Safe at Home

By Megan Willome

A conversation with the public health district director

Outside the Waco-McLennan County Public Health District office is a yellow Safe Place sign, and the A in the word “place” is a house. That simple image has taken on a whole new meaning since March 23, when the city of Waco and McLennan County issued shelter-in-place orders, keeping people at home except for necessities.

Since that declaration, the public health district is working harder than ever. At the head of the department is Dr. Brenda Gray, who became the director a year ago this month.

Gray received her master’s degree in public health from the University of Alabama and earned her Ph.D. in education from Jackson State University, in Mississippi. After her husband died, she forced herself to look for jobs outside the state and spent several years in Wisconsin, as executive director of Milwaukee Area Health Education Center and then as system director for AHEC at the University of Wisconsin-Madison. Much of her work has been focused on inequities in access to health care and in improving health outcomes. All her skills and experience are coalescing as she guides Waco through COVID-19.

Gray compares the work of public health departments to an iceberg, where most people only see the tip of all the work that’s being done. The Waco-McLennan County department employs 82 people, who make sure the public has the information and access to care it needs to stay safe and healthy.

Wacoan writer Megan Willome spoke with Gray by phone to discuss what preparations the health district was making ahead of time, what Wacoans can do to stay healthy and what really matters during a crisis.

WACOAN: I’d like to start by just asking how are you doing right now?

Gray: Thank you. Doing good. We have a supportive staff and team. We’re all gonna get through this together.

WACOAN: When did you start preparing for the potential impact of the coronavirus?

Gray: We started about eight weeks before this crisis hit. We were diligent in the background, doing work behind the scenes. People don’t know all the things we do.

You know the diagram of the iceberg — you see the tip of the iceberg, but what you don’t see is what’s under it. That’s the work of public health.

Before COVID-19 became a thing, as early as the late part of December of last year, we were following it closely, looking at the WHO [World Health Organization] and CDC [Centers for Disease Control and Prevention] to see what they were saying. National leaders were speaking guardedly about it, initially. My team — I credit them for having a passion for public health — they took this serious from the beginning. That’s why our community has responded proactively even in the face of lack of national leadership.

WACOAN: What are the duties of the public health department at a time like this?

Gray: When we have an infectious disease report, we have a system in place. The hospitals do mandated reporting to us. That started from the first positive case [of COVID-19]. Our effort has been around coordination. We don’t test for COVID — testing is not done at the public health district, it must be ordered by a physician — but we facilitate transport of specimens to state labs.

A huge part of our communication is early education for the community. Taking information from the CDC and WHO, people who understood early that we had a novel virus. We were pushing daily updates from the CDC, taking their guidance and taking it down to a community level, in a form that’s not so scientific.

Communication with the public is one of our prime charges. Even if it was not a health crisis, our efforts are still to educate the public to get the resources they need.

WACOAN: This crisis must have shifted your regular duties.

Gray: This is beyond our regular duties. We do WIC, Healthy Babies [Coalition], testing for STDs, environmental health, immunizations, tuberculosis prevention, diabetes services, vital statistics [birth and death records]. In a crisis with these emergency conditions, we have to take our focus away a little bit to focus on this enemy of COVID-19.

Public health infrastructure is a very strong network. Historically we’ve been underfunded because it’s hard to quantify prevention. We focus our strategies on acute illness and trauma.

Depending on your generation, you may have heard the saying, ‘An ounce of prevention is worth a pound of cure.’ We do so much for the health of the nation that isn’t recognized until we get to a crisis. I’m OK with that because I don’t want a crisis like this every month.

WACOAN: So what have the last four months been like for you and your department?

Gray: From January on, my job has intensified with communication. I’m doing four to five meetings per day to ensure that my leadership is informed. I have situational meetings with my team at noon every day. In between the local leadership meets, the Community Emergency Response Team. It’s getting us all on the same page so we can move stealthily to address concerns.

WACOAN: Who is on this team?

Gray: Representatives of this team include the public health director and core preparedness team, city of Waco leadership, health care systems leadership, Family Health Center leadership, [McLennan County] Medical Society, Premier ER & Urgent Care, EMS and AMR [American Medical Response], EOC [Emergency Operations Center].

On March 13, Governor Abbott declared a state of disaster due to COVID-19, and the mayor of Waco led in taking appropriate actions to protect the health of our citizenship. His order was the impetus for the EOC being activated.

[Editor’s Note: The Emergency Operations Center is activated as a central command post to coordinate decision-making in a crisis. The public health district works with the Waco-McLennan County Office of Emergency Management, local hospitals and first responders to plan for emergencies under the Public Health Emergency Preparedness program.]

WACOAN: How has the CDC’s advice changed during the course of this pandemic?

Gray: When we started this process, we were mostly monitoring if someone had a travel-related background to become exposed. Then we’d do investigation and monitoring of individuals before any positive cases arose. Our routine was busy, monitoring individuals twice a day.

We’d do a contact trace — figure out who that person had come in contact with and follow those people as well. That’s one of the key things in public health: surveillance. That is a piece that people don’t have the language to put to what the public health district does.

Then we had a hotline [254/750-1890] so the general public could get information. We still went through the CDC guidelines. If people say yes they have the symptoms, then we say they need to seek care — first call! Do the initial assessment on the phone before showing up at an [emergency room] or at their primary care provider so they’re not putting health care teams in harm’s way.

WACOAN: It seems like the official advice changes from day to day. How do you cope with the changes in advice from the CDC, since communication is one of your primary jobs?

Gray: Early on national voices were saying you didn’t need to wear a mask, that those should be reserved for doctors. This week the guidance has come down that the general public should wear masks.

We’re putting out a message to the public about wearing masks. We don’t want people to wear health-grade masks, medical-grade masks. You’ve probably seen people showing how to make homemade masks. That’s the message we want right now. Reserve the medical-grade and health-grade masks for those on the front lines, dealing with sick patients.

WACOAN: What are the pros and cons of masks?

Gray: Masks are not foolproof. They provide a layer of protection in public. It’s social distancing that will make the difference. We hope people will still maintain social distancing [until the order is lifted]. The more people you come in contact with, the more you increase your risk. You have to go to the grocery store or get medicine or go to the doctor, but otherwise stay at home and flatten the curve over time so the health care system will not be overwhelmed.

People feel like, ‘If I wear a mask, I can go out in public,’ but when you have to go out in public, you still can’t do gatherings of more than 10 people. We’re not trying to negate the order. It’s best to not be out in crowds.

If you’re contagious and don’t know it but you wear a mask, you won’t infect other people. The mask is to keep you from infecting other people.

WACOAN: I know there is a risk that someone may be a carrier and not have symptoms.

Gray: The early message from the CDC was, ‘If you’re healthy, you don’t need a mask.’ Now we have evidence that you can be spreading the virus one to three days before you know you have it.

WACOAN: Once a person tests positive, what happens next?

Gray: There’s a notification process. When we get that test and it’s confirmed and the patient has the initial diagnosis from their physician, then we follow up. We recommend that you quarantine. This is what public health districts are doing across the U.S. and the world.

WACOAN: How has this crisis affected your approach to your work?

Gray: I’ve tried to find language to describe how we approach this. The best way is ‘passion for the work.’ I’m not excited, but I’m passionate because [my work] allows our community to be more resilient, to enact protective things for ourselves and our families. I would not want this to be the status quo because this impacts the health of individuals and has great potential for loss of life. We approach our work with somberness and passion.

WACOAN: There is a lot of speculation about when the peak will hit. How do we know when a virus will peak?

Gray: This is something even Dr. Fauci [director of the National Institute of Allergy and Infectious Diseases since 1984] and his team are wrestling with. We have these models for determining when the peak will happen, but the best scientists will say, ‘We don’t know.’ The models are only as good as the information we have, but this thing is changing so rapidly that it’s hard to project.

[As a nation] we’re putting our energies into adequate testing, into shelter in place, into providing financial resources for families so they don’t have to go to work when they’re ill and spread the virus. Our country has put in place many things to help us during this dire time.

Once we hit our peak and are recovering, there’s potential for a second wave.

WACOAN: Is there a time frame for a potential second wave?

Gray: There are many national and local models forecasting the peak by states as well as efforts to project the second wave, but as we know, the models are only as good as the data. I am hesitant to give a projection but will use my platform to encourage all communities to adhere to the shelter-in-place orders and to remain hopeful. We will get through this together.

WACOAN: What do Wacoans need to do in the meantime?

Gray: These are difficult times for most if not all Wacoans. What I will urge each of us to do as we are able or capable of doing it is to remember the most vulnerable in our community. Although we must shelter in place and practice social distancing, we can donate to time-tested organizations that support and meet the needs of our community that are burdened by these types of incidences.

WACOAN: How do you think Waco-McLennan County has handled its response to the crisis?

Gray: It would be easy to jump to conclusions that it’s because of the measures we took early on that our rate is low, but that’s hard to quantify. It has to be a factor, that we were early in instituting shelter in place. I think we were one of the first three cities in the state to do so. Then we extended the order to align with the national voices. Until after the peak hits, the leadership here will keep the order in place.

I don’t think anybody can say, until the dust settles, what is the impact of shelter in place, but countries who were aggressive about it were able to flatten the curve and not overwhelm the health care system.

WACOAN: Your background is focused on reducing health disparities. What are you seeing in that area during this outbreak?

Gray: My team members are working on a process of evaluation, looking at metrics where we’ve had communications with the public. It’s too early to say, but in my research and reading anecdotally, subpopulations and minority populations are experiencing more health disparities with COVID-19. We’re looking at the impact of COVID in those communities. We’re taking data and collecting it now. Post-crisis we’ll have a comparative analysis for how these things fare with different populations.

WACOAN: You only started this job about a year ago, correct?

Gray: I started May 28, 2019, so not quite a year.

WACOAN: You’ve said your mother and grandmother both influenced you to take an interest in public health, although the work they did wouldn’t have been called that.

Gray: I tell my public health story as much as I can. As a little girl, I grew up with them as public health workers though they had no formal training. My grandmother in the early 1900s was a midwife, though there were no credentialed midwife programs for her. Her craft was passed down to her. She’d talk to me about the babies she delivered. I’d see her go to elderly neighbors’ homes to cook and clean, take them to the doctor and grocery store — all the things that made their lives better. My mother, growing up in that house, lived the same lifestyle when she grew up. She’d feed kids in the neighborhood, take people to the store. They shaped me as a young girl in helping people more vulnerable than me.

I took a public health course as a senior in college and knew that day I’d spend the rest of my life doing this work.

WACOAN: Obviously no one knows the endpoint of the disruption caused by COVID-19. What do we need to learn from this crisis that we can apply when a new virus emerges?

Gray: My first thought is we have to fully and adequately fund every public health office across the U.S. and globally. When we look at advances since the late 18th century and early 19th century, it’s been done through public health: sanitation, clean water, vaccination. It’s improved quality of life and met people’s basic needs.

But to move more nimbly, we need to be fully funded. We have tremendous leaders in public health in our network, but without being fully funded, it’s hard to turn on a dime in these devastating crises that will ultimately hit us again in decades coming up.

WACOAN: I’ve heard that people on Facebook are loving the scarves you wear at press conferences.

Gray: I haven’t done a press conference in a couple weeks. I was doing the best I could do, when it was cool, as it was then, to cover my throat, to keep my throat warm. My voice can get lost by the end of the day. It’s a fashion thing too.

I have not had a chance to see any news clips or briefs of myself. People say, ‘Thank you. Have you seen the coverage?’ I say, ‘No, we’re busy here, very busy.’

WACOAN: Any last pieces of advice for the good people at home?

Gray: I always say to my team, I’ve always espoused this principle: Lead within your own sphere of influence. Work at the top of your practice. Enable people to lead and have innovation and novel-thinking to advance a healthy community and a better world.

For up-to-date information, go, a partnership between the Waco-McLennan County Public Health District and the city of Waco.