How to Prepare for the Next Public Health Crisis?

[00:00:00] Jared: Hello everyone, and welcome back to another enlightening episode of the med+Design Podcast, where we dive deep into the journeys and insights of healthcare innovators. Today we're genuinely privileged to host Dr. Maurice Ramirez, a seasoned professional in emergency medicine and disaster response.

Dr. Ramirez's remarkable career spans the challenging and evolving field of disaster medicine, making him an eminent figure in addressing global health crises. From his initial steps as an independent emergency physician to his leadership roles in the Florida Department of Health and National Disaster Medical System, Dr. Ramirez exemplifies how healthcare can rise to the demands of our rapidly changing world. He stands at the forefront of understanding and responding to the significant impacts of climate change on human health and healthcare systems leading the High Alert Institute to prepare for the consequences of these growing challenges.

His insights steeped and rich experience, and shaped by an ardent drive to protect communities, position him as a truly exceptional guest for our conversation today. We're thrilled to explore his journey, unpack his pioneering initiatives, and hear his thoughts on the future of healthcare and the planet.

So without further ado, let's dive into our engaging conversation with Dr. Maurice Ramirez. Welcome.

[00:01:12] Maurice: Thank you, Jared. It's a pleasure to be here. How are you today?

[00:01:15] Jared: Hi. I am doing fantastic. It's a nice cool day here in Southern California, and from what I've seen in the news, looks like everyone else around the country is having a lot tougher time.

So I'm very grateful.

[00:01:25] Maurice: We're, we are having a typical Florida summer, 98% humidity, 108 degree temperatures, pretty average for us.

[00:01:33] Jared: Average. Just average stuff for you guys. And so I wanted to start the conversation today talking about disaster medicine. I think a lot of people are not super familiar with it.

If you could just give us an overview of what it is and where is it, excelling and maybe where are things falling short in disaster medicine? I guess I would say in the US cause I'm sure we could talk globally as well.

[00:01:54] Maurice: Disaster medicine exists in three spaces in healthcare.

Really we refer to it more as disaster healthcare because it includes more than just physicians and medical specialties. It includes nursing, behavioral and mental health. It even includes veterinary medicine, and as I said, it exists in three spaces. The first is what most people think of a disaster occurs, an earthquake, a flood.

A hurricane unfortunately, also manmade events, mass shootings and terrorist events, and a team of healthcare professionals arrives on scene, usually led by first responders and EMS. Fire rescue law enforcement followed very quickly by teams that help reestablish healthcare in that community.

And then a transition to the community reestablishing its own health.

Jared did You just froze. Did you lose me for a moment? I froze you. Yeah, I was frozen. You were frozen as well at the same time. I'm not sure who lost who, but with, all yeah. Apologies there.

And for your audience's information I come to you actually from a, from our facility, which is an austere environment test space. So I come to you via satellite from the Tiger Creek State Forest in Lake Wales, Florida. Hopefully we'll stay stable from this point forward. But this is a prime example of what I was speaking about. We have the disaster response phase for healthcare, where you have first responders, law enforcement, EMS, fire rescue, even line workers who come in and people say line workers.

How does that have to do with emergency medicine and disaster medicine? It's very hard to deliver healthcare in the dark. It's very hard to send people to a shelter when there's no power. So it's an integrated system that involves everybody and every service in the community when resources are limited.

And that's the definition of a disaster, is when your needs exceed your resources. So in disaster medicine, the second component is planning. We want in disaster healthcare to get ahead, to educate the public, to educate every individual who may be impacted, ideally, regardless of their means.

So we were the original people in health equity. Because it doesn't matter whether you are homeless or whether you live in a 20 billion mansion, when a disaster strikes, you all suffer the same loss of resources and therefore you all need the same levels of preparedness and education. And that's where the High Alert Institute got its beginnings was in that disaster preparedness education readiness education.

The third component of disaster healthcare. Really deals with a greater concept of the planet, what we call One Health, One Nature. Most recently it's been renamed One Health Security. The idea that, as we saw with Covid, diseases very often and other challenges don't come just from the human system, just from human healthcare diseases, move from animals or even plants eventually to people impacts in the environment, things that affect environmental health.

Just today there was an Associated Press article that reported on a new scientific study looking at forever chemicals in tap water. And what are these impacts on health and what will they do to our resources if there's a flood or if there's hurricane or, yeah, Detroit. Think about Detroit and bottled water.

What if Detroit in plus bottled water had also had a blizzard that incapacitated delivery of bottled water? The disaster isn't just the hurricane or just the blizzard anymore. Now it's the fact that people don't have any water to drink. That's safe. Which was a preexisting problem. So what we sometimes refer to as complex healthcare emergencies and Covid 19 augmented a number of those for the public.

You saw shortages in personal protective devices, in masks, in face shields, in healthcare spaces, yeah. Places to deliver healthcare. We had to bring in hospital ships, set up tent hospitals in major cities. The cities that have the highest number of physicians, nurses, and healthcare beds ended up needing the most support because they also had the highest number of people in the population, and therefore patients when the disease struck.

So that's Disaster Healthcare. It is not one specialty. Although we talk about it in terms of emergency medicine primarily I'm also boarded in family practice. And family practice is far more important in disaster healthcare over time than is the emergency medicine component. Now, I'm a very proud emergency medicine physician.

I am very proud of having been the founding chair of the American Board of Disaster Medicine, having served as a board examiner for emergency medicine for decades. But on the family practice side, when those of us who come in with our tents and our fancy equipment and our helicopters and our federal trusts and all of the, and FEMA's, yeah.

Checkbook leave after two to four weeks. It's the family practice, doctors, the OBGYNs, the pediatricians, the internal medicine doctors, the community nurse, the community es. The therapists, it's all the people, the psychologists, everybody in that community who has to come back. And we saw what happens when the healthcare community doesn't come back right away.

In all the way back in Hurricane Andrew in 92. In 92, we evacuated South Florida because a category five hurricane was coming. Wow. Now, A lot of healthcare people stayed behind to staff the facilities, but a lot of facilities were in a place where a category five would render them inoperable. So we evacuated those people.

They went north on I 95 with every intention of only going far enough north to get out of the storm and turn around and come back. So these were well-meaning healthcare people. The problem was that 95 was a traffic jam coming back after the storm because of all of the other resources that were needed.

And so local healthcare was delayed in their return by 14 days. We saw it again after Hurricane Rita in 2004 five, where healthcare wanted to get back in. But they literally couldn't get down the road fast enough to get home to start taking care of their own patients. In 2004, in the Orlando Central Florida area, we saw that with hurricane Charlie, Francis, and Gene. The same thing, evacuees, who then come back.

But they can't get back in and get their offices get their hospitals restaffed. And so you need those other specialties to come from unaffected parts of the country, other nurses to come from other parts of the country to support temporarily. Until everybody can get home, get their home taken care of, and get back to work themselves, taking care of their patients because in the end, they were their patients before we arrived, before the disaster struck, and they will be their patients again when we all go home after our response.

[00:09:06] Jared: That's fascinating. It reminds me of the firefighters as well. I have a buddy that's a firefighter and he went up to support the Canadian firefighters throughout their struggles up north. And it seems like it's all hands on deck moment, for the greater disaster preparedness community, when things like that happen.

[00:09:23] Maurice: And Yeah, and we refer to that as mutual aid and there are actual agreements.

That's how it's possible for a standards carrying firefighter from the United States to go to Canada or Australia during the Australian fires, if you remember a few years back. People came from all over the world to Australia to help under mutual aid agreements. And that's one of the things that the High Alert Institute also helps coordinate our mutual aid agreements in animal rescue and shelter.

Again, because of that overlap veterinary disaster medicine and human disaster medicine in a One Nature, One H ealth model.

[00:10:01] Jared: I love that model. I'm excited to delve into that more and in a little bit, I think let's stick on disaster medicine a little bit. And actually, I wanna know what got you into this space in the beginning.

You were an emergency physician in your earliest days. And when was, number one, what was the most challenging disaster that you've had to overcome? And then number two, just what got you started into the business, I guess you could say.

[00:10:21] Maurice: All disasters are local, so everybody looks for that big event. For me it was a gradual, it was a gradual transition. I had worked as a government consultant over, over a number of years. I was, because of my knowledge and experience in disaster medicine as well as rural disaster excuse me, rural emergency medicine. After several different manmade events in the United States I was one of those subject matter experts that was asked to comment or advise various leadership at a governmental level.

And that brought me in little by little. And then 9/11 occurred as was the case for many of us. And, I was one of those people who got a phone call but couldn't move. I was sitting in Florida. And as all the commercial airlines were immediately grounded. And there was a period of time where if you weren't a specific vetted government asset, you just weren't going to be moving.

So you helped by phone, you answered questions, you gave advice and there was a lot of uncertainty. There was a lot of local that just happened that where I was at the time, a number of the physicians I worked with the FAA and were at a national meeting, and so we're stranded on the other side of the country and just was the one literally left in the office. Wow. So there I was. That was my new job. Temporarily. After things got back into motion and we started getting a national response plan and frameworks written, those of us who had experience in fire rescue and in EMS and or law enforcement began to be drawn in to the process, and one of the first things that was very evident as we did, began our reviews of disaster preparedness, including here in Florida, where we're very good at it because of we deal with hurricane season every year. Remember in 2000 we had already been doing hurricanes at a healthcare level for decades in Florida.

And were very good at disaster planning in Florida, and some of that became some of the model that went forward. But one of the things that, that was very evident after 9/11 was that healthcare was not ready in the United States for a mass casualty event of any kind. 20, 30 people after a massive car accident can overload a very well-functioning trauma center.

Imagine 200 or 300 which has happened, or Katrina 5,000 a day. We weren't ready for that in 2002, proven by multiple reports and investigations that were published in 2004 and five. So we began, yeah, the federal government began doing funding training and High Alert was born out of that need to get basic knowledge, things that were well known to a combat medic, an 18 year old combat medic from the military, but were totally unknown on the other hand in healthcare. Some of that information as well as some of the few lessons that had been learned over the years in hurricane response, in blizzard response, mine collapse response, the things that we could study that we had studied.

Going back into the 1960s that were well-documented that we could take our first lessons from and begin building a system that not only supported us here in the United States, but taking lessons from Israel, from Europe, from Asia, where they had also dealt with disasters in very austere environments in some cases, and bringing all of that plus the brand new Homeland Security into one space and get that information out to at what was then 5,800 hospitals and healthcare systems around the continental United States, Alaska, and Hawaii. Just to bring us up to the point where if it happened in your community, regardless of what the, that is, And that was the concept of all hazards.

It doesn't matter what the hazard is, what's important is to support the resources of healthcare so that when the demand increases, the resources don't run out.

[00:14:31] Jared: Do you feel that also worked during the Covid Pandemic, it seems we got blindsided as a whole healthcare system during that time.

And this is off topic, but I'm curious. No, it's not at all. Oh. Cuz it just, yeah, it just seems, it was, it seemed like it was too much. And like how you said maybe we're not fully prepared for these sort of mass nationwide events, like how you mentioned.

[00:14:55] Maurice: One of the realities of medicine in general and disaster medicine in specific is that no matter how well prepared, no matter how ready you are, no matter how big your stockpile of extra resources or how well you position it, it won't be a disaster

unless your needs exceed those resources. We're back to that basic equation. Disasters happen when needs exceed resources. Let's take something much smaller than Covid for just a moment. The Northridge earthquake. Okay. Yeah, you're young. You may not remember that happened in the 1990s. The earthquake occurred.

The highways pancaked down, so these were elevated tiered highways and the supports broke because of the earthquake. And there were hundreds of people trapped around Northridge, California. Okay. Tens of deaths, but it wasn't hundreds of deaths and lots of patients that needed to flow into hospitals.

The hospitals didn't receive a huge flux of patients right away because people were trapped. Wow.

They're used to earthquakes. They had very good distributed warehousing system for resources. The problem was the warehouses were where? In industrial places? Oh, in the industrial parks. When the highways pancake, the highways go through and around the industrial parks, and so the highways became concrete barriers blocking the surface streets that prevented resources from flowing from these very full warehouses.

To the hospitals where the added resources were needed. So the problem wasn't immediate cuz the hospitals had stores on site. The problems came the next day, the second and third days down the road, and it took time to reestablish the flow of supplies to those hospitals. At first, there was the attempt to bring them from the warehouses that was fruitless.

Roads are blocked by pancaked highways that are, that you can't just bulldoze because you're still rescuing people. So you had to bring resources from outside of the community, which takes time to truck in because why the highways are blocked and collapsed. So even though you were fully prepared, more than enough supplies than you needed to take care of all the patients that would eventually come, you and your supplies were separated.

Your needs just exceeded your available resources disaster in covid. Believe it or not, we started planning for pandemic in 2008 2008, with training to hospitals. 2008, 11 years before Covid broke onto the scene 12 years before the public health emergency was declared. High Alert Institute, in fact, trained all of North and South Carolina, all of Colorado, half of Georgia, and half of Florida for pandemic preparedness

in partnership with several different universities, including University of Miami's Deep Center. We worked extensively to work on pandemic. Yes. The concentration was mostly H1-N1 and H5-N1, but we also included coronaviruses in the pandemic training because SARS had occurred in 2004 and Mers had already broken onto the scene.

We had that training from 2008 to 2011, 2012. So for four years we trained, and then the training continued on all the way up to 2019. It has been part of our national disaster pining scenarios. There was a fully written playbook just for Pandemic for Global Pandemic as part of our emergency response framework at a national level.

The problem wasn't that we weren't planned. The problem wasn't that hospitals had not practiced for this. Healthcare did a very good job of practicing for it. The problem was that when you have a third of a population, the size of the US population fall ill. Over a 24 month period that simply exceeds the available resources.

An N 95 mask is good for four hours, eight on the outside maximum. Average ER shift is 12 to four 14 hours. You need two masks. At a minimum, if the mask gets wet, you need to replace it. That couldn't happen simply because it was not possible to manufacture enough masks for all the healthcare workers and patients and family members and frontline workers at an N 95 level and distribute them.

Even if you made all those masks. How do you get them here from China? When we've stopped international travel? How do you get them from Indiana to Florida? When you have full shutdowns? How do you get them to Yeah. Out of your distribution warehouse when a quarter of your staff is sick?

You get to this point where the disaster will eventually over amp your resources. And when that occurs, we get into something called a graceful degradation of care. Now, I will say that this is one of my favorite governmental misnomers. First of all, it's anything but graceful. It happens suddenly when the system finally collapses, we run out of masks.

We can't protect our people and so our healthcare workers begin to get sick themselves. So it doesn't happen slowly or gently. It happens suddenly just like any illness, just like any system collapse. So it's far from graceful. It is a degradation of care. And I think that's an important phrase we are used to in the industrialized world, whether it's here in the United States, Canada, Europe,

most of Asia, Australia, we are used to being able to get healthcare almost on demand. Our biggest concern is does our insurance cover it? And how much does that prescription cost and thank rx, hey, we can even deal with and I'm not making a commercial just for them and many other organizations. But I've been playing this game for 40 years.

I remember when there wasn't a good RX and so good. Yeah, very good physicians would write the absolutely most appropriate and least expensive generic medication and patients would get sick because they couldn't afford the medicine. Thanks to patient assistance programs, discount programs, better insurance the Affordable Care Act, some of that problem has gone away, and we've gotten used to being able to get at least minimum sustaining healthcare in the United States.

Along comes Covid 19, we still did pretty well. Along comes the first wave of disease in the healthcare workers where we started seeing our colleagues in the ICU beds and in the morgue. And at that moment, the disaster broke. It went from being just a pandemic to being a pandemic disaster, because now healthcare couldn't keep up.

What was the one thing that we absolutely needed during the pandemic? Healthcare. Once healthcare got behind, the only way to get ahead was for the disease to break below a level where we could start getting ahead. And unfortunately, that took two years. We just kept getting surge after surge because Coronaviruses mutate quickly.

Because yeah, while it is miraculous that we had a vaccine as quickly as we did, when you consider how long, and I've consulted in the medical device, in pharmaceutical industry for over 15 years, the period of time to go from no clue what this disease is, to a vaccine in mass production and mass distribution in under 18 months with full testing is nearly unheard of. It was a miraculous event. Remember that we weren't able to pull that off during the HIV epidemic in the 1980s. Yeah. So the next closest pandemic of a disease that mutates as quickly, we didn't do it, and we still haven't gotten that vaccine because of all the variants and mutations.

So we pulled off a modern miracle from of science. But you still had 18 months. And our own institute lost my predecessor, the chairperson before me, Dr. Ed Martin Thornton chose to go even though he worked for Joint Commission. So he was out of the ER. He chose to go back to emergency medicine because there was a rural ER in his state that was at risk of closing because they were without staffing.

And the community couldn't afford the loss of an ER entirely, even though he bought his own PPE and enough to share with his staff. He went back to work there working 10 day stretches, one day off, 10 days again. And unfortunately on his 42nd day, he came down with Covid and because of preexisting conditions passed away and this is an expert in disaster medicine.

This is one of the published greats in our profession. He literally was the poster child. The gentleman that you see helping people off the helicopters from the FEMA pictures in Katrina was Dr. Thornton. That's his back that says TX one in the blue shirt helping an elderly person from a Blackhawk in first days after Katrina.

This is one of the, one of the greats of emergency medicine and of disaster medicine. He did everything right and provided PE at his own expense, his own pocket that, that he arranged for with some institute help, but that he arranged to get to this hospital just to get it staffed. And fortunately he stayed healthy long enough that he was able to get an entire ER, staff, nursing, and everybody else back into the facility.

Because they had lost their first staff to the disease that he kept that hospital open. Unfortunately, he did pay the ultimate price to protect his community. He went out a hero and oh, he's absolutely a hero. And there are so many of those heroes and not just in healthcare. And this is again, part of this one, all hazards, one health, one nature model.

Is that, yeah. Keeping people healthy, involved, grocery workers, farm workers, and truckers. And so in Disaster Healthcare, we coordinate with all of that. And we do so through our federal partner agencies, our local partner agencies, our hospitals, reaching out into their own supply chains, through their own contracting hospital that in Canaveral, Florida, in that near Cape Canaveral.

During the hurricanes discovered that one of the biggest impediments to their own staff getting home or getting to work rather, was worried about their home. So they made part of the hospital's emergency maintenance contracts like fix the roof after a hurricane for the hospital. Part of that contract says that once the hospital's roof was fixed, they had that company pledged to first do the roofs and home checks for all of their employees.

That meant the employee didn't have to run home and check their house. Wow. The employee could take care of patients. Smart takes their shoulders, yeah.

Not only that, it takes it off their shoulders. It takes it off their mind. It lets them know, most importantly, that their supported and cared for.

Yeah. You saw this again, in Covid 19, all of the people that made the news because they were singing to their colleagues. I love that. Yeah. Group choir events and people thought, oh, isn't that cute? No, it was brilliant. Oh, because here is something that costs nothing. It took nothing away from patient care.

It used no resources, but it created a support, not just for those workers there, but by extension to the community and to other healthcare workers in other places. And by doing that support, it made it possible for those people to come to work the next day to take care of you. Take care of my, of me, take care of our neighbors.

That's part of that preparedness that's a component of community that is part of all hazards, one health, one nature, taking care of the mental health, taking care of the community health, taking care of the environmental health. Yeah, and we've seen that as well with sustainability issues. One of the things that the institute here has is a division in environmental stewardship and determinants of health because environmental determinants of health social determinants of health impact, and we saw that again in Covid 19, one of the tragedies of Covid 19, and you might remember this in February of 2020.

We learned that Covid 19 was airborne. Worse. And how did we learn that? We learned that from the transmission of Covid 19, SARS CoV-2 in a Chinese restaurant in Wuhan, from a single infected individual who was seated nearest the door to people throughout the restaurant. Multiple cases all traced back to a single person.

When they looked at it, they discovered that it had been blown around the building by the central air conditioning system. People two and three days later were getting sick. Even though there were no further cases, new cases that came to visit the restaurant. Turns out that SARS CoV-2 lives for up to 96 hours on galvanized metal.

That's what air conditioners are made of. That's a problem. So we started ventilating and buildings. Far more in order to reduce the transmission. Now that sounds, like an environmental good. And it was, except in the inner city. In the inner city, we ventilated these highrises. Their air intakes were down at street level next to trucks and buses.

Oh geez. They sucked in exhaust. It turns out that the microcarbon in diesel exhaust gets stuck in your lungs. One of the problems of SARS CoV-2, as you might recall, is that lungs filled with thick fluid. That thick fluid got thicker. If there was exhaust particles, if that was that carbon black, oh my God.

Suddenly, inner city, by April of 2020, we saw a 180% increase in death rates of inner city public housing dwellers compared to non-public housing age and sex matched patients. Everybody said, oh, this is a proof of health in inequity. Yes and no. Yes. Because some of those people had more preexisting conditions.

No, because the inequity wasn't healthcare. The inequity was housing. The inequity was environment.

[00:29:54] Jared: I did not think of that. Wow.

[00:29:56] Maurice: Okay. It wasn't until December of 2020 when we stopped that practice of ventilating what we did, for all good reasons, we thought we were protecting these people.

We thought we were doing the right thing, and we did. We reduced the amount of virus in their air, but we replaced it with so much indoor air pollution that we gave them a new problem that if they got covid 19, made their covid 19 worse. So now you had to deal with determinants of health.

An environment. And, the institute, while we did not do that research we were already working in that space before Covid 19 because of, again, this all hazards, one health, one nature approach. It has to be considered. It's not just, are you ready for a disaster? Is your community ready for a disaster?

But it's where will the disaster come from? Will it come from, will it come from bats? Or in Florida during Covid 19, the Florida Department of Health, the Florida Department of Fish and Wildlife, the Florida Department of Agriculture, did a great job of preventing a mini epidemic of something called a screw worm.

It turned out that a foreign disease entered the Southern Keys. And nothing I'm saying is classified. So I can talk about this. Entered the Southern Keys. It was immediately detected by a agriculture inspection station. And they used the seven mile bridge as the airlock, if you will, the barrier.

And they did agricultural and vehicle inspections on both sides of the bridge, and they stopped the progression of that disease, which was animal based, but can jump to humans from making it north of the seven mile bridge and out of the Florida Keys and into the rest of the nation.

It took only a few weeks. It was a 100% success. It didn't make the papers. Why? Because other than a few domestic animals and wild animals that had to be treated, they didn't even have to euthanize any animals. Wow. And a few humans that got a mild infestation, but no big infections. It didn't go anywhere.

It didn't go anywhere because our animal welfare and health colleagues and our agricultural colleagues, our environmental colleagues were on surveillance. They observed and correctly identified a potential risk, a pandemic or an epidemic on top of a pandemic. We had a plan. It did not exceed our resources, and therefore it never became a disaster.

And these kinds of interdiction occur on a monthly basis. In every state of the Union and on a near daily basis on a global level. And we have success after success. And we don't talk about them. Why? Because it's just another day at the office. For those of us in disaster and emergency medicine, in public health, in animal welfare, in environmental health, this is just another day for us.

And we see these things come through, and every now and then we realize, oh, wow, that could have been really bad. Whew. But we did it. Yeah. And we get together once a year maybe at a World Association Disaster and Emergency Medicine meeting, or at American Academy of Disaster Medicine meeting or at some other meeting, and we talk about how successful this was so that we can learn from each other the successes as well.

Yeah, and this was a great success. That was, that I learned about from a National Association of Animal Welfare Professionals meeting even though I'd still consult some to Florida Public Health, Department of Health, it was a busy time during Covid. I missed that one on the newsletter.

Yeah. It was a small blurb. I went back and found it later. I found the report later, but it was a small blurb. I happened to catch it. Yeah. Several months later at a meeting. I was like, oh, wow. And that was just south of me. But at the time, we were busy with other things.

[00:33:50] Jared: Yeah, golly. It's in, it's fascinating also how you brought up like the AIDS era, in the eighties.

And my dad was an emergency. He was he was just an ER tech, but he was around the hospital for a lot of that, and he was talking to me about how, we saw this before and we saw this with aids, which I had never, got to see. I was born in 93 and it was just, Now, this time around, it felt like, at least how you mentioned, we've actually had a vaccine.

I hate to bring it back to this again, but something that, I wanted to ask you about, which was what's one of the most impactful innovations that has happened during your time? And I'm curious of, is it the vaccine for covid at the speed at which till we got it out to market or, to the greater population across the world or maybe that's one of them, and maybe there's others that come to mind for you as well that just had so much impact.

[00:34:40] Maurice: There have been literally millions of technological innovations. In fact, the institute also has a division in all hazard, one nature technology and innovation specifically to look at those things and in some cases help companies and innovators along when they're having some problems, getting a really great innovation to, to that next step that they need to so that they can then take off and run with it. But that aside, to answer your question, I would say that actually the greatest innovation has been the recognition of the importance of behavioral health and community and resilience in disaster medicine and in the workplace. And we see that with the empathetic leadership model. The concept and understand. I am an old school. Yeah. Scientist. Yeah I started computer programming in the mid seventies. I transitioned into hard sciences, engineering, biology, chemistry, physics in the eighties.

Went on, started in medical sciences and virology in the mid eighties, right around the AIDS epidemic period. And moved into medicine a little much later in the late eighties. I've been in this realm of rigor for well over 40 years and the softer sciences used to be off to the side.

One of the things that, that I have learned by hard experience both personal and professional, as well as by observation of huge populations going through disasters even before covid 19, is the importance of resilience and empathy. Now we're not talking about sympathy. Sympathy is very different.

Sympathy is feeling with you. You go to a funeral, you're sad, you cry because you feel the loss with those other mourners who have lost. Okay? Empathy is feeling through you, okay? Empathy is where I understand your feelings, and I am here to support you and I'm not here to fix it for you. I'm not here to get you to feel better.

I am here to support whatever it is that you feel and to help you ensure your own safety. I'm here to bring you to a point of resilience, to get you to the point where, yes, that might mean giving you resources because your needs have exceeded your resources on a physical level.

And Maslov was right. If I don't ensure the fact that you can A, breathe, B, have water, C have food, D have shelter, you are never going to get to a point where you can take care of yourself or others. So yes, there's a certain physical and that's what FEMA does. FEMA does a great job of that in the United States.

In other countries, there are FEMA equivalents and they take care of those basic maslovian needs. Then we have to get you to the point where you feel safe enough about your tribe, whether that tribe is your nuclear family, or just you and your significant other, or just you and your kids. Or it's your extended family, or it's you and your neighbors and your community, or it's your work community, your coworkers and you.

We have to get you to the point where you and they feel safe together so that then you as a individual, as well as in a group, have the resilience, have the emotional strength in the bank, in your personal bank to then go and do the same for others. That's empathy in action. And I think the greatest innovation, the greatest awareness that I have seen come in medicine in general in business and business leadership on a much larger scale, is that understanding that empathy in the workplace, empathy in the disaster response, empathy in the preparation is absolutely essential to success.

Without it, yes, you can succeed without it. Just like you can succeed without resilience, but it's a lot harder. When you take that to the next stage, we start getting back to this one health, one nature model again, because it isn't just empathy for the human standing next to you or the human and their pet, but it is the empathy for the entire system, whether that's the environment and that has come around to a concept in healthcare known as sustainability and joint Commission in December of 2022.

Signed the White House climate pledge. And the US Health and Human Services Healthcare sustainability pledge. The High Alert Institute, by the way, are also signatories to those documents. Those pledges look to change the current model, not just in healthcare, but in disaster planning at a national and international level.

The International Association of Emergency Managers has an entire new section on sustainability and disaster, because disasters breed their own disasters. Disaster response is a dirty business. We leave a lot of trash behind. We burn through a lot of resources without the planning and preparation to recycle and reuse.

Now we don't waste resources by any stretch, but we have a huge burn rate. And think about it, a hurricane comes through, it knocks down all the buildings in the community. What's the first thing we do? We scrape all those buildings off to build new buildings. We have to put that in trash someplace.

We don't take the time to do building material recycling because we're trying to get it out of the way so that we can reestablish the community. So we take it to the landfill and we fill it into the landfill. We don't even necessarily get a chance to pulverize it and make it fit in the landfill better.

We just bury it or burn it. Neither one of which is great for the environment. Then, the next year, what are we worrying about? Okay, so last year we had in Florida two major hurricanes. One a category five. It turns out, wipe the communities clean, cleaned up the communities, started rebuilding this year.

What are we worrying about? You mentioned it at the start of our show. And that was temperature, climate change. Yep. A decade ago we worried about a one and a half degree increase in global temperatures. Over the next 30 years. Last week, the greater concern was avoiding exceeding the critical point of 2.7 degree global temperature increase over what is left of that same time period.

Because that is a global climate disaster, if we exceed that 2.7 degree rise in that same timeframe. That means we have to be more sustainable. And that doesn't mean just ev cars and solar power systems. Although again, the institute is involved in some of those technologies, we actually have patented two technologies in renewable energy to make wind turbines more quiet. Because quiet wind turbines are healthier wind turbines for the community, right? To make solar thermal and solar electric able to occupy the same physical space because that means that you can have both on the same building. But we're now involved also in sustainability for healthcare because healthcare is responsible for 40% of the solid waste production in the United States, 40% from a single sector of the economy.

Wow. Why Think about it. Everything in healthcare is disposable. Why is it disposable? Because it's gonna be contaminated with human body fluids. Okay. We used to, back when I started in healthcare and you mentioned your father was an ER tech in the eighties. I was an OR tech in the seventies and eighties.

Oh, wow. We used to wash all of that. All of those gowns and drapes were washable cotton. We would wash them. They would go through an autoclave and we would reuse them. Hospitals had huge laundries, bigger than any hotel. Now all of those fibers, which are synthetic fibers, so they come from the petroleum industry.

That's a whole nother carbon chain. All of those fibers are disposable and because they're contaminated they're not recycled. The interesting thing is they could be recycled and there's an entire technology stream that is coming.

And the institute in fact will be presenting a poster later this year at the American Solar Energy Society international conference on the use of solar thermal in healthcare sustainability. Because there's the possibility of recycling and joint commission has been very clear that needs to happen and they're starting in the OR because of the same things that I saw over the last 40 years in the change from reusable to disposable and the climate pledge and the healthcare sustainability pledge is a 50% reduction

in carbon footprint for healthcare. I hope we can do it by 2030. Golly. I hope it's doable. Yeah, it's doable right here at the institute we have, yeah we have been experimenting and doing demonstrator projects and using renewable energy for disaster preparedness. We ran through the last two hurricanes off grid.

For two weeks, all the way back in 2017, we ran off grid for five weeks until the grid came back online in our area, lost no communications, ran our entire system and actually had to shut down part of our renewables because we were producing more power than we could use on site. Even though we have an animal shelter here with 60,000 gallons of filtration.

Our daily utilization here is between 89 and 140 kilowatts per 24 hours, we produce more than that. We produce on average to the grid 50 additional kilowatts per day. During a hurricane, we can back it down. Before we had batteries, that meant we had to run generators at night.

Now that we have batteries, we almost never even have to activate our generator other than as the third backup to test it once a week for 20 minutes. In 10 years at this, excuse me, now, 13 years at this facility, we have used less than 750 gallons of propane through all of the disasters natural disasters that have occurred, and our facility as at the intersection in the peninsula of all the hurricanes that crossed the state and we're here on purpose to be able to prove and test this.

This kind of sustainability. In all of that time, we've lost one solar panel out of 126. Oh my gosh. Wow. Including baseball size hail just a few weeks ago. That didn't damage any of them. The technology has gotten better. The technology is at a point where it is equivalent to a diesel generator.

For backup, which means it now could be backup for hospitals, and that would mean that all the times that the hospital is not using it for backup, they could actually be generating power for the community and reducing that carbon footprint. So is 50% reduction possible by 2030? Absolutely. In fact, it is so possible to do that.

It could be done in half that time. Wow. If the healthcare community and the healthcare industry makes the commitment, I hope we do. And many of them are.

[00:46:20] Jared: Yeah. We had another guest on who was a he was a surgeon and he was mentioning how anesthesia as well, is very harmful to the environment or like a form of it that they were using and phasing it out right now.

And we're, I can't believe we're already getting up to the end of the hour here. We didn't even get to talk about really all the questions I had for climate change and further on disaster preparedness. So I think happy to come back. I was gonna say, we're gonna have to do this again. But,

[00:46:43] Maurice: I think something else, absolutely we would love to, happy to come back, let us know when.

Yeah. And if your audience is in favor, we'd even be willing to make it a recurrent event. Not just myself, but we have 126 experts around the world who donate their time and expertise to these problems through the institute. And I know many of them would love the opportunity to share with you and your audience the amazing opportunities for healthcare and healthcare innovators.

Go going into the future, that help would help not only those companies and those individuals, but the greater world community and the planet as a whole.

[00:47:23] Jared: That's what we need, so let's get that rolling. I'm really excited for that. And thank you so much for joining us. I do have another question for you though, and it does go towards you just looking towards the future and talking towards the next generation that's coming after you.

And so what advice do you have to those that are coming up next, to those that are trying to sit in your seat one day and, they have a huge task ahead of them to try to, save the planet, save our people. Trying to change the way we live on the planet earth.

What sort of messages do you have to those that are coming up after you right now?

[00:47:52] Maurice: The old question of if you could go back and tell your 18 year old self three words. Stay the course. You will in life and particularly in healthcare. Encounter, challenge, encounter disappointment, encounter, crushing defeat. Okay? It is easy to celebrate the victories. I've had the privilege of delivering 53 children in my career.

All of them, unfortunately, in emergency circumstances. Fortunately, all the mothers and all the children survive. Sometimes after great challenge and great times in the hospital. Those are the victories that are easy to celebrate. The ones that are hard are when you lose a colleague, when you lose a patient, when you see something that you warned administration or the system or your colleagues was coming.

For instance, the Covid 19 pandemic and people didn't listen. You were dismissed. Stay the course. There are two possibilities. One, you are right. You may never get credit for being right, but the fact that you did not shut up and sit down will raise awareness somewhere. Whether you ever learn about it or not will save not one life, but many.

The other possibility is that you'll sit down, shut up, and go along, in which case, you just became part of the problem. I believe in being part of the solution. Now, that has gotten me told by Four Star Generals that I should never go into a career in politics and a right. I am one of those people who tells emperors they have no clothes on a regular basis.

On the other hand, I have the respect of my colleagues. I have the love of my friends because the one thing they can rely on is the fact that I will stay the course. They can stay the course with me, and that if we change course, it's because there was no alternative. Or that the change in course was in fact the course.

I feel like that's gotta be our theme right now. Stay the course. We can all do this if we all band together and I think we all kinda have to at this point in human history. So I'm excited to delve further into this in the future.

[00:50:17] Jared: But Dr. Ramirez, thank you so much for your time. Thank you so much for what you do at the High Alert Institute. We didn't even get to talk about that, in great detail, so there's just so much we have to talk about in the future. But just thank you so much for your time. I really appreciate it.

My pleasure, Jared. Thank you for having me.