When Michael Sequeira ’73, moved into his office on the third floor of the Department of Public Health building in downtown San Bernardino, California, it was late in 2020 and the COVID-19 pandemic was taking the lives of more than 1,500 Americans each day. On average, over 1,400 of the cases and four of the deaths were in San Bernardino County, the nation’s largest county by area, where Sequeira became public health officer on November 23, 2020.
Vaccines were about to receive emergency authorization from the Food and Drug Administration. Organizing a vaccination campaign for a population of 2,181,654 people, more than 40% of whom do not speak English at home and whose communities extend from Montclair on the edge of Los Angeles County to the Arizona state line, was a daunting prospect.
Eighteen months later, Sequeira appears unruffled by the challenges he has faced in leading a 1,500-member workforce and doing a job that in some parts of the country has proven to be dangerous. County public health officers make decisions that are not uniformly popular, especially during a pandemic. Working with fellow health officers “has become like a brotherhood, a fellowship,” he says. He knows of some whose families have been heckled and who have had windows broken. “When you shut down businesses and schools,” as was necessary at times during the pandemic, “it’s a major thing,” he says. “It’s not just medical. You’re interrupting society.”
Sequeira has spent most of his career as an emergency critical care physician, which he asserts “is much easier. I see someone dying, I’ll just rush in. Airway, breathing, circulation—I would know what to do.” Public health, he’s learned, is different. “Here, you’d better just take a little bit of a pause and deal with the right channels of communication and anticipate the repercussions in the political as well as the health realms,” he says. “They say public health is where medicine meets politics.”
“Drinking from a firehose”
If medical school is described as “drinking from a fire hose,” starting a career as a county public health officer in the midst of a pandemic isn’t any easier. “We were still learning about COVID, and we had to institute and implement the whole vaccination program,” Sequeira says. “It was very political, very fast.”
At the same time, Sequeira notes, California was in the midst of a congenital syphilis epidemic as well, with babies being born to mothers with the disease. “And we had another epidemic of overdose deaths, with opioids, fentanyl and methamphetamines. Because of the pandemic and the closure of society, the opioid crisis just got worse.”
COVID-19 has consumed much of Sequeira’s time in the first 18 months on the job, but it’s far from his only responsibility. He also oversees a wide array of programs, ranging from Communicable Diseases, Animal Care and Control, Environmental Health, Nutrition, Family Health Services, and Women’s, Infants and Children’s programs.
Rebuilding public confidence
Going into the job, Sequeira knew that one major challenge would be to win the trust of the public, especially those who had lost confidence in what they’d been told by authorities. This was especially true in the COVID vaccination campaign and other disease mitigation efforts. “We were trying to control the disease until we could get an adequate amount of immunity in the system, but people were just getting tired of it,” he says. Some “chose to say, ‘It’s my right not to be vaccinated.’”
Relating to vaccine-resistant populations in the county required that Sequeira accept the challenge of understanding the root causes for their feelings and responding with science, not emotion. “I tried to understand why they’re feeling that way,” he says. “Unvaccinated people die at 10 to 15 times greater incidence than vaccinated people. So it’s just a matter of looking past the emotion and keeping your eye on the goal, which is the health of everybody in the County.”
As of May 5, 2022, San Bernardino County has fully vaccinated 57.5% of its eligible population. Sequeira is concerned about the social determinants of health in the pockets of the county that score lower on the Healthy People Index. “Look at those pockets and you can predict the incidence of COVID, and the mortality from COVID, which is going to be three to five times higher. It just reinforces the need to solve issues like their access to medical care, their economic development, their educational level, and their cultural resistance to medicine.”
Sequeira also knows that some segments of the population have vaccine skepticism because of historical experience. He says the county will never give up trying to regain their trust. “We’ve searched out community-based organizations, churches, community leaders. It’s still difficult.” But he believes vaccine efforts are making progress.
Is herd immunity possible?
Early in the pandemic, health officials hoped the nation, and world, would someday reach “herd immunity” where so many people have acquired immunity to COVID-19 through prior infection or vaccination that community transmission becomes unlikely. The successive waves of variants—Alpha, Beta, Gamma, Delta, Omicron, Omicron BA.1, Omicron BA.2 and its subtypes—have changed the calculation. Experts in infectious disease now hope we can reach an endemic stage where the virus becomes predictable and manageable.
“There’s a very simple formula to calculate herd immunity,” says Sequeira. “It’s 1 minus 1 divided by the number of people likely to be infected by a person who is already infected with a particular virus.” For the original [alpha] COVID virus, each infected person, on average, infected 2.5 other people. With Omicron, that figure went up to 15. Plug that into the formula and you need about 96% of the population to be immune to reach herd immunity. “That’s why herd immunity is so difficult,” he says.
While COVID-19 may be here to stay, Sequeira says that people who are vaccinated and boosted should not be so afraid. Flu is endemic also, “and we’re just accepting of the fact that in flu season, many of us will catch the flu,” he says. “We try to avoid it. We get a vaccine. We use masks situationally. That’s going to happen with COVID.”