Health Partnerships in Action: Managing COVID-19 at the Southwest Border

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: leaning on partnerships during a crisis; how public health leaders are working together to manage COVID-19 concerns among migrants at the southwest border.

DR. PRITESH GANDHI:
If we don't have strong, enduring relationships with local partners that we can lean on in times of crisis and—when in steady state—we can use to improve our own processes, all of this work goes nowhere. And so, we have really endeavored to maintain those lines of communication and, in fact, we try hard to build out transparency in a process that is typically fairly opaque.

DR. ERICA PAN:
You can never communicate too much or too often, right. And trying to, in these complex settings with so many entities involved, really clarifying roles and authorities—and not only who might have the resources, but who will actually authorize utilizing resources in these settings—has been challenging. But I think considering all that, it's gone relatively well based on a lot of foundational partnerships that have evolved over the years.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, the importance of partnerships and their impact on an effective response to the crisis along the US-Mexico border.

When thousands of migrants and responders find themselves in close proximity during a global pandemic, an immigration challenge suddenly becomes a public health nightmare. A crisis like the one at the Southwest border draws together many agencies and interest groups representing public health, immigration, law enforcement, and local government. Keeping everyone healthy while policy issues play out depends to some degree on how well they cooperate on jurisdictional questions. Our guests today are living these challenges, directing resources deployed to the border on behalf of the federal government and the state of California.

Dr. Pritesh Gandhi is the chief medical officer at the U.S. Department of Homeland Security. He's along shortly to share his views on the importance of partnerships.

But first, we hear from Dr. Erica Pan, the state epidemiologist for the state of California and deputy director for its Center for Infectious Diseases.

PAN:
Yes, it's really been quite a challenge, and our border region has certainly been disproportionately affected by the pandemic when we compare it to other regions of our large state of California. Our border region has some unique issues—and, of course, there's actually not just one but three different local jurisdictions at our border. So, that's one of the challenges there.

And, you know, of course, it's a very dynamic environment, there's a lot of variation even within those three jurisdictions, and within, across that large border. We do have a team of public health professionals that are dedicated to addressing public issues that arise and to prioritize those needs. This has really meant ensuring provision of shelter, you know, non-congregate shelters—we'll get into that later—probably being able to provide testing, you know, for new people coming across the border, and vaccination, and other social services and wraparound services, and collaborating with a lot of different entities.

JOHNSON:
What have been some of the public health issues unique to the pandemic component of what's happening down there right now?

PAN:
I think one of the biggest ones is, of course, is that providing shelter, right. So, we typically work with other either, again, local jurisdictions or non-governmental organizations to provide housing for people to come and try to provide non-congregate sheltering.

And then, also providing other tools like testing to really try to minimize any spread of disease in those settings has been probably one of the biggest logistical challenges.

JOHNSON:
And you really need those partnerships, don't you? Because California is not prepared to do this on its own.

PAN:
Absolutely. I think we, as far as partnerships, really have taken an all-hands-on deck from, you know, all levels. So, everything from cities, counties, NGO, state, federal partners, and then working of course with our state epi in Baja California and our colleagues across the border with Mexico.

JOHNSON:
How has it been going so far?

PAN:
I think it’s been going relatively well, considering how complex it is and how many different entities are involved.

I think, you know, we all know that you can never communicate too much or too often, right? And trying to, in these complex settings with so many entities involved, really clarifying roles and authorities—and not only who might have the resources, but who will actually authorize utilizing resources in these settings—has been challenging.

But I think considering all that, it's gone relatively well based on a lot of foundational partnerships that have evolved over the years.

JOHNSON:
I think a lot of your peers are glad that they're not dealing with the border situation on top of everything else, but they probably are interested in how you are affecting good partnerships. Can you give us a little insight into your process? Tell people like you listening elsewhere in the country and in the territories how you're doing it.

PAN:
Yeah. I mean, I think, again, as far as having a preexisting office of binational border health, that team has met monthly to maintain situational awareness and preparedness. Coordinating, again, with these different partners with our state in Baja California. So again, I think the organizational relationships, thankfully, have been preexisting and just led to frequent calls, communications.

I think on our end too, one thing that helped is we sort of used an incident command system structure to help just for ourselves, at least for the state—even at the state level, just so many different departments involved: our department of social services, our health and human services, and emergency medical services.

So, setting up an incident command structure to really clarify within our agency and state departments, who's kind of doing what, and how we coordinate and communicate information has been helpful.

JOHNSON:
We've had many discussions with your peers about COVID response these last 18 months, and they're all talking about the importance of relationships with stakeholders. It's really not possible to respond and get this right if you are starting these relationships now, is it?

PAN:
Yes and no.

I mean, I'll be frank that I'm actually new in my role. I just started last July right in the middle of this pandemic. And I do think, again, as far as our team, thankfully, a lot of our team have been preexisting though and had some preexisting relationships. But there's always transition, right, in our different roles. So, I think you can.

It's obviously easier if some of those entities already have those or there's existing structures, which we always try to do both for day-to-day. And again, with these emergency responses, I think some of the goals are to have the structure so that you can rotate people or add people.

But it is true at the end of the day that strong relationships are what really helped make successful partnerships and collaborations.

JOHNSON:
It sounds like you think the outcome, or at least the progress you've made so far, might be something different where it not for those relationships.

PAN:
I think it would have been more challenging to coordinate and share data even, for sure, if we didn't have those preexisting structures and communication channels. For sure.

JOHNSON:
We hear often that people on the ground, the folks who live wherever the crisis is happening, have the best view of what's going on and that they ought to really be at the front end of the response. How important are those viewpoints when you're trying to get your arms around the pandemic with so many people involved?

PAN:
I think that's crucially important. And actually, I think a strength that we have had as well is that our office is based in San Diego. We have one of our lead team members is actually from a city that is closer to the border. And I think really getting the pulse from our local health jurisdictions. So, you know, for us, the three counties are Imperial county, and San Diego county, and Riverside county, so working really closely with our local health officials and then being able to try to provide some state consistency and resources.

But yes, absolutely. To get a really good view and really the pulse of what's happening and you need the local on the ground intelligence and we've deployed people to the border to really kind of get a sense from our state outside of even our office of binational border health, having others on our team kind of be deployed to really get a sense on the ground and be reporting back.

So yes, that's absolutely true.

JOHNSON:
Is that because people trust local people more than they do folks from Sacramento or Washington, DC, or anywhere else?

PAN:
I'm sure that's part of it.

But I think just knowing everything from the lay of the land, literally, you know, the geography, what are some of the barriers or challenges that might be there, what are some of the local politics you need to be cognizant of, and what the resources are, honestly—like having intel on the ground and literally working with the people that are there, and also knowing which other kind of partner organizations can come to bear or recruiting those or, you know, building those all really need people to be there. And that, of course, is another challenge with the pandemic, you know, how much can you do virtually versus really the on the ground. And certainly for this border response, it has been crucial to have people on the ground and in-person there.

JOHNSON:
Do the relationships make communication easier?

PAN:
Sure, of course. Again, especially—we have mentioned there's been a mix of in-person on the ground, but also virtual—and as we all know, too, I think so much of our communication can be misinterpreted, whether, you know, just emails or even voices.

So, I think having the longer standing relationships and knowing people's styles can certainly help to smooth the waters. For example, of some people, you know, might have taken something personally if they didn't know that person and you know, all of those, just really human things that are important.

JOHNSON:
Well sometimes when you're in the middle of your own situation making decisions, all of a sudden you've got a lot of bigger agencies coming in from all over, taking over in many cases—that can be rough if people don't know the folks who are showing up at their door.

PAN:
Yeah, absolutely.

JOHNSON:
What about the takeaway for public health people across the country, in the territories? This experience—you're living this, you've been dealing with it for about a year now, maybe a little more—what's the big takeaway for everybody else? Yeah.

PAN:
I think a huge lesson—both at the border and in this pandemic that I know many of my colleagues will agree with—is that we absolutely have to find more sustainable resources to invest in these responses. So, because building relationships is so important, as we discussed, having one-time or short-term funding or emergency funding is really just a band-aid. And what we really need is to be investing in long-term public health staffing, building that infrastructure to have those relationships.

We know this border response will be for the next several years, and we need to incorporate this kind of work and an infrastructure into our investments for the future and in the long-term investments.

JOHNSON:
Less than a year ago, Dr. Pritesh Gandhi was helping to run a safety net clinic for uninsured and medically underserved people in Austin, Texas. Now, he's nine months into a job that directly impacts the health of thousands of migrant people waiting to enter the US.

GANDHI:
It's challenging. You have got increased numbers of migrant families coming to the United States at the same time struggling with a pandemic and, particularly in the proceeding weeks and months, the Delta variants. The challenge is twofold, then: one, how do you maintain the health and well-being of those in our care and custody; and how do you do so in a way that maintains the health and well-being and, really, the health security of border communities and interior cities and states?

And so, that's the balance we've tried to walk. And I think—look, we were very aggressive in terms of our strategy. We wanted to ensure early on this year that we rolled out a program to maximize vaccine utilization by our frontline staff, whether it's CBP or ICE or elsewhere. We wanted to ensure that we had standardization of our COVID protocols across the board, again at ICE and CBP, and again for workforce and those in our care and custody.

And then, we wanted to ensure that we were really medically optimized as it related to all of the non-pharmaceutical interventions for COVID in our facilities. Did we have adequate ventilation? What was our process like for masking? For handwashing stations? What about physical distancing in our facilities? And so, we've had to ensure order stand up very complicated systems and fairly resource limited settings across the entirety of the Southwest border. I'd be lying to you if I told you that wasn't challenging, but we've been up to the task.

JOHNSON:
I wanted to ask you how you think it's been going.

GANDHI:
It depends on how you're asking me that question.

How's it been going in terms of our overall data and how we've been doing in the course of the pandemic? I think by all accounts, we have been as successful as one could be in the situation that we're in. We closely follow our COVID positivity rates for those in our care and custody. Lord knows we do that for our workforce, and we do that at all elements of the immigration journey, whether it is for unaccompanied children, single adults, family units, whether it's at CBP on interdiction, or onward to ICE, or onward to community release. And it is, I think all things considered, we worked very hard to enhance our relationships with community partners to do this together. That's been a huge part of this. And on any given day, we are talking with local mayors, with local public health, state public health, local hospital leadership, and having that conversation on Monday with hospital leadership in El Paso, I was on the phone with the mayor of Brownsville the week before last—these are ongoing 24/7.

JOHNSON:
What do people who are on the ground need to know from you about how to interface with the federal government during a dual crisis like this?

GANDHI:
Yeah, so I think we've really tried to take away the red tape here. And I'll tell you, I’ve spent my career in service of vulnerable communities, really focused on social determinants of health and poverty reduction, spent a number of years working with undocumented families. And I think, from that other end, I believed that government was a challenging entity to engage with. And we have worked very hard to tear down those barriers.

So, quite literally, I don't know of a border mayor or public health department that it doesn't have our direct contact information. We want to hear from people. Now, we set up a biweekly southwest border coordination call that occurs with our shop, the DHS CMO, and all of the local state public health and other investor partners across the entirety of southwest border. That's an opportunity for direct engagement with those that have equities in this—DHS CMO, with CBP, with ICE, with our colleagues in Mexico, our HHS attaché, and others. And so, we've got these standardized places where that kind of interface can happen.

And then we have really tried hard to open up lines of communication so, if there are questions, folks can directly reach out to us. And I think we've also tried to engage with stakeholders, you know. Just now I'm looking at the clock here about two and a half hours ago was on a conference call with Physicians for Human Rights, who raised a series of questions on our vaccination rates and wanted to talk through that process, and I've had similar kinds of calls with the AAP and others.

And so, I think we take it very seriously, our stakeholder engagement, because it's an opportunity for us to improve our processes.

JOHNSON:
And it’s as much about communication as it is about what you're actually doing to respond, isn't it?

GANDHI:
You bet it is. I mean, I think particularly in this space, right, particularly in a space that is stigmatized as it is. No matter what your political philosophy is, I don't think anyone objectively looks at the United States immigration system and thinks to themselves, “By golly, that's an efficient, optimized way of doing things.”

I think that, you know, you set that all aside and you realize that if we don't have strong, enduring relationships with local partners that we can lean on in times of crisis and—when in steady state—we can use to improve our own processes, all of this work goes nowhere. And so, we have really endeavored to maintain those lines of communication and, in fact, we try hard to build out transparency in a process that is typically fairly opaque.

JOHNSON:
Sometimes people expect the feds to just show up and start bossing them around at the local level, but that's not the way to get work done, right?

GANDHI:
Yeah. I think our partners on the ground would probably think the exact opposite now after having a number of months under our belt here in the sense that we come to our local and state public health partners really with an outstretched hand because we need them in this work. There isn't a way to do this without their collaboration help. I mean, look, just last week I was on the phone with San Diego's chief medical officer and we were, quite literally, you know, throwing ideas on the wall because that's what it takes, you know? And I'm not quite sure—at some point, it seems things at times can get so formalized that government loses the ability to be nimble and to lean in on folks that are on the ground that understand the situation and have ideas to offer. And so, we have, I think to your point have really come in leaning on local public health to guide us in what is optimal for them and for their communities because, ultimately, folks on the ground know their communities best, and we need to be able to serve.

JOHNSON:
Both of these crises have been going on for a long time—we’re looking forward to the day when they're resolved. How has the response on the public health side this equation evolved during the time that you've been involved with it?

GANDHI:
Look, I think folks know here that I started this role, quite literally, on day one on January 20th and on January 19th I was still seeing patients with the federally-qualified health center I was working at.

Early on, you saw, I think, a desire to try to implement large-scale solutions for what are really large-scale problems, right—and we’re talking about a pandemic, we’re talking about the challenge at our southern border. And, you know, whether we’re talking about setting up large federally funded vaccination sites or broad policy instruments, thinking about migration pressure is at the southern border, I think what you've seen across both of these issues is a more targeted approach, a laser focus on local conditions and how to implement local solutions, right? So, what works in the Valley as it relates to community COVID testing for migrants that are released is actually a very different solution than what works in Tucson, which looks markedly different than the partnership we have with state and county and city in California. And, quite similarly, the answer or the federal level for how to increase vaccine uptake looks quite different in southwest Texas or in El Paso than it does up in Bismarck.

What we're seeing is I think a more curated measured approach at the federal level as to how we think about the pandemic and what our guidance looks like and how we're thinking about our solution set as it relates to COVID-19 and migration.

JOHNSON:
So, eight or nine months into this thing, what's been working well, in your opinion?

GANDHI:
Well, I think, you know, I can speak for our lane here at DHS Medical. I believe that we have made inroads in the relationships we have with our community partners. And I'm a part of—our team participates in weekly calls with stakeholders across the inner agency, so it's interagency-held calls on on core issues. And so, we are in constant contact with people on the ground, whether these are the governmental or non-governmental organizations. And I think, to me, that is a pretty marked shift in the way that we're doing business.

JOHNSON:
What would you like to do better over the next few months? Anything on your list?

GANDHI:
I think what is challenging about being in the Department of Homeland Security is that it really is, at times, jumping from pressing national and homeland security issue to pressing homeland security issue.

And so, you know, in the first few weeks when I was here, it was all hands-on deck to increase the vaccine uptake in our workforce. And then, obviously pivoting to the challenges we have with the unaccompanied children at the border, and then moving quickly into thinking about our federal strategy for vaccine uptake, and then shifting again as we saw an increase in families making that journey to south Texas.

And now, I'm speaking to you from Philadelphia where, at early in the morning tomorrow, we'll accept the first plane of arriving Afghan nationals. And we're standing up in all of government approach to how we're doing public health, both here and Dulles and across the country. And so, you know, I am hopeful that, in the midst of dealing with these issues, as they come up, we find steady state time to optimize the procedures we have, right? Cause we got to focus on what is going to be the enduring footprint, you know, again, of the medical work that we do. So, how do we build a unified health system that is data forward, that is patient- or migrant-centric, that respects the dignity of those individuals and follows evidence-based guidelines. That's a desire of mine to be able to do for our department, because what we have is a disparate system across different entities. How do we think critically around our electronic medical record across our different agencies? What is our approach to the interplay between public health and targeted violence and terrorism across the country? We've got to find time to dig in on those issues and build out a solution set that looks at the long-term game here. And that's the hope over the next few months.

JOHNSON:
Public health people in the states and territories are listening to this show. Wrapping up, what should they know from you about working with the federal government in these kinds of situations?

GANDHI:
We were all hands-on deck.

You know, I'll tell you an anecdote, if you will, as we started mobilizing for this effort to receive arriving Afghan nationals and American citizens, we looked at each other here at the Department of Homeland Security, in our chief medical officer office, and realized in the federal footprint—in fact, we know with HHS, and ASPR, and CDC and our colleagues in health departments across the rest of the interagency—our overall footprint is actually a little bit smaller than our colleagues. But we knew that we had a role to play as public servants to put all hands-on deck, and all hands we did. We deployed our team to Dallas, our team to Philly. And we are really leading the federal effort as we think about the health and well-being of those arriving today and tomorrow and onwards. And I think that is reflective of the approach that we are taking to any of the medical and public health issues that come up now and in over the ensuing years, which is there is no formality to the way that we work. If there are questions and concerns, and those concerns should be escalated to us, and we will engage with those and we will adjudicate those, and we will answer with the best data that we have available. And whether it is a good outcome or bad outcome, we’re there, we’re in the fight. And I think that's really important for folks on the ground to understand that we are in the fight and we are going to work at night and day because what matters to our local public health departments and our state public health departments matters to us at the federal level.

JOHNSON:
Thanks for listening to Public Health Review.

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For Public Health Review, I'm Robert Johnson. Be well.