Travis Khachato...: You're listening to Sagecast, the podcast of Pomona College, where we talk with faculty and alumni who are making a difference on campus and beyond. I'm Travis Khachatoorian. Marilyn Thomsen: And I'm Marilyn Thomsen. This season we're talking with Sagehens who are tackling the difficult in the world, and today's guest, Michael Sequeira, Pomona class of 1973, certainly is doing just that. Travis Khachato...: After a long career in emergency medicine, Dr. Sequeira became Public Health Officer of San Bernardino County in Southern California in November of 2020, just as COVID-19 vaccines were about to become available. Marilyn Thomsen: Dr. Sequeira soon learned that public health is where medicine meets politics. We sat down with him in the studios of KSPC to talk about his experiences in the age of COVID, fentanyl, and other public health challenges. Here's that conversation. Travis Khachato...: Michael, welcome to Sagecast. Dr. Michael Seq...: Thank you. Travis Khachato...: Tell us a little bit about your pathway to Pomona. Dr. Michael Seq...: Well, it's actually amazing how I got to Pomona. First time, an immigrant son, I came to the US when I was five years old. We were born in Hong Kong, and my parents had to scrap their money to actually ... They got a sudden permission to emigrate after many years. My dad and mom came over when I was five years old, and my dad was 44 and my mom was 47, with five children, with no job assured, into the US. So they did it for us, for our education, and so we put our nose the grindstone as first generation children do. Marilyn Thomsen: So how'd you get to Pomona? Dr. Michael Seq...: Well, good story. So I played football in high school, and I was a decent football player, but nothing more, but in terms of my college choices I was going to one other school other than Pomona, it wasn't Pomona, and my high school football coach came and said, he took me aside at lunch hour and he said, "Sequeira, I think you can play college football." I said, "Coach, look at me." You can't see me on this Sagecast, but I was five-five at the time, 145 pounds. I said, "Coach, come on, look at me." He goes, "No, I've got a friend, his name's Walt Ambrose." He was the football coach at Pomona College. He knew I was the valedictorian in my class, he basically put me on track to come to Pomona. Marilyn Thomsen: When did you know you wanted to be premed? Dr. Michael Seq...: The high achieving students in general, as a default, frequently pick premed, and half of the football team were premed, so I ended up going premed. But that led me to such professors like R. Nelson Smith and Dr. Hansch for organic, and Dr. Lyman Benson, just they were towering intellects who wrote their own textbooks, and they basically took an interest in me. I was like, "Wow." I'm just this little immigrant kid without much of a background, and they took an interest. They opened office hours and mentoring me, and teaching me how to think and just completely opened me up. I just still remember coming there, I was a high school valedictorian, but probably half my class were valedictorians from their schools. So it was eye-opening, and I walking home one day noticed at about 2:00 AM, walking home from the library, and I looked up at the dorm and three-quarters of the lights were on, and people were all studying still. I was saying, "What? This is going to be a challenge." Travis Khachato...: I would imagine it was a little bit more than being a valedictorian that drove you into the health profession. Was there a drive to want to work in hospitals? Dr. Michael Seq...: Yeah, there actually was. Thanks. It's part of that drive that led me to where I am now in public health. I really wanted to pay it back, I really wanted, at the time, I loved the concept of service and being able to help people. But at the same time, be really well respected and be assured a good life. Marilyn Thomsen: Is there anything that's different today about critical care medicine than when you first started? Dr. Michael Seq...: Oh, yeah. It's completely different now. Marilyn Thomsen: What's different? Dr. Michael Seq...: Well, it's so much technological, the science, and we now know it as AI, but progressive evidence basis for progress has led basically to logarithmic jumps in technology and the way we approach things. Marilyn Thomsen: Does it help in diagnosis? Dr. Michael Seq...: It absolutely does. Emergency medicine, when I took it on, it was a new specialty, and I basically chose it. I've always liked to basically trail-blaze a little bit, and so I chose emergency medicine because it had immediate gratification, I could save lives immediately. But a lot of it we were learning what we were doing, as it became specialty in emergency medicine. I then developed training programs, research programs, and worked more and more with internal medicine and ICU medicine. So it became a lot more academic, a lot more evidence based. Travis Khachato...: So I'm hoping you can take us into the room of an ER facility, what is it like on a day to day basis when you're dealing with patients on their worst days? Dr. Michael Seq...: Yeah. It's actually controlled chaos, it's amazing. Because you basically have to be able to multitask every minute you're there, because even from the time you come on you take sign-off and it could very well be two, three, four critical patients with three ambulances in a day, and 10 people checking in. We basically have to triage these people, and these patients in terms of by severity of illness, but also what's happening in emergency medicine is we learn the service portion. So we had to move them through quickly, because people don't like to go to the ER and sit six hours, even though they do. So you basically have to learn to triage, and we developed a pretty sophisticated mechanism for screening patients, so that we can screen the quick people with the ankle sprains and the sore throats that we could quickly get in and out, and then take care of the critically ill ones and then order up the lab tests. Marilyn Thomsen: Is there any case that you think of that just sticks with you in you mind? Dr. Michael Seq...: There are a lot. Marilyn Thomsen: Is there one in particular that you'll never forget? Dr. Michael Seq...: It sounds gruesome, but we had one of our medical school professors who came in, he had been attacked on the street, and he basically came in with an icepick in his eye. Marilyn Thomsen: Oh, my goodness. Dr. Michael Seq...: Having to deal with someone you knew and respected, and who was in critical shape like that, it broke through that objectivity. In medicine you have to create a veneer of objectivity to be able to function correctly, because if you get subjective, if you think about emotions and reactions, it really screws you up. So that's the kind of thing that stopped us all in our tracks, but fortunately we're conditioned enough to be able to do that. But trauma, trauma creates so many interesting cocktail stories. Travis Khachato...: Is he okay? Dr. Michael Seq...: He is, he lost significant vision in his eye of course. Travis Khachato...: Oh, my god. Marilyn Thomsen: But he made it? Dr. Michael Seq...: He made it, he made it. Marilyn Thomsen: Wow. Now, you became a leader in medicine in the State of California, in San Bernardino County, tell us about that. Dr. Michael Seq...: Thank you. So when I came from Portland, that's where I did my residency trainings, I came back down, my parents were getting older so I wanted to come back to Southern California. So I took over a directorship of an ER in Redlands, California, not too far from Claremont, and then progressively I joined a physician partnership that basically staffed multiple emergency departments. So I was basically given more and more ERs to oversee, so I eventually oversaw 12 different ERs in the area, including the one local to here, Pomona Valley. During that time, I got into organized medicine as well. I became the National Risk Director for Vituity Medical Group, and basically one of my jobs was to keep everyone out of trouble. We had this pandemic hitting us, so my job was to keep track of all the new evidence that was coming in about COVID. So I was close to actually retiring at the time, so I was approached at that point, late 2019, to become the health officer for San Bernardino County because- Marilyn Thomsen: So you would have been going from the practice of medicine and supervising doctors, to running a public health entity as the medical officer? Dr. Michael Seq...: Yeah, as the health officer. Marilyn Thomsen: Health officer for San Bernardino County, with how many people on your team? Dr. Michael Seq...: It initially was 900, and when COVID hit we had to hire all these contact tracers and disease investigators, and it swelled to over 1500. Marilyn Thomsen: Wow. What's the range of services that you oversee now in that capacity? Dr. Michael Seq...: Well, public health, it's big-time surveillance and investigation and disease control, so we oversee all of the communicable disease emergencies, from COVID to syphilis to TB to HIV to hepatitis-C. Public health also oversees other related things like environmental health, which gives you your restaurant grades, your ABCs, that's public health that does that. Water surveillance, so it's a huge spectrum. Animal control is even under public health. Travis Khachato...: I remember working as a journalist, public health departments, they were important but they lived on the periphery of what was going on in the zeitgeist. Suddenly, they were thrust in front and center. Was that a jolt to you to be the public face of public health during a global pandemic? Dr. Michael Seq...: It was a jolt for public health for sure. Talk about being on your heels and then having to respond to probably the largest public health challenge in history. That's what public health had to do. It blew away the previous health officer, and that's why they needed help. So I had worked with the Medical Society and I had worked with all the hospitals, and I knew the data, so they approached me. But I'll tell you, Travis, talk about eye-opening. When I came in, I had to learn how to be a public health officer, and learn public health, and keep track of what's going on in all the hospitals that were completely overrun with COVID patients, and a sense of anxiety and panic throughout our society. Marilyn Thomsen: Yeah. This was eight months after the start of the pandemic in the US? Dr. Michael Seq...: Yes. Every one of our hospitals in San Bernardino County were full. We had patients in our hallways, in our cafeterias, and in our gift shops. Marilyn Thomsen: Oh, my goodness. Dr. Michael Seq...: We had people dying right and left, including the doctors and nurses. So we had to learn how to control this thing, so we had to simultaneously learn what COVID does, learn what the disease was and how to treat it, and learn actually how does it spread? How do we even test? We had no test. We went through three months without a good test for COVID. So we had to do what we call syndromic surveillance. Oh, it looks like it, it's a flu like syndrome where you lose your smell and taste, and so that's COVID. But the CDC, they tripped up in giving us a good reliable test that we could just spread throughout the community. So we had to fly by the seat of our pants. So that's why you see a lot of things with Dr. Fauci, and the politicians basically jumping all over him. "Well, he changed his mind. One time he says wear masks, and other times don't." So as the evidence grew, as we learned more about the disease and how it spread, we had to change. There was one point where- Marilyn Thomsen: Big learning curve. Dr. Michael Seq...: Absolutely. It got so bad we just needed time. You remember that flattening the curve, we needed time to learn about this disease and gather ourselves, that was why there was the lockdown. We had to just, "Everyone stop." The world is being threatened, we need to just stop and really learn how to do this, and we have to learn how to develop that vaccine. We made amazing progress, but it was quite a ride. Marilyn Thomsen: You came into your new job right when the vaccine rollout was getting organized, tell us about what that was like. You were in a county, San Bernardino County is the biggest by geography county in the whole country, all the way from the Arizona border over to Montclair I think, right on the edge of LA County. That's a huge area, and then you've got a vaccine that has to be kept super cold in a lot of cases, ramped up for a lot of people. How'd you do that? Dr. Michael Seq...: It was really tough. What we learned in public health is there's what we call the social determinants of health. The social determinants of health basically are things like access to medical care, education, transportation, and food, food security, et cetera. So when you have a huge county, the largest county in the country, 21,000 square miles, we had to get this out. The populations, the vulnerable populations, the elderly, the immuno-suppressed, but also the people who didn't have the income, didn't have transportation and access to medical care, they were disproportionately hit with COVID. So we had to go out and get them. So we had this new vaccine, and it started with tremendous scarcity, so we had to develop all these criteria of who needs it most and the most needy first. So we actually spread this out and we just used it up, used it up. But then down the line, as we're using it up, we're looking where else do we need to go in terms of our high needy population, our elderly, our home-bound, our African American population, our LatinX population, our Native Hawaiian, Pacific Islanders. So we really had to get out there, so we had to not only get through cultural barriers, but we had to get through geographic barriers. So we have this system called MPODs, which we could go through Needles or Trona or way out there into the depths of our county, and we developed a mobile team, multiple mobile teams to go out and not only test and teach, but to vaccinate. Marilyn Thomsen: You also mentioned that it was really important to rebuild trust. Tell us about that. Dr. Michael Seq...: This was a tough time, as we all know, but public health is defined as where medicine meets politics. So politics, it couldn't have been worse in that it was a perfect storm for politics. We had a president who basically started by, when being asked how to control all these increasing cases, he responded, "Stop testing." He denied that COVID was even a disease. It got to where it was, "Why should our people have to choose between to vaccinate or test or not based on your politics?" It doesn't make sense at all. So what happened was when politics gets in the middle, you get concept our surgeon called misinformation, we had this epidemic of misinformation where things were thrown out like, "COVID is a hoax, and the vaccine causes genetic mutations." So we had to just battle, not only do we have to battle the disease, now we had to battle this whole epidemic of lies and misinformation. So people started doubting doctors, and so that's where the trust is. We had to build that trust back up, and we had to educate and base on education and things that people could actually see, and ground their knowledge and their beliefs on to where they could start to believe us again. So it was really difficult. We had to build ... When people are in a situation of life or death, they have to trust who's leading them through that sea. So we had to get them back. Travis Khachato...: Did that change you and your relationship with medicine and your relationship with patients? Dr. Michael Seq...: It changed me, Travis, yeah. It actually did, because I hadn't realized how much we needed to rely on other people. As a critical care physician, I knew I had the skills to save a life one on one, when that patient came one on one. But in this situation, I couldn't do that, I had to work through groups, I had to work through community based organizations, faith based groups. I had to be the conduit from the CDC and the CDPH to bring those truths, and actually convert and gain the trust of those people. So it really changed me, it opened me up in that way. It was really traumatic too. But I think I was blessed at least with the ability to absorb trauma, and so I was able to assimilate that. But it was very stressful. Marilyn Thomsen: Do you think there's any way to depoliticize public health today? Dr. Michael Seq...: No. Marilyn Thomsen: Really? Dr. Michael Seq...: Yeah. Partially because if you put yourself in a situation where you see a potential public health crisis, if I see an epidemic of dengue fever coming or whatever, I've got to be able to shut that business down and isolate everyone involved, quarantine the ones who might be ... To do that, you need basically to go through and get to the businesses, pass the policies, past a law to be able to do that. So we are at the interface, the things we do affect businesses, affect schools, and it's all political in that regard. Marilyn Thomsen: One of the things that we're seeing today is that there are some new laws that are being passed or suggested in a number of states that would reduce public health authority in those kinds of circumstances. Does that worry you? Dr. Michael Seq...: It does worry me, but as long as it's couched in a regular progression where ... The problem is people who are not physicians should not be making medical decisions. That's a big thing. But if the law actually entails the actual implementation of medical orders in conjunction or in partnership with physicians and with medical care, then I think it's okay. Because docs and doctors, we don't know the mechanisms of how to get this done from a business standpoint. We can tell you what needs to be done. So there needs to be a partnership, you need to work together in groups. So it's a little bothersome, but that's why we need, and I was involved with the Medical Society, California Medical Association, and now we have the Health Officers Association and the CCLHO. So we need to basically work together to inform our congresspeople who are voting on those laws, and so that they make informed decisions. So it's scary, but it's actually just extra incentive to stay involved from an advocacy standpoint. That's probably why I got involved with our state organization as well, so I'm on the board now of the California Coalition of Local Health Officers, and just because I realized the need for doing that. Travis Khachato...: I want to change gears just real quickly. So my dad was a firefighter paramedic back in the 1980s in LA City, and one of the things that he mentioned is that over the course of his decades-long career is that his job changed in a certain way to become more about pain management. I was curious from your perspective, because he'd bring them to the ER, if that was the same situation that you saw change over the course of your career as well. Dr. Michael Seq...: Yeah. Your dad pointed out a really important, and actually potentially tragic turn that acute care medicine took, and that was the emphasis on pain. The fact that part of our job was just to eliminate pain, and that was pushed at the same time certain pharmaceutical companies were saying, "We've got the great drugs for you to eliminate pain." So we pushed that, and pain became the fifth vital sign, besides blood pressure, pulse, heart rate, oxygen saturation, the fifth vital sign was pain. So yeah, great point. Marilyn Thomsen: So what made it so bad? The opioid crisis, now fentanyl, were there factors beyond the management of pain that made it so bad, the country today? Dr. Michael Seq...: Yeah, the drugs themselves. We basically, the drug companies developed these long-acting pain medicines that gave you basically a prolonged high, were highly addictive. So the opioid crisis has three phases, the first was prescription. The doctors over-prescribed pain medications, and there were these pain meds like Oxycontin, which was the big one, that were sold initially developed for cancer pain, but were told, "Oh, it's great for chronic pain." So we over-prescribed it, there were no prescription guidelines, and so all the leftover opioids were picked up by children, the children of those people who had those extra opioids. So it basically fed on an opioid addiction or use disorder, and then heroin came in to replace that people couldn't get the Oxycontin. So heroin took off, and then what happened after heroin of course they learned about fentanyl, which is 50-times stronger, so they could use 50-times less drug and they could feed it into almost everything, in pills, Xanny bars they call them, Xanax bars, any pill. So that we're in our third phase now of fentanyl, or illegally manufactured fentanyl, that are basically killing innocent young people, including college students, high school students, who are basically just experimenting. They're just taking on Oxycontin pill because they were told you can get high with it, but no, it's not Oxycontin it's fentanyl, and it's killing people. Travis Khachato...: How scary is fentanyl since you've seen it come in a wave of popularity, or unknown in the drugs that people are taking? Dr. Michael Seq...: It's really scary, Travis. If you just take a salt shaker and take out 12 granules of salt, it's that much fentanyl that can kill someone who doesn't have a tolerance. So they're putting it in everything, and the problem is it's not controlled by the FDA, so one pill may have barely anything, another pill can kill two people. It's being sold on the street, so the FDA completely has lost control. Not to put down their efforts, they're trying as hard as they can, but it's just everywhere. So now we have this new legion of victims, these kids who are not addicted to opioids, who are just basically doing what we all did, experimenting. We used to drink our parents' whiskey from the liquor cabinet or whatever. They're experimenting now and not even realizing it, and they're dying. So what we've got to do now is get the word out that anything that you buy illegally or not manufactured could have fentanyl in it, could kill you. We're trying to get what we call harm reduction out there, which is Narcan, which is the antidote that just with a nasal sniffer basically can reverse and save a life. So that's what we're doing now. Marilyn Thomsen: What kinds of programs are people involved in public health promoting to address the opioid crisis, the fentanyl crisis? Dr. Michael Seq...: You can imagine as pervasive as this is, and as unpredictable of where it will head, we've got to get it out there everywhere. So we're working with the schools, we're working with all of our community based organizations, and we're basically getting the concept of harm reduction. Because harm reduction is basically de-stigmatizing drug use, because if you tell kids, "You need to come and get Narcan if you're going to use drugs." A good kid, even a Sagehen kid is not going to go up and say, "I'm going to use narcotics." No, they're not going to. So you have to de-stigmatize it, you have to open it up and make it available. The other thing is what we're doing is we've developed this database, it's a hot spot identifier, it looks at all of our overdoses, it's based on that Pareto principle. But we're looking at our hot spots and we're sending out teams of harm reduction to areas that suddenly have four or five overdoses. So we're getting Narcan out there, and harm reduction education out there as well. So we've got every organization that wants to participate, and hopefully the Claremont Colleges and Pomona has it available, and if not I'm here. Marilyn Thomsen: Are you seeing progress? Dr. Michael Seq...: Yeah. I think we are, but it's still too early to tell. Last year, the number one cause of mortality in the age group 14 to 17 in our county was fentanyl. 14 to 17, it's scary. But we're making progress, unfortunately our data ... We're trying to get realtime data to be able to respond as quickly as possible, but it's difficult. Travis Khachato...: So I'm curious, after it's been quite a long few years from a public health perspective, is public health your future or are you set in the emergency room? Where do you prefer to be? Dr. Michael Seq...: Actually, I'm now a health officer, and public health is my future now. I'm not a young man anymore either, as you knew from class of '73, so it's actually ... I wanted to do Peace Corps when I was in med school at Pomona, and never got a chance because we couldn't afford to take that time off. But this is service too, and I love it because public health is service. So you're able to use what you've accumulated, I've been able to take that experience from my high school football coach, from what Pomona gave me, and give it back. Marilyn Thomsen: What gives you the most sense of satisfaction? Dr. Michael Seq...: Saving lives, there is no greater high than to save lives. That's the one real endorphin rush of an ER doctor. But for every life you save, you've got four or five that you don't save. So that balances and you've got to ride that out. But as a health officer, to make a difference, to make a difference in a community, to save all those lives, to make an intervention like getting fentanyl out there, or preventing syphilis. We're in a big epidemic of congenital syphilis right now, and saving that one baby from getting congenital syphilis, which is dooming them for the rest of their lives. So it's a constant endorphin rush. Marilyn Thomsen: I was going to ask you what makes a really good day? Dr. Michael Seq...: In the ER it's easy, a really good day is when you've seen all the patients, moved them through quickly, and saved a few lives. With public health, it takes a while. But knowing that you've reached a group, getting the right policy through, instilling some trust in people, and making a difference in people's lives. I think it's a great day when you do that. Marilyn Thomsen: What makes you optimistic for the future? Dr. Michael Seq...: I think we've got great people, there are a lot of smart good people who basically will do things. I really truly believe regardless of political party people still want to do the right thing. So I think in the long run, if we get the right people, the good thinkers with the right attitudes, we'll definitely move past all of this. Marilyn Thomsen: Dr. Michael Sequeira, this is a great way to end. Thank you so much for sharing with our Sagecast audience today about some amazing work that you're doing to help our communities be healthier. Thank you. Dr. Michael Seq...: Appreciate it, and appreciate the opportunity. Marilyn Thomsen: That's our show. Our thanks to Pomona alumnus Dr. Michael Sequeira, Public Health Officer for San Bernardino County. Travis Khachato...: And thanks to our audio engineer Erica Tyron and KSPC for hosting our conversations. Join us next time for another conversation about tackling the difficult.