idea how to do it, so I had to do it for them.

WEISER: Yes, so being a federal agency [laughs] there are certain bureaucracies like the Privacy Act that prevent us from utilizing some of the most everyday tools like making an appointment online. Talking to your provider about your healthcare online. We still don’t have that readily available. We utilize Facebook. Each of our IHS clinics is able to advertise things like if the clinic was going to be closed for some reason or, you know, we’re having a special campaign about this that or the other, or we have the flu shot available. All of those are messages that they put out on their individual Facebook pages. At that time, any message about COVID had to be cleared by our area PIO [Public Information Officer] who then would send it up to the headquarters PIO. Initially they wanted to clear every single post, every single message. Finally, we were able to get some reasonable accommodation [laughs] to say, well if it’s just a message about you know, you have to close the clinic today because a water pipe burst, you don’t have to get clearance for that. It was only COVID messaging. Then all the COVID messaging was still too much anyway. The way people found out was through Facebook, through the tribal newspapers, through tribal radio stations if they had it. Through tribal council, through communication between the clinic leaders and the tribal leaders. Everyone would be made aware of how much vaccine we have or if we have it and who was the intended recipient audience at this time. A lot of that had already been worked out a little bit through discussions with the tribe. As I mentioned before, during H1N1 for tribes, the elders are the people who are most revered. It varies from tribe to tribe when you become an elder. For some, it’s much younger than getting the retired discount at Starbucks. [laughter]

Q: What is that?

WEISER: I don’t know. So, for some, it’s fifty-five. For some it’s fifty. It’s definitely not sixty-five. When the first vaccines came out, I think we were actually trying to target more like seventy-five and eighty-five. You know, seventy-five and older and not even down to sixty-five yet. But each tribe determined who would be in that first pool based on age primarily. When the vaccines arrived, then the messaging would go out that we have vaccine and it’s for this group of people. Then we tended to do it not necessarily by appointment but by drive up kind of mechanism. Because we were doing so much stuff outside anyway by that time. I mean, all of our testing was being done outside of our facilities. Some facilities, some tribes were so adamant that COVID will never see the inside of our facility that it became actually really kind of difficult to even have normal, any kind of care being provided. Because everything was being done outside.

Q: You mean outdoors?

WEISER: Outdoors, yes. Building tents and temporary structures and things like that for this care to occur. Because we were afraid that if we let people inside, then they’re going to spread COVID around to other people and things like that. Like if you were coming in for chronic illness care, that could be done inside but anything acute, any kind of sick person care was being done outside. Then for vaccines, we were like well we don’t have time to screen everybody before they come in so how are we going to do this efficiently? In some places we set aside a part, like the Yakama has a really big clinic and they had a whole south area that was being unused. They kind of turned that into where they were doing their COVID vaccines. People would come in and they would do their screening outdoors. If they didn’t have symptoms or anything like that, then they would come in and they would get their vaccines. Everyone wore their masks indoors. Everyone complied with all of that. Had the six feet distancing signs and all of that. People would come in and it was first come, first serve basically. Which isn’t really the most equitable way to do it, because if you were connected, if you had transportation, if you had somebody to drive you, you were going to be able to get in line first. We didn’t have a better way to necessarily do that. We didn’t do a lottery. Which I’ll mention in the ACIP work group discussions, it came up that lottery was actually maybe one of the most equitable ways of actually distributing a scarce resource. At first it doesn’t sound like that would be fair or equitable, but it is. It’s random chance. There was a person who worked with us, an IHS employee, one of our statisticians who also brought that up as actually maybe not the most nuanced way of distributing it but probably the most equitable way to distribute it. Everyone has a fair chance to be in a lottery. In any case, we got enough vaccine early on that we were able to vaccinate almost all of these priority populations and even earlier be able to move to the next priority population. Before maybe our counties were able to do that.

Q: Everybody was able to come to the clinic? There wasn’t any kind of in-home vaccinations or mobile vaccinations?

WEISER: No, so we didn’t have, our IHS partners initially, we didn’t have any mobile units to use. We didn’t have any staff to send out to folks initially. Then only one of our sites, Warm Springs, has a mobile unit. It’s owned and operated by the tribe. The mobile unit was actually parked outside of the clinic and was a place where routine vaccinations were being done. Because it was a way that, you know, was outside of the clinic so people could come in there and not potentially bring COVID into the clinic and they could get their vaccines. They did some other care there in the mobile unit, but it was their everyday set up and that’s what they used it for. I think there were community resources that were used to help bring people in. Many of the tribes have a community health representative network and they also have a few transportation vehicles that they would use normally to transport people to dialysis or to referral care and things like that. I think some of those folks were able to be used to transport people for their vaccines if they were having difficulty.

Q: I kind of want to get to more of a personal part of this. Your reflections on the past two and a half years. It doesn’t seem that long to me. You said your wife and daughter traveled to Japan early on and you were managing your day-to-day household. I guess you would be teleworking as well?

WEISER: Right, so in March with the declarations both my usual office at the health board and our IHS Area Office went to telework 100%. I’m employed by the Area Office and prior to the pandemic, I spent probably ninety five percent of my time working on Health Board priorities and projects and maybe about five percent of my time doing IHS stuff. Maybe it wasn’t quite that dramatic. It felt that way. My primary email address was my health board address, and I didn’t really pay much attention to my IHS address that much. When the declarations came out and we set up our ICS team, which was the IHS ICS team that I was now to be the public health lead for, that switched completely. I became ninety five percent IHS and five percent health board. I was still able to participate on health board meetings and things like that and be able to participate on things like the ECHO [Extension for Community Healthcare Outcomes] calls and the weekly health board calls to get the message out. That was a big change, is now my focus is all IHS and I had to drop everything else I was working on. Things that I was saying in February I was working on, now I actually did not remember until I had to look it up what that training was in February. It was for an MMRC, a Maternal Mortality Review Committee. I remembered being there but I didn’t remember exactly what we were there for. Yes, there’s a lot of things. We had hepatitis A cases at the time. We were doing a lot of work around hepatitis A in homeless populations and people who use drugs. Because we were seeing pretty severe hepatitis A. People were dying from hepatitis A and getting hospitalized. That was another focus that we were on I completely forgot about that until this morning when I looked at it again. Yes, I did feel a sense of loss about all the things that I was working on but at the same time this pandemic to me felt, you know, existential. Like this is a big deal. I grew really frustrated with the way some of the things that I talked about [were being done]. Like not being able to have a tool to do contact tracing and case investigation of our own. Therefore, I don’t know how I’m going to get information about what’s happening for our population around this epidemic other than maybe what other people might have. What the state is telling me is happening or that kind of thing. I don’t know. I just knew it was a big deal and I was really frustrated.

At one point I did call my former CMO [chief medical officer], my former boss, who at that time was working for headquarters in our office of quality. I gave him an earful. I said, “What the heck is going on? Why can’t we do what we need to do? Why can’t we say what we need to say? Why does every single message that we put on Facebook for our service units have to be cleared at these highest levels? I’ve never seen this before. Has it always been this way? Have I just never had to work so much with IHS before in the past that I didn’t realize that it was always like this? Or is this something new?” He tried to calm me down [laughs] and reassure me that, you know, we’ll get through this. I called another friend of mine who was an internist that I worked with at White River at the very beginning [of my career] and had risen through the ranks and was now the area director for another area. I called him too and gave him an earful. You know, and I thought that by calling these people that I had worked with in the past for a long time. I know them, they know me. We can speak openly. I couldn’t get a straight answer from either one of them either. It wasn’t that they didn’t hear the frustration and even share my frustration, but there was nothing they could offer. You know? There was no work around that they could offer and there was not much advice that they could offer. How to find any way forward with some of these roadblocks we’re having on the ability to get our messaging out quickly or the ability to utilize innovation in trying to get the information about cases we need. That was really hard.

Q: That didn’t change when there was a shift in leadership at the federal level?

WEISER: No, no it didn’t.

Q: It’s just always been that way, and it doesn’t seem to be wanting to change.

WEISER: Right. In fact, I don’t know how to attribute this necessarily. It’s not my personal experience, but I’ve been told that in dealing with the current administration and the people that are now in ASPR at the highest levels around monkeypox, that some of the same frustrations are happening there too. Like they don’t understand tribes. They don’t know how to work with tribes. They don’t understand IHS at all. They think they can just tell us to do things that we can’t do. That we shouldn’t do. That we know not to do. Our folks who are interacting with them are getting really, really frustrated because you would think that we would have been provided with more competence when there was a shift. Instead, the incompetence seems to have gotten worse rather than better on some levels. It’s not true across the board.

Q: Do you think there’s a solution to that or some sort of détente?

WEISER: [laughs] Yes, I don’t know. I mean, we are part of HHS Region Ten, which includes my three states plus Alaska. Prior to the Trump administration, we had really great regional administrators. Then we were given not so great regional administrators.

Q: So that changed?

WEISER: The actual Region Ten administrator. The current Region Ten administrator addressed our health board meeting this week and I’ve heard her talk before. She’s new, but she gets it. She’s either got good staff who are telling her what she needs to know, and she’s a good study. Because she understands the issues. When she talks to the tribes, you can tell that she understands the issues and she’s tracking those issues. She knows what’s important to tribes and she’s working on it, and it seems sincere. That’s a huge 180-degree difference from the last administrator. It’s not 100%. I mean, some people come in and they have capacity, and they know what they’re doing. I think we have some folks in ASPR who don’t know and who need to be educated. Maybe, you know, part of it, we didn’t have an appointed IHS director, we had an acting director.

We just got our director of IHS confirmed. She’s been in for four weeks or six weeks. Her name is Roselyn Tso and she used to work in our area. I worked for her, so I know who she is. She actually came to our board meeting this week in person and addressed the delegates and the board. You know, I got to say a quick hello. We didn’t have a director for the last two years. We were halfway through the Biden administration, and we didn’t have a director confirmed. The same thing happened with the last administration. We had an acting director for the first two years and then finally we got a director confirmed. I think not having a director in place makes a big difference too because then you don’t necessarily always have the person who can educate other parts, other agencies within HHS to say here’s the deal. This is what IHS is. This is how you need to think about us and remind them that we are funded at fifty percent of the need. So, you’re asking us to do something with nothing and unless you give us resources, you know, we really can’t do it.

Q: Plus, there’s that institutional memory that doesn’t stay with each director.

WEISER: Right, right.

Q: There’s a re-learning each time.

WEISER: Right, so with our directors, they always— the last two have come from the ranks. These are career IHS employees, so that’s helpful. Previous to that, we had a director under the Obama administration who came from outside and who could not get confirmed at all during the second Obama administration.

Q: I didn’t know it was so contentious.

WEISER: Right, so for six years we did not have a director. You know? Unbelievable—

Q: Yes, that is unbelievable.

WEISER: —and unacceptable. There were lots of reasons to be frustrated with, you know, government response and how things work. On a more personal level, I guess going back to like how I felt at this board meeting that I went to, I was telling you about. Part of the thing that makes me choke up and made me choke up there too was, you know, feeling like you’re watching a disaster roll out before your eyes and you have some ideas about what could be done to make a difference. You’re desperately trying to act on your training and what you know to do, but you don’t have a way to do it. [laughs] You don’t have the resources. You know, if we wanted to set up isolation centers, we don’t have a way to staff them. No one seems to have money to do that. Even if you had money, there’s no one to hire. We got a lot of help from CDC Foundation, I’ll say. They were offering help to each of the states. In our region, some of the states didn’t really need it, and so they said, “You know what? You know who needs this help? The tribes need this help.” We had an army of CDC Foundation folks that came to work at the Northwest Portland Area Indian Health Board to help with the response. Which was really tremendous. These were top notch people. Some of them continue to work with us today as either foundation employees or they’re full-time employees now of the health board.

Q: Yes, so I’ve seen this over the years that when there’s a huge emergency, there’s a lot of money and people and personnel thrown at that one emergency. Then once that emergency is gone, so go the people. So go the funding. Instead of just continuously funding something appropriately so that you don’t have this surge, and response, surge, and response kind of thing. Is that something that you’re seeing as well in your work?

WEISER: Right now, the thing that’s really hard for us is staffing. You know, it’s not unique to us. There are hospital systems and healthcare systems all over the country that can’t find doctors, can’t find nurses and are paying through the nose for the few locum tenens that they can hire. Or you hear stories about hospitals where the staff all quit and went to work for a locum’s company and now, they’re all working at the hospital down the street, and vice versa. It’s like staff just switched hospitals so they can work for locums so they can get more money. Because the hospitals themselves couldn’t just pay more money in the beginning. Of course, the IHS mechanisms for payment and things like that, you know, we’re stuck with the GS [General Schedule] system that CDC has or the Commissioned Corps, which is harder to even bring on new folks. We’re really having a tough time on getting enough staff to be here. That’s our number one threat. More money could help, because then we could offer more salaries. You know, it’s so bad that, and actually this has been kind of part of the problem throughout the pandemic, is we also lost support and administrative staff. Like our HR [Human Resources] staff and our acquisitions staff. The people who hire people, and the people who buy stuff for us.

Q: Yes. Where’d they go?

WEISER: Some of them were gone too. They didn’t want to work from home. They got better offers to do the same thing with less stress, and so they did it. Even when we had more money from all the COVID funding, we didn’t have the people to hire the people. The hiring process is so slow and so arcane. It’s unbelievable. There are so many things that need to change in terms of our hiring abilities, how we buy things, the acquisitions, and so forth. You know, it was really ridiculous some of the constraints that we had to try to operate under. All of those frustrations would boil up, and so I would work really hard, you know, Monday through Friday and then Saturday or Sunday I would sleep in. You know, I would do things like watch YouTube videos and catch up on the late-night comedians. There were things that were just like, hit me really emotionally. Like there were music videos, like for me Playing for Change is that group where they have people all over the world playing music together. They’re wearing headphones listening to the track and playing an instrument or singing part of the song. They’re doing covers of popular songs or things like that. I’d watched it before. I was always inspired by it. I thought this is such a beautiful thing, people all over the world, well—that was just one of the things that would just, you know—

Q: What did you do for your own mental health? You didn’t have your family’s support for some months. What did you do?

WEISER: I’d get together with folks by phone or by, you know, FaceTime or something like that. I had good communication with my family in Japan because we could do FaceTime and talk readily and things like that. In my community where I live, we actually started having happy hour. [laughter] Usually all of us would go to work and we would come home. We’d do our thing with our families or whatever. Most of the people that were still working, we have a lot of retirees as well, but between the retirees and the people working at home, we were all home at five o’clock. We would start gathering outside and people would have happy hours, and probably people drank too much. [laughter] My dog would come with me to happy hour, and she loved to go out and meet all the neighbors and stuff like that. Around about 5:00 or 5:30 most days she’ll come up and as I’ve got my mouse in my hand here, she’ll come up and nudge my elbow so I can’t do any work. [laughter] She just hits me with her nose and says like, it’s time to go out. Come on, let’s go, it’s happy hour. My dog was an important support for me in other ways too. Because we live in a condo setting, I don’t have a yard. I can’t just open the door and let her go relieve herself. I have to take her for a walk. I did a lot of my conference calls and things like that, especially the things I was just listening to while walking the dog.

Q: You’re living the life. [laughs]

WEISER: I was that guy.

Q: -- it can be freeing, aren’t they? I love being able to be outside listening to a call and still be outside with your dog walking.

WEISER: Yes, yes, it was great. That was a big support for me. Our church stopped having mass in person, but they quickly went to online and so sometimes I would try to watch that. That was weird. [laughs] Then after a while it was like, this is actually kind of nice. I can just roll out of bed and sit in my pajamas and go to church. [laughter] This is better, actually.

Q: -- but without community, the community is what you look for. Yes.

WEISER: Yes. When I did actually go back to a service in person, it was remarkably like nothing had happened in a way. It was like, it was a place that was so familiar to me, and it looked like it always did. Fewer people, and everyone was wearing masks, but it looked the same. It was very familiar. It was almost like it erased that whole period of time when we weren’t together in a way. I did find myself looking to see some of the familiar faces who would usually sit in the same area. Because people always sit in the same area. I would be like, you know, who’s still here? That kind of thing.

Q: Yes. Check in on everybody, yes. I feel like there’s a collective grieving that hasn’t happened.

WEISER: Yes.

Q: Where you have a period of time where you grieve for whatever that event has happened, and I feel like that hasn’t happened yet here for us. For a lot of people. At least for me. It’s more like an erased period of time.

WEISER: Yes, which—

Q: Remind you of certain things and you’re like, oh my god that was only like three months of time that went by but it felt like three years.

WEISER: Yes. Which I think might be an insight into some of the things I’ve heard about the 1918 pandemic. That there is this gap in information about people’s actual experience during that time.

Q: Right. I was going to ask you what you think the reverberations from this will be like, because you obviously read those 1918.

WEISER: Yes. I think I don’t know. [laughter] I think there’s so much more that was happening too that affected me on a personal and emotional level. We’re in lockdown, and then we had the murder of George Floyd. Then Portland was sort of a hotspot for the protests. A close friend of mine who teaches photography was out there many of those nights at the protests photographing. You know, really aligning herself with some of the leaders in the Black Lives Matter movement in Portland and documenting what happened. I could watch what she was seeing. I felt like I can’t stop for that, because I’m so focused on what I’m doing to respond to COVID, to keep the vaccine thing on track, and all the other things I’m trying to do to help our service units and our tribes. You know, this is such an important thing that’s happening and I don’t feel like I can actually stop for that. That was hard. Those happened throughout the summer of 2020 in Portland. Then at the end of summer we had this horrendous firestorm.

Q: That’s right.

WEISER: We had an east wind come through and blow-up fires in areas that I had actually hiked in, you know, a couple of times during the summer with my daughter when she was here. Like that whole area burned. There was that feeling of loss for places that I loved that were just destroyed, and the oppression of the smoke that not only can I not go to the places I want to go, I can’t even go outside because I can’t breathe the air the smoke is so thick. There are all these dangers. [laughs] It was like, it really felt like the end of the world. I did tell people over and over again— this is a dress rehearsal for climate change in my opinion. You see what a cluster blank, blank, blank it is for us to respond to COVID. It doesn’t give me much hope that we’re going to do any better for climate change. You can already see that we’re not. You know, you would think that when you’re faced with something so devastating and so important that people would pull together. In a lot of places, they did. Our tribes are really good examples of pulling together to do what they can to protect their people. We could learn from that. It’s really hard to see how we’re not able to pull together to take care of things like climate change. Because I mean, if a virus is not tangible, it’s invisible, you can’t see it. One may or may not believe that it exists. Even more so, this change in the entire climate and what it will or will not do to us, what we can or cannot do to make a difference in it. The levels of disbelief and misinformation and uncertainty around it. I mean, even if it’s not misinformation. Just uncertainty around what the impact is, will be, and what our ability to affect it is, is I think it’s such a huge challenge for us.

Q: It is. We’ve come to the end of our time and then some, again. [laughter] I don’t ever want to stop you. It’s been wonderful. I want to also say, what else haven’t we covered that you would want to share for the historical record?

WEISER: [laughs] Well I think—

Q: I mean, you just said it like about three minutes ago. That was wonderful. I should have just wrapped there. [laughter] I thought perhaps there was something that has been on your mind throughout this whole thing other than some challenges that we’ve already spoken about.

WEISER: Yes, no I think for my family sometimes I feel, and even for the work and the people I work for, feeling like I wish I could have done more. Kind of a feeling of apology that, you know, that there were limitations that we had to deal with. Then there were my own limitations too. The things I don’t do well every day. I wish that on some level that I had been able to do more and do better. You know, I was doing all this, all that we did do, and working together to try and make a difference for our tribes. Try and make a difference for all the people that we are with every day, and for our loved ones. For my family. In some regards, we had challenges that we couldn’t overcome. I have a son, too, who lives nearby and lived mostly independently during that time, but who chose not to get vaccinated and still has chosen not to get vaccinated. He has had COVID twice, most recently about two weeks ago. Fortunately for him he did okay. He got through it without too much difficulty. You know, for him and other people like him who have lots of different reasons for why they didn’t get vaccinated, I feel like I wish we could have done more to get out ahead with our messaging and with the important information, and not be highjacked by all the other things that did happen.

Q: Indeed.

WEISER: Yes.

Q: Alright, well I want to thank you for being and taking the time to record with me today, and the other day as well. I’m going to end the recording now.

[END] 00:01:00Q: It is Friday, October 21st, 2022, and this is Mary Hilpertshauser for the COVID Memory Archive History Project. I’m in Los Angeles and I am talking with Dr. Weiser, who is still in Portland. Correct?

WEISER: Yes.

Q: This is our second session.

WEISER: Yes.

Q: We left off talking about Native Boost [Boost Oregon], which is a program to get people to trust vaccines. Is that correct?

WEISER: Yes.

Q: So, let’s start off with when the pandemic hit and the first iterations you saw of the pandemic.

WEISER: Sure. I had been kind of paying attention to some reports from December and early part of January about this novel virus in China. And so far, we didn’t have any cases here. I was already feeling nervous and a little scared because it sounded a lot like SARS-CoV original, which we only had one at the time. And now I call it SARS-CoV-1 but I think I’m the only person who calls it that. It’s still called SARS-CoV. In any case, I was kind of paying attention to that and wondering when we would need to make any kind of a response or you know, what clinicians in my region would need to know about that particular outbreak. I had been doing this for quite a while so our clinicians, we have a face-to-face meeting twice a year, and my spiel is to give the epi update. In that I talk about the things that are of emerging importance in our area. Then I also will focus a little bit more internationally. For example, I’ve talked about MERS [Middle Eastern Respiratory Syndrome] to this group. I’ve talked about Ebola to this group. Things that, you know, we never really dealt with, but I just thought these are the things that I’m watching. That was kind of usually the title slide. We had our last face to face meeting with them in November of 2019. We would have monthly updates by way of a web call, and I think I had already been thinking about, it’s time to start talking about this with them.

The first entry in my notebooks about this was on January 27th – Oh I need to turn that off, let me just turn off this real quick. So, the first entry in my notebooks about SARS-CoV-2 was on January 27th. You know, I didn’t look at the details of why I made those notes. I’m sure it was an update of a webinar or something like that, that we were getting information from. Then on January 30th is when I began what I thought would just be a series of weekly updates to my area clinicians, and I’ll read an excerpt from that because it’s probably kind of helpful. It starts off, “Welcome to the first weekly update from the Portland area IHS [Indian Health Service] regarding the novel— 2019 coronavirus outbreak. Our goal is to distill information for you on a weekly basis to minimize some of the email traffic you receive, allowing you to focus on information that is most relevant to your clinical operations.” Well, one problem with that paragraph is it says we but it’s just me. I don’t have a team necessarily. Then I have a couple paragraphs giving the background, and then in each of the subsequent issues of this little newsletter I keep all of that at the front. Then I have a bunch of links from our state health departments, and then each week as there’s something new added I would add those in and highlight them so you had all the old information plus what was new. It could be readily gleaned from looking at the highlighted information. One thing I noticed is that we have three states that we work with. Oregon, Idaho, and Washington.

Each week there were more entries under Oregon and Washington. I don’t know if I didn’t pay close enough attention to Idaho or if I did— I don’t recall if I did due diligence to look every week at what Idaho’s updates were. In my newsletters there were no updates from Idaho after the first one, which was just a health alert. Idaho, you know, unlike Oregon or Washington doesn’t have a port necessarily so it was less affected by I think any risks of international transmission or people coming into the country. Maybe they felt like they were not quite as affected early on. We tried to mostly link our clinicians to the updates that were coming from the states because our clinicians are going to be reporting cases to the state or to the local health jurisdiction if they happen to have any kind of case. They need to really know what to do and how to do it in their context, their local context. Fast forward to March, where we had the stay-at-home orders and all of that stuff, one of the issues that became a struggle for me personally and for us in our area was sort of a top-down directive that we were only going to share information from CDC [Centers for Disease Control and Prevention]. CDC was putting out the best information, I believe, that they had access to and available to them. As I said, our clinicians also need to know about the local situation and what to do locally. Because that’s where they’re going to be reporting cases. That’s where any help is going to come to them. It’s going to be from the state or from local health jurisdictions. We had some heated discussions, let’s say, about whether we could only provide information that was from CDC or whether we had some latitude or discretion to provide information from these other sources. I argued pretty strongly that we needed to do both. There was no reason for us to limit it. There was distinct reasoning – a distinct need for us to have local information. Officially we were kind of bound. We could only repeat what CDC was telling us we could say or was happening. I looked for unofficial channels to be able to put information out. I think these newsletters stopped on February 28th. That was the last one that I could find on my computer, I think it’s the last one I issued. Because by then it became impossible for me to distill all the information and share it with everybody once a week. Things started to move so much faster.

I was talking earlier about Idaho. One of the things that Idaho and Washington were doing early on and making available was, they began reviewing newsfeeds and the latest literature and things like that and putting out, initially daily and then eventually weekly, distillations of that information. That was immensely helpful. I think under the direction of the CEFO, the Career Epidemiology Field Officer, in Idaho, these weekly or daily initially, kind of updates on information from published articles, from various news sources and reputable websites, became really valuable. Because that was a place, like a little digest every evening, I could get the digest and then kind of look through it and maybe learn something for the next day that I could then share with others.

Q: Who prepared these? I mean, how did this information get shared? Also, when you say we and they, who are you referring to?

WEISER: Okay.

Q: Let’s start with we and they.

WEISER: Okay, give me just a second. Because I always have trouble with names. Can you pause for a second?

(pause)

Q: Alright. Go ahead.

WEISER: Kris Carter. K-R-I-S Carter, she’s the Career Epidemiology Field Officer so she’s the CDC assignee to the Idaho Department of Health and Welfare. She and Michelle Griffin was the other person that was working with her I think, they would send out these daily digests. And those were tremendously valuable because that would come as an email right to my inbox and I could click on it and then I could just scroll through and look at it. For Washington and I think Oregon was doing this too, it was a place on their website you had to navigate to. It wasn’t as readily available. You would have to go search for it. But this was something that would show up in my email box that was really helpful. I have to admit, I didn’t read all of them. Maybe only about ten percent, but when I did read them, I always learned really useful information. There’s just so much out there. I think maybe they were working with some other site too, to put those together. Maybe they were just passing on information from another source. I’m not sure. Wherever they got it from, it was extremely helpful.

Q: So, besides CDC giving you information, you got information from these sources.

WEISER: Yes.

Q: These are more local sources?

WEISER: Well, what was produced on the digest from Idaho was actually, you know, the latest research. So not just local stuff. It was national and international research. You know, links to articles and JAMA New England Journal and other places, MMWR’s [Morbidity and Mortality Weekly Report]— they always gave a little synopsis of it too. The one takeaway from all that was each synopsis would always have at the second or third last line, “The authors opined,” about something and nobody uses the word opined really that much. Every single one of those always said the authors opined about what this means, and I thought that was interesting.

Q: How long did those last?

WEISER: They’re still coming out I think about once a week now. So less often but still available. We recognize, and I say “we”— we, was myself and our chief medical officer at the time, Andrew [J.] Terranella, and Andrew now works for CDC in their opioid prevention on the pediatric opioid response. So, Andrew was our chief medical officer. I was the medical epidemiologist. We also had our CDC assignee, Alex [Alexander] Wu, EIS [Epidemic Intelligence Service] officer. So that was mostly the “we” that I refer to. Then the Northwest Portland Area Indian Health Board were, I was still going there every day to work. You know, we also had a team of folks there as well. Mostly Celeste Davis, who was the environmental health lead for the health board at the time. The four of us would share information between ourselves and try and get together and discuss what might be important. This became kind of the way that we got information to the tribes eventually. Once there was a total declaration of emergency and, which I think was March 13th, then we had our incident command set up. That was for the Portland Area Indian Health Service.

In the weeks leading up to that, I did approach our area director to see if we could have a combined incident command structure that would include myself and our counterparts. Plus, my colleagues at the Northwest Portland Area Indian Health Board as well. Because I thought that would be the best way if we combined into a single incident command, that we could have, you know, a better way of communicating information and keeping everyone up to speed. I don’t know if it was an internal decision or if it was directed from a higher level like IHS headquarters, but we were not able to have a combined incident command. The area office had its incident command and then the health board had its own incident command. I was on both so I had my own combined incident command, but we weren’t always acting together. Part of the difference for that is that Indian Health Service, the area office has its first and foremost responsibilities for the six facilities that we directly operate. Then secondly, to support the rest of the tribes as much as they can with whatever resources and funding was left to the area to distribute or to manage for those tribes. Many of the tribes have taken portions of their funding to operate, for example, behavioral health services or diabetes programs or other programs, and so those funds don’t exist at the area. We don’t have any ability to manage or direct any of that funding or those programs. Those are up to the tribes then. The health board then, the Northwest Portland Area Indian Health Board, represents all forty-three tribes. Including those that have their operations directed directly by IHS. The tribal representatives, tribal delegates from each of those tribes are on the Northwest Portland Area Indian Health Board and so the board is responsive to all of the tribes and has an obligation to provide information, funding, direction, to all of the tribes. Now when I say direction, I use that term loosely because each of the tribes is a sovereign nation. They determine their own priorities and how they’re going to respond to whether it’s a public health emergency or an ongoing program like the diabetes program. It’s up to them to determine how that’s going to be operated and how they’re going to use the funds that they’ve received for those operations. In my role as the medical epidemiologist, in general my role is more as a consultant to the tribes and to the Northwest Portland Area Indian Health Board.

For our six directly operated clinical sites, I don’t really have a direct line of authority but under the ICS [incident command system] structure I guess and with the backing of our chief medical officer, then I could say things that people would have to do. I don’t generally give orders, which some might expect since I have the rank of captain on my collar. If they see me in public they think, well a captain (equivalent of Colonel in the land services) would command an entire military installation in the Army or the Air Force. I do not and I don’t have any staff that I direct other than my CDC assignee, my EIS officer. Which I’m extremely grateful for because having the EIS officer with me and available to me gave me like, it was a way to double my capacity. I really appreciate having those colleagues.

Q: So, after those first couple of weeks and months, how did the rest of COVID play out for you? One more question. Having so many incident command structures, did that create challenges in how you got your messaging out or —

WEISER: Yes. I’ll come to that in a bit. I’m going to start with what else I was doing in February. So, I was putting out these weekly, or I had kind of slowed already to like biweekly because I couldn’t keep up, updates to the clinicians. In mid part of February, February 11th, I traveled to Sacramento to join the California Rural Indian Health Board, another board like ours to meet and have a discussion for a couple of days about maternal mortality review committees. This is the kind of work that I was doing when all this happened. Then later in the month on February 25th I was at the ACIP [Advisory Committee on Immunization Practices] meeting, which I think was Nancy Messonnier’s last public appearance, or maybe the weekend after that. At that meeting, there were two things that happened and one of the things was Nancy gave us the straight talk about what we were facing. I think everyone in the room appreciated that and was already recognizing that that was the case. That we were in for a major pandemic that we weren’t going to be able to readily control. The entire room stood and applauded her presentation.

Q: They did?

WEISER: Well, here’s why I’m not a great historian because yes, I think it was at that meeting. I’ll have to double check, but yes. I think they all appreciated her giving us the straight talk. That standing ovation may have happened later, but I think it was at that meeting. It must have been because we hadn’t met face to face since and I haven’t been to a face-to-face meeting. It was at that meeting.

Q: So, at the ACIP meeting?

WEISER: At the ACIP meeting after she gave her statement, everyone stood and appreciated her. It was kind of a moving moment because it was like, you know, okay it wasn’t as dramatic as Henry the Fifth’s St. Crispin’s Day speech but it was maybe the closest you get in public health to that. It was like, okay we’re hearing what is coming and what we’re going to be in for. What’s that?

Q: How did people react to that? I mean, in the room?

WEISER: I think we all listened attentively, and I think the main thing we appreciated was hearing the truth. Which we were all suspecting was the truth but hearing it from her. You know, most folks in the room are vaccine experts but they’re also public health experts and many of them are epidemiologists. This is the kind of thing that we’re all kind of prepared for. We know that vaccines are going to be probably the most important tool that we get. I think at this time it wasn’t clear like how quickly a vaccine could be developed but one of the things, you know, is that within just like ten days of identifying the virus we had it sequenced. That was a kind of a world record, because for SARS-CoV, that happened in 2003. It took three months to do that.

Q: Why was it so quick?

WEISER: Well, I think the technology has improved in the period of time and so it was sequenced and shared within ten days. I think that was a real key thing about being able to then take that sequence and be able to make vaccines using that sequence and recognizing which of the areas that we need to focus on. The science moved really fast. I know there’s a lot of debacle and you know, complaining about CDC’s first tests not working properly. You know, at the time it was a huge setback and it really affected trust I think in CDC. But when you look now, two and a half years later, those first tests were so small compared to all the tests that we’re doing now. I mean, the millions and millions of tests that happened. While it would have been really critical to have more testing earlier on, I’m not sure how much of a role that goof up made in the overall ability to get testing developed and rolled out.

I think there were for whatever reason— the supply chain issues began early on too and I think that was in my weekly updates. By the second or third one, I had already been communicating to our clinicians that PPE [personal protective equipment] is hard to find. They hadn’t released the national stockpile until later on but for our sites to be able to get updated PPE, N-95’s and things like that, it was already becoming hard to find in early February. Testing supplies, we began to have difficulty with getting the swabs and the transport medium and that kind of thing. To be able to do the testing, which all had to be sent to the state. The process for getting a test, in Idaho you actually had to call the state first before you sent any test because they were prioritizing testing. So, you had to get it cleared that this was a priority patient and then you could send the test to them. And the other states didn’t require a call but they did require this form or two forms to accompany each sample. Those would be reviewed, and if the patient met the criteria, then they would run the test. If they didn’t meet the criteria, they wouldn’t run the test. Early on there was very restrictive testing because it was an asset that we had in short supply. In hindsight, you know, it was that approach that really made all the difference in allowing the virus to spread unchecked. Because we were missing so many people that could have been tested and might have been positive asymptomatically or pre-symptomatically. The focus on only testing symptomatic people was one of those things that really, if we could do it all over again that’s the thing that I think we would want to do differently. Is have our tests developed faster and not run into shortages of swabs and either the liquid viral transport medium that’s required for the swab to reach the lab. Eventually we got permission to use just saline, which that was available. That was a game changer because it allowed us to test more people and get around that supply chain issue.

Q: Testing was important because— why?

WEISER: Our only tools in the first months of the outbreak were to identify cases and make sure that we got back to that case, found that case, and had them isolate so they would stop spreading the disease. If they were indeed not that sick or not symptomatic at all, we needed to communicate that their test was positive and they needed to isolate. And then we needed to get the interview process going so we could interview them, find out who their contacts were, and monitor them. Put them in quarantine where we could monitor them for signs and symptoms. If they developed signs or symptoms, then we would test them. Our early tools were identifying cases, isolating them, doing contact tracing, quarantining those contacts, and all that depended on that test. That was the first thing that we needed to have happen. Then for folks who may have been around someone, there were masking and social distancing recommendations that came out. You know, about mid-March or so is when that really took on a greater importance. We had the different stay-at-home orders from the different states and that sort of thing.

It was in early March, I think a couple days before that, maybe March 10th, I was planning to go on vacation with my family. We had a spring break planned. We had tickets to go see my wife’s family in Japan and it became quite apparent to me that I was not going. It also became apparent to me, I think, that the best thing for my daughter and my wife to go. And my daughter’s a senior in high school at this time and I just had to tell her pretty frankly that, “Honey, your senior year is toast. Take everything with you. You’re going to Japan with Mom. And I don’t expect you guys back very soon.” They left around March 10th and my daughter was gone until the summer, so until I think it was July when she came back. My wife stayed there even longer. She came back after eight months. It was later in the fall that she came back. Yes. That was an added hardship for me in some ways to not have my family with me. It was also a relief because I didn’t have to worry about them or you know, I could focus full time on what we were doing. What I was trying to do. I could go to bed when I wanted to and that sort of thing. I just didn’t have the support of someone who could help with cooking and you know, things like that. So, I was on my own for some of the daily essentials. I also didn’t have the interruptions that I would have probably normally had and probably welcomed and maybe even benefitted from by not having my family there. But also, Japan is a completely different case study. In Japan it’s not controversial at all to wear masks. It’s always been common if someone either feels ill or feels like they might get something from somebody, they’ll wear a mask to protect themselves or to protect others. There is no stigma about wearing a mask at all. In Japan when, for the most part, when the government would declare a lockdown or a quarantine or stay-at-home orders, at the beginning especially there was ready 100% compliance. Everyone did what they were supposed to do. That’s pretty common in Japanese society in general. There wasn’t protesting and that kind of thing. Even though Japan had cases, they also had I think more testing than we had earlier on. They and South Korea and other countries in Asia learned from the first SARS outbreak how important testing was and isolation and quarantine and rapid response to that. I think they did a better job in the early days of doing that.

Q: So, did you feel a little isolated though?

WEISER: Yes, absolutely. Absolutely. Emotionally, it was difficult because yes, I didn’t have much social interaction. I will say however, I live in a co-housing community, which means that we’re like a condominium but we’re self-managed. I was also getting asked to provide guidance for my neighbors as well. Like, can we use the common house? Are we still going to have our potlucks? Are we still going to have our once or twice a week community meals? Things like that.

One of the worst was telling them masks are still not recommended, we don’t know if it helps or not. Then like an hour or two later, “Everyone make masks.” [laughs] “Go buy fabric, go buy elastic bands. Start making masks. Here’s designs.” Then you know, maybe an hour or two later, “Well, it might not work that well.” Whereas my wife in Japan is like, “You guys are so dumb.” “Masks work. And even if they don’t work that well, they don’t hurt anybody. Why aren’t you wearing masks?” I was like, yes. Like always, my wife is always right. [laughs] Okay, yes, everybody just make masks. We had people who were, in the early days, were staying at home. We’re complying with the orders. We want to do something, and so making masks for ourselves, part of it was making masks for healthcare workers who were running out of PPE. It was like, should we be doing that for people at the hospital that’s down the road from us? Or people always want to help the tribes and so they wanted to make masks that I could then send out to people. Actually, some of the best masks were made by some of the folks in tribal communities who also were making masks and are great at sewing. There’s a lot of traditional sewing that takes place and so I think some of the best masks came from those communities anyway. There was that confusion about what works, what doesn’t work, what should we do, what shouldn’t we do, you know? As individual citizens and officially as federal employees and that kind of thing.

Q: Why do you think there was so much confusion in the very beginning of the masking? Not masking, masking— yes, we’re masking, well maybe some masking?

WEISER: Well, there were conflicting messages coming from CDC. Since that was our only source of information that we were allowed to share, you know, it was kind of like a lot of people felt like yes, masking makes sense. We should do that. It doesn’t hurt. But CDC hasn’t said it yet officially. Then you know, it was sort of a lukewarm recommendation of you could wear a mask if you wanted to. People may wear masks, rather than should wear masks. In our healthcare settings, that was different. That was a little bit more— well we weren’t wearing masks in the healthcare setting initially, everyone. Only in the area where we were seeing potential COVID patients, so seeing respiratory patients. Then it was, a mask or an N-95. Then OSHA [Occupational Safety and Health Administration] regulates N-95 use for employees in healthcare settings and other employment settings. There are rules and regulations about wearing an N-95, it’s not a mask it’s a respirator and it’s regulated by OSHA. Our employees who were asking to wear N-95s all had to be fit tested to demonstrate that they are wearing the right size respirator, that it has a good seal, and that it’s actually providing the protection that it’s supposed to. That’s why they have these regulations. Because if you wear an N95 that’s too big or too small or doesn’t fit properly, it’s not providing you the protection that it’s supposed to.

The protection comes from filtering through the face mask, or the filtering part of this respirator. If it’s got gaps on the side or over the nose then the pathogens are going to follow the path of least resistance and they’re going to come in through those gaps, and you’re no longer protected. But we hadn’t done a mass fit testing for our staff. We found that there are two ways to do it. Many large hospital systems have a qualitative, testing systems and CDC has this, they have a machine, you hook up a tube to the N95 and you breathe through it. It tells you, quantitatively, I’m sorry, how much of a seal you have and what the pressures are and things like that. Most places, most small healthcare places, which we are, use qualitative testing. That means you wear the mask, you put on a hood, and you spray something and see if you can taste or smell it. We usually use saccharin spray, which will taste sweet if it gets into your mouth. Well very quickly, there was a shortage of those sprays that are used for fit testing. We had that constraint as well. We had one of our six service units had an extra set of sprays, and so we then mailed those around to the different sites. You know, sent it to one site, when they’re done with it, they sent it to the next site, send it to the next site. Trying to rapidly get all of our staff fit tested that would need to be fit tested to wear N95s.

We had a lot of N-95s in a stockpile from H1N1 [H1N1pdm09 virus] and these had variously gotten extensions of their shelf life for being still functional. They were kind of running low on their shelf life but the ones we had were still valid to be used. Those were what we were able to use initially, and we were able to use our— IHS runs a national supply service center located in Oklahoma City. That’s kind of our main clearing house for supplies and medications and vaccines and things like that. We were able to get some things from them. Once stuff started coming out from the national stockpile, we could either get them through that source or through our states. Both of them were getting allocations [from the stockpile], and so that was helpful. In short time we had boxes and boxes of N-95s and one of the things I remember thinking was, yes, we need these for our staff but we’re not doing critical care for very sick patients. We stopped doing any aerosol generating procedures within our clinics so the need of having to wear an N-95 to avoid any kind of aerosolization was really low. At that time, hospitals and things like that were really in need. I felt like, I wonder if we should redistribute some of these to our local hospitals. You know, we didn’t do that because if we gave those away, we wouldn’t know when we would get more back. We continued to use what we had for staff.

Q: You never experienced a shortage?

WEISER: No, I don’t think we ever experienced a severe shortage of N95s, masks, or gowns. We were impacted by the shortages of vaccine transport medium for a short time until they said, well you could just use saline if you have to. That allowed us to be able to do that. I think we did have short term shortages of the swabs as well, but the folks in Oklahoma City at that center were able to reach out. We had additional spending authorities to engage in contracts that allowed us to reach out to other vendors that we hadn’t normally worked with. Sometimes paying through the nose and then of course there were a lot of allegations of fraud from some of those vendors that jacked up the prices of things in order to make them available to us. You know, we didn’t have much of a choice. If we really needed something and there was only one or two sources to get it from, we just had to pay the price.

One of the other things that I spent a lot of time thinking about and not knowing really whether we could or how we could do something, was we were seeing the pictures from China initially and then from New York City that these patients were being put into these temporary facilities. Temporary hospitals. Field hospitals, if you will. In China, it was if you were exposed then you were put into these quarantine, mass quarantine centers, right? We didn’t have anything like that. In some of our pandemic planning there was allusion to being able to do that, but nobody really had concrete plans on how that might work. Once we had the emergency declarations and FEMA [Federal Emergency Management Agency] was brought on board, we quickly learned that FEMA would be the resource that we would turn to, to help us plan for setting up any kind of structure like that and would provide the material and the funding for putting it together. But they didn’t have a staffing package for it. That became, for me, the critical question. Like I think we could probably build this if we needed to in a tribe or at one of our facilities, but who’s going to staff it? Who’s going to be there twenty-four hours if someone is there and gets sick and needs to be seen by a provider? Needs to be transported somewhere? I mean, there were so many questions about that, and we didn’t have any experience or resource at that time to think through that. So, one of our—go ahead.

Q: In April, end of April, President Trump launches Operation Warp Speed and that is creating a vaccine.

WEISER: Right.

Q: Which is pretty early on, for April.

WEISER: Yes. Yes, I was part of that because I was on the ACIP representing IHS at the time. With that effort there were a lot more meetings that suddenly came onto my schedule. There was the COVID-19 work group for ACIP and I joined that. In addition, I was on other work groups, those other work groups really slowed their cadence, the pneumococcal vaccine work group and some of the other work groups kind of took a backseat to the COVID-19 work group. Because we were meeting like every week for a while and then every two weeks at some times. Then just before any new change or considerations were coming, then we were meeting sometimes twice in a week. We had the ability to have presentations from Pfizer, from Moderna, directly to the work group so that we could learn what they were doing. All of that was held in the strictest confidence. It was a challenge to hear what they were working on and not be able to talk about it outside of the work group. You know, I could only say that we heard from, maybe I could mention that we heard from them about the developments. But I couldn’t say anything really about any of the details. Being on the work group allowed me to be able to listen to all of the CDC experts that were also on the work group and be privy to their thinking. You know, what they were thinking about. What their considerations were.

Early on, discussions about equity were an important part of what the COVID-19 work group worked on. I really appreciated that because as we were by then seeing in April and May, how the Navajo [Diné] nation was impacted early on by COVID and how it just rapidly spread through those communities. Which frankly was a bit surprising, because you know, I haven’t worked on Navajo but I’ve been around there and there’s large distances between the population centers on the reservation. Then many of the people live quite a ways from their neighbors. I mean, miles apart sometimes. But the challenge is they don’t have running water. They don’t have electricity. Communication is a challenge. They don’t have the internet in many of these places. There’s such a challenge of getting information to folks in those regions. If you can’t wash your hands, if you don’t have a ready water supply, you can’t wash your hands, then a disease like this is going to spread really easily. Even though there’s a large distance between houses out on Navajo, the houses are small and the families are large. There are many people living under the same roof. That’s not unique to Navajo, that’s true throughout Indian country and in our region too. I think that’s one of the issues that we faced early on with cases. That you know, sometimes we would have outbreak clusters that were related to an event like a funeral or some other social gathering. Usually, it was related to household clusters, because there were ten people in that household. When one person got it, it very quickly spread to the other people. On some level I thought, well I would have thought that maybe Navajo would have been more protected because of these large distances. It wasn’t really too much of a surprise how heavily they were impacted.

There were other stories we were hearing from other parts of Indian country. Where I started my public health service career with the White River service unit in Arizona, White Mountain Apache actually stood up their incident command and their response. They actually had some really early on great success stories. A big part of that was being able to mobilize a team to be able to go out and visit people in their homes. They had an article in, I think it was New York Times Magazine, if you haven’t seen that I think I have a copy or a link to that I can send. You know, one of the stories they shared was that they would go to see a patient that they knew had been exposed or had a positive test and they were following up on that person with a positive test to see how they were doing. As they made that home visit, they would look and they would see the elder in the kitchen in the corner who hadn’t come in for testing who looked sicker than the person they came to see. They identified that very ill person, were able to get them into care, and that was a big factor in the success of their home visiting program. Yes, they were able to follow up on the people they intended to follow up, but they found all these other people who were also ill or maybe even sicker than the persons that they were trying to visit. We were all trying to set up some kind of outreach to the communities by partway through March and April.

Our cases were really slow in starting. We had trickling cases in March but then by April we started to have more and more cases. We were trying to get ready for that because we had in our six service units, we have public health nurses in three of them that we manage. In the other three the public health nurses are managed by the tribes themselves. Those three service units that were tribally operated, only one of them really had public health nursing capacity at the time. The other two did not. They had a couple of community health nurses, but community health nurses are different. They’re the people who maybe help make sure someone gets oxygen for their chronic lung disease or wound care supplies or ostomy supplies and things like that. They may be doing home visits to check on people with chronic illnesses. They weren’t in the job of doing contact tracing and case investigation. Our EIS officer, Alex Wu, he got materials together through working with the states and from CDC and from IHS. He went out and he did trainings on contact tracing and case investigation in these communities so that they would be able to have a workforce that was trained and could respond. Early on, the states asked the tribes, do you want the local health jurisdiction to do these case investigations for your patients or do you want to do it yourself? I was a bit surprised that the vast majority of our tribes responded and said no, we want to do it ourselves. This was something they hadn’t been in the habit of doing. Whether it was pertussis cases or sexually transmitted infections or TB [tuberculosis] or anything else, most of the time those things were being investigated and followed up and contact tracing done by the local health jurisdictions. The county health departments around those tribal lands. In some coordination and consultation, oftentimes the counties are— they don’t feel like they have the ability or the right to just go on the reservation and talk to folks. They always want to try and coordinate and get permission to do that. In this case, the tribes were saying no. I think they probably felt early on that this was an existential threat and they wanted to be the ones to really take care of their people. There’s also some legacy from H1N1 and some of the other past interactions with government that the tribes were understandably reluctant and skeptical the government would be able to take care of their needs.

I mentioned earlier about the ICS and the health board had its ICS and IHS had its ICS. In the health board ICS, they began a data collection of cases, testing and cases from each of the tribes. It was voluntary. Each day the tribes, and this is still ongoing, each day the tribes were asked to fill out like this survey— SurveyMonkey survey that gave the basic information about how many people were tested, how many people were positive, how many were negative, how many were hospitalized, and how many had died. We didn’t have 100% reporting from all of the tribes on that. Not on every day and not on any day. We only collected information when we received it and it was voluntary. We couldn’t compel that information collection. This was to support IHS’s effort to collect the same information. What IHS set up at a national level was a spreadsheet that would be completed every day and then forwarded to headquarters. Well, it’s forwarded to the area and the area person compiles it and then sends that area report or area spreadsheet to national. At the national level I think there was just one person who would receive these national reports and have to collate those national reports into a daily report. The information is only based on testing. It’s only based on the patients who were tested in our facilities. A site could report on tests that were done elsewhere that they knew about. Like, you know, we had three patients who got tested at the hospital this week and this is their results. They could add in that information. It was really about collecting on the testing that we were doing. We don’t know how many of those tests were conducted by us and how many of those tests were conducted outside of our system. Moreover, the tool was designed to be as quick as possible and tried to be as low of a burden as possible. There was no information collected on demographic variables or risk factors or underlying conditions or, when they became available, vaccine status. Those kinds of things. To this day, that’s the only information that IHS has.

Q: Oh, really? They didn’t get updated or adjusted?

WEISER: No. No. In a recent conversation with someone at, you know, one of the highest levels in our agency, I confirmed this. I said, “So, if someone asked you for the age breakdown or the sex breakdown of our patients, you couldn’t tell them, could you? If they asked you how many of our patients were hospitalized or died, you couldn’t tell them, could you?” Because we don’t have that information. This is probably, for me, the most vexing part of our response, what hampered me the most as an epidemiologist. CDC and NIH [National Institutes of Health] use a system called REDCap [Research Electronic Data Capture], which is not that different than SurveyMonkey in the sense that you get a link, you open that link, and you have like a survey. You fill in the survey and then it goes to a server. Then there are some tools within REDCap where you can do data analysis or you can export it to SAS [Statistical Analysis System] or [Microsoft] Excel or whatever you want to work in. However, complex you are. You can do more analysis of that. You have certain functionalities. You have fields that are validated. You can only put in information like yes or no, not a mixture of yes, no, plus signs and minus signs. P or N or Y or things like that.

There are data quality parameters set for the field so that you get consistent data, so that you don’t have to spend hours and hours cleaning the data before you can actually analyze it. Stop me if I’m getting too deep in the weeds of this stuff.

Q: It’s okay.

WEISER: But for an epidemiologist, these are the kinds of things that you know, it’s like talking to a carpenter about the right kind of wood or nail or screw to use. Or the right kind of chisel to use for this particular thing. We need the right tools to do our job. So, NIH uses REDCap, they have used this for a long time for many of their research studies. It’s HIPAA [Health Insurance Portability and Accountability Act] compliant. It’s secure enough for NIH to collect very detailed information about people participating in clinical trials. CDC uses REDCap. Many of our states when their information systems for collecting cases, their usual systems became overwhelmed. There was just no way they could handle the volume that was coming into their usual systems. They turned to REDCap to be a way that they could offset that load and more quickly get the information they needed. If you sign up with REDCap, it’s free. You have to have the server and infrastructure and stuff, but you design your own data collection forms in this system to meet your needs. Then people put in the information, and then you see the information. There were also some other, you know, black box tools that were made available to in different jurisdictions to help with contact tracing and case investigation. None of those could be approved by IHS to be used.

Q: Do we know why?

WEISER: Yes.

Q: Are you willing to comment on why?

WEISER: Absolutely. It comes down to, you know, a bureaucratic red tape issue. It may have something to do with interpretation of rules and regulations. It may actually be, they were actually right on some level. When other HHS [Health and Human Services] agencies can use this software to collect HIPAA protected information and we’re in a pandemic, it seems to me that when it comes to security and those kinds of things, better funded agencies than ours have already gone through this and determined that it’s okay. Our agency, which is severely underfunded, determined that they weren’t secure enough for us to use, number one. Number two, they determined that it would actually be considered a system of record. Which is an OMB [Office of Management and Budget] term, or yes, I think OMB. You have to go through certain steps to be able to adopt a new system of record. It has to meet like all the national archives criteria and things like that. It’s a federal system of record and so it has to meet all these specified criteria. You have to, you know, request that or apply for that and demonstrate that you have a need for this and that this meets that criteria and all of that. That probably takes a couple of years for most systems, I would imagine. What they determined was that we had an electronic health record, which is our OMB authorized system of record. They felt that, you know, we could not justify requesting a new system of record. Myself and several other people, we tore our hair out time and time again when we had these discussions because we could not make any headway with the folks at headquarters who were making these decisions. You know, our office of technology and it still defies logic for me. That a pandemic of this scale was not justification enough to have a system of record or that we could get some kind of a waiver from OMB to adopt this now and do the paperwork later or something. Of course, bureaucracy can’t operate like that, right? You can’t say let us have it now, we’ll get back to you later with our promise to comply with all the rules and regulations. I understand that on some level, but no one was willing to go to bat for us. No one could look and say—Hey NIH, can we tag on, or CDC can we tag onto your OMB authorization for using this system? If they had one. Or if CDC doesn’t have an OMB authorization for this as a system of record, then why in the hell do we have to have that? Are we being held to a different standard and is it a matter of people’s interpretation of those standards? These are the questions I still have. I don’t know the answers to these.

I tried working with our public health nurses. Particularly one of our service units, the Yakama service unit which serves the Yakama Nation, was being really hard hit. They are the biggest of our service units. They’re user population is around 12,000. I think the enrollment of the tribe is even more than that. They were having a lot of cases when this happened. We only had one of four public health nurses filled, so there were three vacant positions. So, she was working— the one public health nurse, Marie Bastin, was working really hard to try and set things up and put things together. You know, she developed a spreadsheet and that became her system of record for tracking cases and contacts. Eventually we were able to establish an agreement with the tribe, but it took a long time to get this agreement through where the tribe would assist with the contact tracing piece. As a federal employee the public health nurse was primary in charge of the case investigation. She had the information in the electronic health record of a positive test. She had their contact information in that electronic health record. She would reach out by phone if she could and talk to them and do the clinical follow up a little bit. Like, give them guidance if they’re sick, when they need to go to the hospital. Then she would each day provide information to the contact tracers about the contacts that needed to be followed up. She was actually doing the case interviews and then she would collect the names of the people that were contacts, and she would share that with the contact tracers.

The difficulties around HIPAA and interpretation of HIPAA and trust between the tribe and IHS were such that initially, we couldn’t share with them who the case was. I’m not sure how this played out in other jurisdictions. You know, when they’re doing contact tracing, are they saying, “You were exposed to Mary A. last week and we’re calling to follow up and see if you have symptoms or can you get tested or have you been tested?” I mean, usually in case investigation and particularly if it’s a sensitive thing, you’re not going to disclose who the case was. You would just say, “We know that you were exposed to somebody”. So there really wasn’t necessarily a need for the contact tracers to know who this person was. One of the issues was, in the communities everyone knows everyone. If you know who the case was, you know that out of these three contacts you’re given, you know the whole family and there’s ten more that should be on this list that aren’t on this list. You would know that if you knew who the case was. There were reasons why I think the contact tracers probably should have had that level of information. Eventually I think we did iron that out where they could have that, but we had to really make sure that they were on board with, you know, HIPAA compliance and not revealing that to other people. Either the people they’re calling or anyone else that they might talk to about their work. Family members, council members, things like that.

There were pressures early on from tribal councils, not just there but other tribal councils, where council members wanted a list every day of who was positive. Especially in the early days. Because you know, if they had one case or two cases, they wanted to know who it was. We had to like push back and say, “We can’t tell you.” “We’re not allowed to tell you. It wouldn’t be good for that person, for you to know, for everyone to know that they have COVID.” Right? Try and really explain the nuances of the stigma and everything like that that would quickly arise. On the other hand, when IHS is providing the care and the tribes providing the support, including the home visits, and delivering food boxes and delivering oxygen sensors for family to have at home and thermometers and over the counter medications for someone who might have COVID. They need to know where to go. And as soon as they get the address, they’re going to know who lives there. You know, at some level we had to be able to share information and work together. It was a rocky road for many reasons initially.

Q: Has that rocky road gotten a little bit smoother?

WEISER: The road’s closed now. Right? We don’t do case investigation or contact tracing anymore. We do case investigation but not contact tracing. Some of the tribes have stopped almost all of their COVID activities.

Q: Really?7

WEISER: Yes.

Q: Is that because the vaccine came out and everybody got vaccinated and everybody’s complacent?

WEISER: Part of it I think is that the funding has run out, so they’ve spent all the COVID funding that they received. There isn’t any new or ongoing COVID funding coming, so there’s that. There’s also the desire to get back to normal. You know, schools are opening up. Businesses are opening up. Things like that. And we do have the vaccines and we have treatments available. In many of these communities, like you know, there are still county and local health jurisdictions that are working to still track cases and provide guidance and things like that. Almost everything now is such that, you know, yes, there’s not much of a response left to COVID anymore. Anywhere you go.

Q: Is that due at all the vaccine coming out and the lack of funding, I guess?

WEISER: The response has pretty much stopped because we have vaccines and because we have treatments. Because people are not dying at the rates that they were dying initially. Of course, the economy can’t handle being closed for all that time. As far as masking and some of the other social distancing things, in my opinion those should still be ongoing. Because they work. Because not everyone is vaccinated. Because these variants keep coming out and because like it or not, COVID has an asymptomatic and pre-symptomatic period that that is the, I don’t know what the right term is. The coup de grâce? I don’t speak French but I mean, that’s the thing that sets this virus apart from flu or other things is that piece. Because people can be infected, not know it, and spread it. As long as that continues, we really should be wearing masks. Even I have been to gatherings recently where initially I wear my mask. I’m the only person in the room wearing a mask, or one of five or something. I’m like, it feels safe, it could be safe. I’ve got all my boosters. I’ve got my bivalent booster. I think I’m going to take my mask off. You know? Especially if I have to speak and I want to be heard. It’s hard to speak through the mask. I’ll tell you in a week if I got COVID or not.

Q: Yes, same here. I’m probably one of the few people wearing a mask when I go to the large gatherings. If ever I’m on a plane, I’m probably the only one on the plane wearing a mask.

WEISER: Yes, yes. Airports I do. Grocery stores I do. Because, you know, I don’t know anybody at the grocery store. They don’t need to see me if I have a mustache or not. I’m here to buy stuff, you know? Gosh, especially like Costco or something. Yes. You don’t need to see my face. It’s okay.

Q: Now I want to return back to vaccines, and you’re work. The ACIP and how you were able, you were privy to what was going on and how that felt with that information and not being able to share it. Thank God your family wasn’t there because you probably would have inadvertently said something.

WEISER: Yes. Related to that, IHS headquarters set up a vaccine task force. When Operation Warp Speed was first announced, it was within the first weeks of Operation Warp Speed, IHS set up a vaccine task force to prepare and plan for this. We had staff who were embedded with ASPR [Administration for Strategic Preparedness and Response], the Assistant Secretary for Prevention and Emergency Response. I’m a terrible bureaucrat. I can’t remember acronyms to save my life. We had folks from IHS from, mostly these were pharmacists, from either the Oklahoma City National Service Supply Center or from the vaccine task force, who were pharmacists from different parts of the country who were specifically asked to participate or take on leadership roles within the task force and stepped up to do that. These folks were embedded with folks at ASPR and in Operation Warp Speed, so they were there with them as things were developing. Then they would report back to the vaccine task force about how things were developing. There was this other channel too where some of the information that I was hearing through ACIP, you know, we were hearing it from these folks as well. From the Operation Warp Speed directly. You know, one of the main lessons that we learned from H1N1 was when that vaccine was developed and rolled out, and the nature of H1N1 was such that it really affected younger people and middle-aged people more than older people for whatever reason. We still don’t know why. When the vaccine came available, the priority population was those younger and middle-aged people. Not the elders. And in tribal communities, elders are like the most revered. Those are your traditions, your knowledge keepers, you want to protect those folks. They’re usually the older, more vulnerable part of the population too. It was completely opposite to anything that the tribal communities were used to or expected or planned for when H1N1 came out. There was pushback, because CDC said you have to use this vaccine in the way that its detailed and you can’t deviate from that. They called them deviations. If a tribe said, yes, we’ll get the vaccine but we’re going to use it however we want to. You can’t tell us what to do, we’re a sovereign nation. The sparks flew over those issues with H1N1.

The other thing that happened was that as sovereign nations, they expected to deal directly government to government. Like tribe and federal government. That level of government interaction. For tribes, it’s an insult to say, you have to work with your county. They are more and more willing to work with the state in lieu of the federal government, but not the county. We heard this in every after action, every emergency preparedness meeting we had after H1N1, we would have discussions about this particular issue. It was really well known, particularly in Washington state, that if we’re going to have any kind of an asset delivered like this again to tribes, the state has to be the one that delivers it and not the county. Because the state can maintain a certain level of responsibility and interaction with the tribes on a government-to-government basis. It won’t be left up to some county person who might not have a good rapport with the tribe and might not have the same level of respect for tribal needs or tribal wishes. That lesson was learned. I’m thinking particularly Washington state, which is where it came up a lot. When COVID vaccines were being readied for roll out, IHS for the first time was being looked at as a jurisdiction. In H1N1 we weren’t really a jurisdiction. We got a little bit of extra H1N1 vaccine that we could allocate each week for our healthcare workers but we weren’t given a full allotment as a jurisdiction. This time, we were. I think our membership, our embedding of people with Operation Warp Speed, and our vaccine task force and our headquarters incident command and the level of interaction there really made it possible for that to happen. There was a lot of skepticism at first because previously IHS said the central Oklahoma City National Service Supply Center did not have the surge capacity to handle receiving from the Strategic National Stockpile or from any other large federal repository, how to get that back out then to the sites. We don’t have the ability to bring in 100 new warehouse workers to do that work. They never really wanted to do that, but through the discussions and how things were going to work out, you know, they took on a leadership role as well to dispense some SNS [Strategic National Stockpile] supplies. The vaccine was outside of the Strategic National Stockpile. So, the vaccine was going to go to jurisdictions, which included states, territories, and federal entities like DOD [Department of Defense], VA [Veterans Affairs], and Indian Health Service. We were getting our own allotment.

Then we tried to have a— things were moving so fast we couldn’t do our usual tribal consultation with tribes, which requires a certain amount of time of notice that there’s going to be a tribal consultation so they can prepare. Then the tribal consultation occurs. Then the decisions that follow after that tribal consultation are then vetted and happen. That’s how it normally would work out. There just wasn’t time to do that fully so they had tribal listening sessions, I think they were called, convened by HHS and IHS to try and get feedback from the tribes. One of the things was, do you want to get your vaccine from IHS, or do you want to get it from the states? That was kind of the way we determined the best we could do to honor tribes and recognize their level as sovereign nations, and yet not compel the vaccine distributors to have to ship, to make those agreement with all 574 individually recognized federal tribes and all the states. We have to somehow streamline this distribution to larger scales because some tribes are very small. Some tribes are very large. None of them is as large as the state. Well except Navajo Nation, it’s probably as large as Montana perhaps. That was sort of the decision made through Operation Warp Speed and it took a lot of talking to the generals of Operation Warp Speed, to really explain to them how IHS works, who tribes are, what their status is. Because they had never had to work with tribes before. We really had to fight strongly to get that in place, to say we need to provide this choice to tribes and if it comes to IHS, we’ll manage the orders and help with the distribution. Then if the tribes choose to go with the state, then the state will manage that. In our area, I think overall in IHS about 300, it kept fluctuating so between 330 and 350 or so, of the tribes in IHS of the 574 federally recognized tribes chose to go with IHS as their point of contact for distribution.

Q: And the others picked their states?

WEISER: Yes, they went with their states. You know, and I don’t mean this to be flippant or disrespectful or anything, but it kind of came down for the tribes, it came down to which of these government entities do you trust the most? Which of these has harmed you the least in your recent memory or recent history? Or ever? You know? It was a tough decision I think for tribes because you know, for some tribes, like they don’t trust the state or the national government or IHS. I think it was really tough for them. Some of them still really wanted to have their own distribution and not have to go through state or IHS, but it was the best plan that we could come up with to distribute a scarce resource in as timely a manner as possible in keeping with the goals of Operation Warp Speed. It worked quite well. We got our first vaccine distributed in December along with everyone else. We were part of the first allocation. The challenges of having the ultra-cold freezers to handle the Pfizer vaccine, that was one of the big challenges. Like nobody had those— except one site, and that was the Lummi Nation.

The Lummi Nation is located up near Bellingham, Washington. They were pushing the envelope through many parts of the earlier part of the pandemic. They struck out on their own to try and put together a field hospital on their land. I have to preface this to say, none of our tribes or IHS operate a hospital in our three-state area. They’re all ambulatory care centers. To set up a hospital would be unprecedented. I think in the distant past there were a couple of IHS hospitals, but none exist today. To set up a hospital would be something new and unprecedented. But the Lummi were so adamant about trying to protect their people. They wanted to do everything they could. They were seeing what I was seeing, what we were all seeing on T.V. and stuff where we were like, you know, our local hospital in town might become overwhelmed. When push comes to shove, they felt as Indian people that they would not get fair treatment. They felt like in case that happens, we need to be able to provide for our own. That was what was behind that. I think they purchased a modular building. They started purchasing equipment to put it together and set it up. They were trying to develop policies and procedures. I can put you in touch with folks if you want to learn more about that. They also were participating initially in the AstraZeneca trial in the US. As part of that participation, they had an ultra-cold freezer. That’s why the first vaccines in our area were shipped directly to the Lummi tribe, or Lummi Nation. Nickolaus [D.] Lewis, who is a tribal leader for Lummi, I think he was on the council but not necessarily the chairman. He’s also the chairman of the Northwest Portland Area Indian Health Board. He is the leader of this organization that represents all forty-three tribes. He’s a busy guy with all that going on. He personally picked up an allocation, a subset of that first allocation of vaccines, and drove them— first to the Yakama Nation. Then on to the Confederate Tribes of the Umatilla Indian Reservation in Oregon. This week we had the fiftieth anniversary celebration for the health board.

Q: Is this the Indian Health Board?

WEISER: Yes, this is the Northwest Portland Area Indian Health Board. I’m just going to take a moment.

Q: That’s fine.

(Pause)

WEISER: Yes, I may not be able to say everything I want to say but it was a pretty emotional event. You know, because we were meeting at the Confederate Tribes of the Umatilla Indian Reservation so out near Pendleton in Eastern Oregon. Nick Lewis, our chairman, was there to celebrate fifty years of being together as a board and to joke that, you know, he wasn’t even born when the board started. Which made for some good laughter. I think he actually wasn’t born then. He recounted that journey of driving those vaccines. The first vaccines for tribes.

Q: Wow. That’s pretty powerful. I mean, I know it’s like, yes. I mean, getting that first shot I think everybody almost felt that. I asked a lot of people what they felt like right after they received their first shot. So many different emotions that come up. Some people were like, oh I really didn’t have time to really think about it. Then there were people like, it felt like now this is a whole other level of my protection. Then a lot of people felt guilt.

WEISER: For me, because I had been sitting on all of those COVID Vaccine Work Group meetings and all of the ACIP deliberations and the public meetings, and I was also part of the vaccine task force for IHS. My role was in the prioritization sub-team, so we tried to figure out, you know, when we get this vaccine, how are we going to roll it out? Who’s going to be our priority populations? Will we be able to vaccinate the people that we think we need to vaccinate? How to work with tribes to define that. Yes, it had all these other layers as well and it was more meaningful, I think to see the roll out of those first vaccines for me than even my own vaccine. I mean it just really overshadowed it. You know, Chairman Lewis said that he’d never drove as carefully in his whole life as he did then. I was sitting next to our now area director, he was in a different role during that day, but now he’s our area director. He just became our area director about a month ago. His name is (CAPT) Marcus Martinez, he’s a Spokane tribal member. I was sitting next to him as we were hearing this talk from Chairman Lewis and CAPT Martinez told me that he was the one who picked it up from Yakama and then drove it to Warm Springs, [Oregon].” Which is one of our federal service units. That one box of vaccine, and you know, we got the one shipping case of 144 vials or whatever, that got distributed up between I think these four clinics and service units. Two tribal and two IHS, and these were some of our biggest tribes and IHS facilities (in the Northwest) that received the first shipments.

Q: Was it easy for a lot of tribal members to get an appointment? Because I feel like in the community where my parents were, there was a lot of ageism on how you would sign up for your vaccine. So much so that they’re not internet savvy but they’re not internet, they’re in their nineties so it’s hard for them. It was kind of an ageist way of rolling out the vaccine. They had no idea how to do it, so I had to do it for them.

WEISER: Yes, so being a federal agency there are certain bureaucracies like the Privacy Act that prevent us from utilizing some of the most everyday tools like making an appointment online. Talking to your provider about your healthcare online. We still don’t have that readily available. We utilize Facebook. Each of our IHS clinics is able to advertise things like if the clinic was going to be closed for some reason or, you know, we’re having a special campaign about this that or the other, or we have the flu shot available. All of those are messages that they put out on their individual Facebook pages. At that time, any message about COVID had to be cleared by our area PIO [Public Information Officer] who then would send it up to the headquarters PIO. Initially they wanted to clear every single post, every single message. Finally, we were able to get some reasonable accommodation to say, well if it’s just a message about you know, you have to close the clinic today because a water pipe burst, you don’t have to get clearance for that. It was only COVID messaging. Then all the COVID messaging was still too much anyway. The way people found out was through Facebook, through the tribal newspapers, through tribal radio stations if they had it. Through tribal council, through communication between the clinic leaders and the tribal leaders. Everyone would be made aware of how much vaccine we have or if we have it and who was the intended recipient audience at this time. A lot of that had already been worked out a little bit through discussions with the tribe. As I mentioned before, during H1N1 for tribes, the elders are the people who are most revered. It varies from tribe to tribe when you become an elder. For some, it’s much younger than getting the retired discount at Starbucks.

Q: What is that?

WEISER: I don’t know. So, for some, it’s fifty-five. For some it’s fifty. It’s definitely not sixty-five. When the first vaccines came out, I think we were actually trying to target more like seventy-five and eighty-five. You know, seventy-five and older and not even down to sixty-five yet. But each tribe determined who would be in that first pool based on age primarily. When the vaccines arrived, then the messaging would go out that we have vaccine and it’s for this group of people. Then we tended to do it not necessarily by appointment but by drive up kind of mechanism. Because we were doing so much stuff outside anyway by that time. I mean, all of our testing was being done outside of our facilities. Some facilities, some tribes were so adamant that COVID will never see the inside of our facility that it became actually really kind of difficult to even have normal, any kind of care being provided. Because everything was being done outside.

Q: You mean outdoors?

WEISER: Outdoors, yes. Building tents and temporary structures and things like that for this care to occur. Because we were afraid that if we let people inside, then they’re going to spread COVID around to other people and things like that. Like if you were coming in for chronic illness care, that could be done inside but anything acute, any kind of sick person care was being done outside. Then for vaccines, we were like well we don’t have time to screen everybody before they come in so how are we going to do this efficiently? In some places we set aside a part, like the Yakama has a really big clinic and they had a whole south area that was being unused. They kind of turned that into where they were doing their COVID vaccines. People would come in and they would do their screening outdoors. If they didn’t have symptoms or anything like that, then they would come in and they would get their vaccines. Everyone wore their masks indoors. Everyone complied with all of that. Had the six feet distancing signs and all of that. People would come in and it was first come, first serve basically. Which isn’t really the most equitable way to do it, because if you were connected, if you had transportation, if you had somebody to drive you, you were going to be able to get in line first. We didn’t have a better way to necessarily do that. We didn’t do a lottery. Which I’ll mention in the ACIP work group discussions, it came up that lottery was actually maybe one of the most equitable ways of actually distributing a scarce resource. At first it doesn’t sound like that would be fair or equitable, but it is. It’s random chance. There was a person who worked with us, an IHS employee, one of our statisticians who also brought that up as actually maybe not the most nuanced way of distributing it but probably the most equitable way to distribute it. Everyone has a fair chance to be in a lottery. In any case, we got enough vaccine early on that we were able to vaccinate almost all of these priority populations and even earlier be able to move to the next priority population. Before maybe our counties were able to do that.

Q: Everybody was able to come to the clinic? There wasn’t any kind of in-home vaccinations or mobile vaccinations?

WEISER: No, so we didn’t have, our IHS partners initially, we didn’t have any mobile units to use. We didn’t have any staff to send out to folks initially. Then only one of our sites, Warm Springs, has a mobile unit. It’s owned and operated by the tribe. The mobile unit was actually parked outside of the clinic and was a place where routine vaccinations were being done. Because it was a way that, you know, was outside of the clinic so people could come in there and not potentially bring COVID into the clinic and they could get their vaccines. They did some other care there in the mobile unit, but it was their everyday set up and that’s what they used it for. I think there were community resources that were used to help bring people in. Many of the tribes have a community health representative network and they also have a few transportation vehicles that they would use normally to transport people to dialysis or to referral care and things like that. I think some of those folks were able to be used to transport people for their vaccines if they were having difficulty.

Q: I kind of want to get to more of a personal part of this. Your reflections on the past two and a half years. It doesn’t seem that long to me. You said your wife and daughter traveled to Japan early on and you were managing your day-to-day household. I guess you would be teleworking as well?

WEISER: Right, so in March with the declarations both my usual office at the health board and our IHS area office went to telework 100%. I’m employed by the area office and prior to the pandemic, I spent probably ninety five percent of my time working on health board priorities and projects and maybe about five percent of my time doing IHS stuff. Maybe it wasn’t quite that dramatic. It felt that way. My primary email address was my health board address, and I didn’t really pay much attention to my IHS address that much. When the declarations came out and we set up our ICS team, which was the IHS ICS team that I was now to be the public health lead for, that switched completely. I became ninety five percent IHS and five percent health board. I was still able to participate on health board meetings and things like that and be able to participate on things like the ECHO [Extension for Community Healthcare Outcomes] calls and the weekly health board calls to get the message out. That was a big change, is now my focus is all IHS and I had to drop everything else I was working on. Things that I was saying in February I was working on, now I actually did not remember until I had to look it up what that training was in February. It was for an MMRC, a Maternal Mortality Review Committee. I remembered being there but I didn’t remember exactly what we were there for. Yes, there’s a lot of things. We had hepatitis A cases at the time. We were doing a lot of work around hepatitis A in homeless populations and people who use drugs. Because we were seeing pretty severe hepatitis A. People were dying from hepatitis A and getting hospitalized. That was another focus that we were on I completely forgot about that until this morning when I looked at it again. Yes, I did feel a sense of loss about all the things that I was working on but at the same time this pandemic to me felt, you know, existential. Like this is a big deal. I grew really frustrated with the way some of the things that I talked about [were being done]. Like not being able to have a tool to do contact tracing and case investigation of our own. Therefore, I don’t know how I’m going to get information about what’s happening for our population around this epidemic other than maybe what other people might have. What the state is telling me is happening or that kind of thing. I don’t know. I just knew it was a big deal and I was really frustrated.

At one point I did call my former CMO [chief medical officer], my former boss, who at that time was working for headquarters in our Office of Quality. I gave him an earful. I said, “What the heck is going on? Why can’t we do what we need to do? Why can’t we say what we need to say? Why does every single message that we put on Facebook for our service units have to be cleared at these highest levels? I’ve never seen this before. Has it always been this way? Have I just never had to work so much with IHS before in the past that I didn’t realize that it was always like this? Or is this something new?” He tried to calm me down and reassure me that, you know, we’ll get through this. I called another friend of mine who was an internist that I worked with at White River at the very beginning [of my career] and had risen through the ranks and was now the area director for another area. I called him too and gave him an earful. You know, and I thought that by calling these people that I had worked with in the past for a long time. I know them, they know me. We can speak openly. I couldn’t get a straight answer from either one of them either. It wasn’t that they didn’t hear the frustration and even share my frustration, but there was nothing they could offer. You know? There was no work around that they could offer and there was not much advice that they could offer. How to find any way forward with some of these roadblocks we’re having on the ability to get our messaging out quickly or the ability to utilize innovation in trying to get the information about cases we need. That was really hard.

Q: That didn’t change when there was a shift in leadership at the federal level?

WEISER: No, no it didn’t.

Q: It’s just always been that way, and it doesn’t seem to be wanting to change.

WEISER: Right. In fact, I don’t know how to attribute this necessarily. It’s not my personal experience, but I’ve been told that in dealing with the current administration and the people that are now in ASPR at the highest levels around monkeypox, that some of the same frustrations are happening there too. Like they don’t understand tribes. They don’t know how to work with tribes. They don’t understand IHS at all. They think they can just tell us to do things that we can’t do. That we shouldn’t do. That we know not to do. Our folks who are interacting with them are getting really, really frustrated because you would think that we would have been provided with more competence when there was a shift. Instead, the incompetence seems to have gotten worse rather than better on some levels. It’s not true across the board.

Q: Do you think there’s a solution to that or some sort of détente?

WEISER: Yes, I don’t know. I mean, we are part of HHS Region Ten, which includes my three states plus Alaska. Prior to the Trump administration, we had really great regional administrators. Then we were given not so great regional administrators.

Q: So that changed?

WEISER: The actual Region Ten administrator. The current Region Ten administrator addressed our health board meeting this week and I’ve heard her talk before. She’s new, but she gets it. She’s either got good staff who are telling her what she needs to know, and she’s a good study. Because she understands the issues. When she talks to the tribes, you can tell that she understands the issues and she’s tracking those issues. She knows what’s important to tribes and she’s working on it, and it seems sincere. That’s a huge 180-degree difference from the last administrator. It’s not 100%. I mean, some people come in and they have capacity, and they know what they’re doing. I think we have some folks in ASPR who don’t know and who need to be educated. Maybe, you know, part of it, we didn’t have an appointed IHS director, we had an acting director.

We just got our director of IHS confirmed. She’s been in for four weeks or six weeks. Her name is Roselyn Tso and she used to work in our area. I worked for her, so I know who she is. She actually came to our board meeting this week in person and addressed the delegates and the board. You know, I got to say a quick hello. We didn’t have a director for the last two years. We were halfway through the Biden administration, and we didn’t have a director confirmed. The same thing happened with the last administration. We had an acting director for the first two years and then finally we got a director confirmed. I think not having a director in place makes a big difference too because then you don’t necessarily always have the person who can educate other parts, other agencies within HHS to say here’s the deal. This is what IHS is. This is how you need to think about us and remind them that we are funded at fifty percent of the need. So, you’re asking us to do something with nothing and unless you give us resources, you know, we really can’t do it.

Q: Plus, there’s that institutional memory that doesn’t stay with each director.

WEISER: Right, right.

Q: There’s a re-learning each time.

WEISER: Right, so with our directors, they always— the last two have come from the ranks. These are career IHS employees, so that’s helpful. Previous to that, we had a director under the Obama administration who came from outside and who could not get confirmed at all during the second Obama administration.

Q: I didn’t know it was so contentious.

WEISER: Right, so for six years we did not have a director. You know? Unbelievable—

Q: Yes, that is unbelievable.

WEISER: —and unacceptable. There were lots of reasons to be frustrated with, you know, government response and how things work. On a more personal level, I guess going back to like how I felt at this board meeting that I went to, I was telling you about. Part of the thing that makes me choke up and made me choke up there too was, you know, feeling like you’re watching a disaster roll out before your eyes and you have some ideas about what could be done to make a difference. You’re desperately trying to act on your training and what you know to do, but you don’t have a way to do it. You don’t have the resources. You know, if we wanted to set up isolation centers, we don’t have a way to staff them. No one seems to have money to do that. Even if you had money, there’s no one to hire. We got a lot of help from CDC Foundation, I’ll say. They were offering help to each of the states. In our region, some of the states didn’t really need it, and so they said, “You know what? You know who needs this help? The tribes need this help.” We had an army of CDC Foundation folks that came to work at the Northwest Portland Area Indian Health Board to help with the response. Which was really tremendous. These were top notch people. Some of them continue to work with us today as either foundation employees or they’re full-time employees now of the health board.

Q: Yes, so I’ve seen this over the years that when there’s a huge emergency, there’s a lot of money and people and personnel thrown at that one emergency. Then once that emergency is gone, so go the people. So go the funding. Instead of just continuously funding something appropriately so that you don’t have this surge, and response, surge, and response kind of thing. Is that something that you’re seeing as well in your work?

WEISER: Right now, the thing that’s really hard for us is staffing. You know, it’s not unique to us. There are hospital systems and healthcare systems all over the country that can’t find doctors, can’t find nurses and are paying through the nose for the few locum tenens that they can hire. Or you hear stories about hospitals where the staff all quit and went to work for a locum’s company and now, they’re all working at the hospital down the street, and vice versa. It’s like staff just switched hospitals so they can work for locums so they can get more money. Because the hospitals themselves couldn’t just pay more money in the beginning. Of course, the IHS mechanisms for payment and things like that, you know, we’re stuck with the GS [General Schedule] system that CDC has or the Commissioned Corps, which is harder to even bring on new folks. We’re really having a tough time on getting enough staff to be here. That’s our number one threat. More money could help, because then we could offer more salaries. You know, it’s so bad that, and actually this has been kind of part of the problem throughout the pandemic, is we also lost support and administrative staff. Like our HR [human resources] staff and our acquisitions staff. The people who hire people, and the people who buy stuff for us.

Q: Yes. Where’d they go?

WEISER: Some of them were gone too. They didn’t want to work from home. They got better offers to do the same thing with less stress, and so they did it. Even when we had more money from all the COVID funding, we didn’t have the people to hire the people. The hiring process is so slow and so arcane. It’s unbelievable. There are so many things that need to change in terms of our hiring abilities, how we buy things, the acquisitions, and so forth. You know, it was really ridiculous some of the constraints that we had to try to operate under. All of those frustrations would boil up, and so I would work really hard, you know, Monday through Friday and then Saturday or Sunday I would sleep in. You know, I would do things like watch YouTube videos and catch up on the late-night comedians. There were things that were just like, hit me really emotionally. Like there were music videos, like for me Playing for Change is that group where they have people all over the world playing music together. They’re wearing headphones listening to the track and playing an instrument or singing part of the song. They’re doing covers of popular songs or things like that. I’d watched it before. I was always inspired by it. I thought this is such a beautiful thing, people all over the world, well—that was just one of the things that would just, you know—

Q: What did you do for your own mental health? You didn’t have your family’s support for some months. What did you do?

WEISER: I’d get together with folks by phone or by, you know, FaceTime or something like that. I had good communication with my family in Japan because we could do FaceTime and talk readily and things like that. In my community where I live, we actually started having happy hour. Usually all of us would go to work and we would come home. We’d do our thing with our families or whatever. Most of the people that were still working, we have a lot of retirees as well, but between the retirees and the people working at home, we were all home at five o’clock. We would start gathering outside and people would have happy hours, and probably people drank too much. My dog would come with me to happy hour, and she loved to go out and meet all the neighbors and stuff like that. Around about 5:00 or 5:30 most days she’ll come up and as I’ve got my mouse in my hand here, she’ll come up and nudge my elbow so I can’t do any work. She just hits me with her nose and says like, it’s time to go out. Come on, let’s go, it’s happy hour. My dog was an important support for me in other ways too. Because we live in a condo setting, I don’t have a yard. I can’t just open the door and let her go relieve herself. I have to take her for a walk. I did a lot of my conference calls and things like that, especially the things I was just listening to while walking the dog.

Q: You’re living the life.

WEISER: I was that guy.

Q: -- it can be freeing, aren’t they? I love being able to be outside listening to a call and still be outside with your dog walking.

WEISER: Yes, yes, it was great. That was a big support for me. Our church stopped having mass in person, but they quickly went to online and so sometimes I would try to watch that. That was weird. Then after a while it was like, this is actually kind of nice. I can just roll out of bed and sit in my pajamas and go to church. This is better, actually.

Q: -- but without community, the community is what you look for. Yes.

WEISER: Yes. When I did actually go back to a service in person, it was remarkably like nothing had happened in a way. It was like, it was a place that was so familiar to me, and it looked like it always did. Fewer people, and everyone was wearing masks, but it looked the same. It was very familiar. It was almost like it erased that whole period of time when we weren’t together in a way. I did find myself looking to see some of the familiar faces who would usually sit in the same area. Because people always sit in the same area. I would be like, you know, who’s still here? That kind of thing.

Q: Yes. Check in on everybody, yes. I feel like there’s a collective grieving that hasn’t happened.

WEISER: Yes.

Q: Where you have a period of time where you grieve for whatever that event has happened, and I feel like that hasn’t happened yet here for us. For a lot of people. At least for me. It’s more like an erased period of time.

WEISER: Yes, which—

Q: Remind you of certain things and you’re like, oh my god that was only like three months of time that went by but it felt like three years.

WEISER: Yes. Which I think might be an insight into some of the things I’ve heard about the 1918 pandemic. That there is this gap in information about people’s actual experience during that time.

Q: Right. I was going to ask you what you think the reverberations from this will be like, because you obviously read those 1918.

WEISER: Yes. I think I don’t know. I think there’s so much more that was happening too that affected me on a personal and emotional level. We’re in lockdown, and then we had the murder of George Floyd. Then Portland was sort of a hotspot for the protests. A close friend of mine who teaches photography was out there many of those nights at the protests photographing. You know, really aligning herself with some of the leaders in the Black Lives Matter movement in Portland and documenting what happened. I could watch what she was seeing. I felt like I can’t stop for that, because I’m so focused on what I’m doing to respond to COVID, to keep the vaccine thing on track, and all the other things I’m trying to do to help our service units and our tribes. You know, this is such an important thing that’s happening and I don’t feel like I can actually stop for that. That was hard. Those happened throughout the summer of 2020 in Portland. Then at the end of summer we had this horrendous firestorm.

Q: That’s right.

WEISER: We had an east wind come through and blow-up fires in areas that I had actually hiked in, you know, a couple of times during the summer with my daughter when she was here. Like that whole area burned. There was that feeling of loss for places that I loved that were just destroyed, and the oppression of the smoke that not only can I not go to the places I want to go, I can’t even go outside because I can’t breathe the air the smoke is so thick. There are all these dangers. It was like, it really felt like the end of the world. I did tell people over and over again— this is a dress rehearsal for climate change in my opinion. You see what a cluster blank, blank, blank it is for us to respond to COVID. It doesn’t give me much hope that we’re going to do any better for climate change. You can already see that we’re not. You know, you would think that when you’re faced with something so devastating and so important that people would pull together. In a lot of places, they did. Our tribes are really good examples of pulling together to do what they can to protect their people. We could learn from that. It’s really hard to see how we’re not able to pull together to take care of things like climate change. Because I mean, if a virus is not tangible, it’s invisible, you can’t see it. One may or may not believe that it exists. Even more so, this change in the entire climate and what it will or will not do to us, what we can or cannot do to make a difference in it. The levels of disbelief and misinformation and uncertainty around it. I mean, even if it’s not misinformation. Just uncertainty around what the impact is, will be, and what our ability to affect it is, is I think it’s such a huge challenge for us.

Q: It is. We’ve come to the end of our time and then some, again. I don’t ever want to stop you. It’s been wonderful. I want to also say, what else haven’t we covered that you would want to share for the historical record?

WEISER: Well I think—

Q: I mean, you just said it like about three minutes ago. That was wonderful. I should have just wrapped there. I thought perhaps there was something that has been on your mind throughout this whole thing other than some challenges that we’ve already spoken about.

WEISER: Yes, no I think for my family sometimes I feel, and even for the work and the people I work for, feeling like I wish I could have done more. Kind of a feeling of apology that, you know, that there were limitations that we had to deal with. Then there were my own limitations too. The things I don’t do well every day. I wish that on some level that I had been able to do more and do better. You know, I was doing all this, all that we did do, and working together to try and make a difference for our tribes. Try and make a difference for all the people that we are with every day, and for our loved ones. For my family. In some regards, we had challenges that we couldn’t overcome. I have a son, too, who lives nearby and lived mostly independently during that time, but who chose not to get vaccinated and still has chosen not to get vaccinated. He has had COVID twice, most recently about two weeks ago. Fortunately for him he did okay. He got through it without too much difficulty. You know, for him and other people like him who have lots of different reasons for why they didn’t get vaccinated, I feel like I wish we could have done more to get out ahead with our messaging and with the important information, and not be highjacked by all the other things that did happen.

Q: Indeed.

WEISER: Yes.

Q: Alright, well I want to thank you for being and taking the time to record with me today, and the other day as well. I’m going to end the recording now.

[END OF INTERVIEW]