Raquel Bono
Senior Fellow, Johns Hopkins University Applied Physics Laboratory
Retired Vice Admiral, U.S. Navy
Former Director, U.S. Defense Health Agency
Former Director, COVID-19 Health System Response Management State of Washington
How an Admiral Steered Washington’s COVID-19 Response
As the first state confronted with COVID-19 cases in early 2020, all eyes were on Washington as it struggled to get ahead of the virus. Dealing with the multiple challenges the pandemic presented—health, economic, and social—required a credible, nimble leader who could work across sectors, geographies, and political constituencies. Governor Jay Inslee found that leader in retired Navy Vice Admiral Raquel (Rocky) Bono, whom he appointed in March 2020 to first serve as the state’s COVID-19 Health System Response Management. A former head of the U.S. Defense Health Agency, Bono is a trauma surgeon who has honed her crisis decision-making skills with both battlefield experience and hurricane response. As Washington’s COVID-19 leader, she forged compromises among localities across the state – listening, learning, and helping local leaders access resources and respond more effectively.
We Are All Washingtonians
While home to some of the world’s leaders in pandemic preparedness and response, Washington’s diverse communities nonetheless had varied perspectives and needs. What was right for urban, high-tech Seattle might differ from what made sense for less densely populated, more conservative agricultural communities in eastern Washington – or for military families stationed on the southern coast of the state. Bono saw her job as working for all Washingtonians. This mindset drove her approach and was critical to overcoming divides on polarizing issues like masking and social distancing.
Governor Inslee was invested in saving as many Washingtonians as possible. That resonated with me and I latched onto phrasing – “Washingtonians” –as a key priority for our team and everything we did when he brought me on site.
I learned a lot about Washington State, including how the Cascade Mountains divide east and west Washington and how that geography distinguished each side in different ways. Ultimately, we ended up getting some of the best traction for our COVID-19 response in counties where local leadership from across public health, county officials, the health care leaders and local businesses could agree on common areas that would protect the greatest number of Washingtonians. It was intriguing how collectively, public health interventions could be agreed upon and operationalized.
It was easy to see how something like face masks could be a lightning rod. I traveled with the governor to different places and different counties across the state. The governor would talk about what he needed, and we would see some reticence. Somewhere along the line, my team and I would go back into those counties and talk to the same people. That presented us with an opportunity to listen to their objections and concerns and then we would work to reframe what the governor was trying to do without going into personalities or politics and re-framed through the local needs. What we oftentimes uncovered were concerns that are very unique to the county, and they weren’t necessarily getting the attention or the resources to be more responsive to their own needs.
Problem Solver In chief
In many ways, Bono became the state’s “chief problem solver,” empowered by the governor to find out what was happening, listen to people across the state, and find solutions driven by data and by communities.
“In Yakima, which is in the south of the state, I was there when people were starting to work in the fields and in the meat factories, and we started seeing an uptick in COVID cases. We wanted to try to get face masks and social distancing implemented.”
“It was incredible how quickly people said, “You know, it’s because of the workers who are bringing COVID into the area.” There was a lot of reaction to that sentiment. When our team went into the area and looked at the public health data, we noticed a number of different factors – primarily, the epi curve for the county showed that COVID prevalence for the area was already high. The workers had been tested negative prior to working in the meat factories and were now being placed in congregate settings both in the factories and in their housing. We shared our findings directly with the governor and were able to show that it was more likely that workers were being exposed to COVID within the county rather than bringing it into the area. Messaging and interventions were tailored to address what the data showed us.”
We had to have that conversation and share that information in small groups. Then we went back to the county and, using the numbers, showed what the more probable transmission routes looked like and discussed what public health interventions could be applied whether face masking, social distancing, housing and appropriate quarantine and isolation measures.
“Did the county then share that information with the public? Not specifically, but it didn’t matter at the time.”
One of the things I learned is that you don’t have to prove that somebody’s wrong to make something happen. You certainly don’t have to share broadly that they were mistaken. It allowed us to start looking at the working and living conditions of the workers who had come into the area.
“Another example was in one of the eastern counties of Washington state. The conversation ended up being about oxygen saturations. We found, in the eastern counties, they were giving people pulse oximeters so they could monitor themselves. We had a conversation about how there was then a need to coach people to come back if they saw a drop in their oxygen saturation. The discussion that followed was an exploration of whether wearing face masks could lessen how many people were reporting to the ERs because of a drop in the oxygen saturation that they were picking up from self-monitoring with their pulse oximeters.”
These were things that could have gone haywire. But, instead, we started getting traction, and we would watch the epi curves for each of the 39 counties and then target interventions by county to see what measures were having an impact.
No Single Sector Solutions
In Washington state, it was clear very early in the pandemic that the pandemic response would only be successful if public health needs and the needs of communities and businesses were considered equally.
I took the approach that this was not a single sector solution – that public health and medical sectors couldn’t do this on its own. I wasn’t pigeon holed in my efforts. When I looked across the other states, and looked at my colleagues who were trying to do something similar to my efforts, many of them were primarily working in a public health role. I wasn’t. I had access to so many of the community leaders and sectors, and I didn’t help influence only public health issues related to the COVID response. I eventually became the Director, Washington State COVID-19 Pandemic Health Response which was broader than just the public health response. So I went everywhere. I went to the universities. I went to schools. I went to nursing homes. I went to hospitals. I talked to big-box businesses.
We intentionally worked to be on the same side of the ledger: (1) saving as many Washingtonians as possible; and (2) saving as many jobs as possible by keeping employees as safe as possible so they could work and run their businesses and return to school and (3) we protected the frontline health workers. We would have iterative and derivative conversations about what that could look like and what we would need to do collectively to achieve these outcomes
Helping Hospitals
Like most states, Washington suspended elective surgeries to preserve surge capacity for COVID patients, yet there was no process for working with key stakeholders (e.g., hospitals, medical specialties, nursing unions, and tribal nations) to craft solutions that could maximize public health benefits and minimize impact to routine healthcare and hospital operations. Bono was instrumental in finding ways to meet both needs.
“Many of the hospital systems were really starting to suffer the financial impact of the decision to suspend elective surgeries. After a couple of months of not having elective surgeries, it was hard to maintain a fairly steady revenue stream. Since we were still deciding how we were going to do virtual care, hospitals and ambulatory surgery centers were severely challenged. We worked with the University of Washington and IMHE (Institute for Health Metrics and Evaluation) on modeling to forecast what we could expect our hospital capacity to look like and what our projected hospitalizations would look like given certain epi curves and outbreaks. We had been suspending elective surgery to preserve PPE (personal protective equipment) and to mitigate spread, but we also recognized that some surgical care shouldn’t be delayed even if considered elective. “
“Policy-making for pandemic management was originating from the WA State Department of Health with a few key stakeholders. In drafting the Governor’s policy for resuming elective surgeries, it needed to be designed to ensure that we had enough surge capacity to accommodate an uptick in hospitalizations if another breakout occurred.”
For this, we expanded the number of participants in drafting the policy to inform how to re-start elective cases safely while preserving at least a 20% surge capacity and continuing to have sufficient PPE for the front line health workers – all conditions had to be met before elective surgery could be done. The policy wasn’t going to tell the providers or hospitals what procedures could be done, but rather under what conditions should they decide to prioritize performing elective surgery. Everyone shared some of the risk, but were able to exercise a greater say in the prioritization of care.
“We drafted the policy and brought it to Governor Inslee. When he signed the policy, it was with the contributions of a broad number of stakeholders who were able to support the policy, which we were able to monitor its implementation with a dashboard to see who was maintaining their personal protective equipment and their surge capacity while making sure their internal COVID rates were not rising. “
Everybody contributed, shared their concerns and identified what contributions were needed from each party to make the policy work. All participants knew what transpired to draft the policy. Everybody participated in the timing of bringing it to the governor. We televised him signing the policy with representative members of the team who helped draft the policy. We were very transparent with each other and the Governor’s office and the Department of Health. It ended up being no surprise when he signed the policy. The other important part of creating that policy was deciding that we would review it periodically to see what we needed to change as things proceeded through the pandemic.
The Secret Sauce
Bono envisioned her role as serving the people of the state, balancing public health needs with other elements of the pandemic response like the economy.
“When Governor Inslee called me, he had three criteria. He wanted somebody with deep healthcare knowledge, including how health systems work. He wanted somebody who had crisis management experience, and that was something I had as a trauma surgeon and as a military officer. The third thing that he wanted was someone who knew how to give orders.”
“On that criterion, I said, “Well, that’s not how we actually get things done in the military. It’s not by issuing a set of orders.” And I asked him what kind of success rate he observed when giving an order and expecting people to follow it? I explained that a military order comes only after a plan of action has been discussed, examined and adjusted and generally agreed upon with the input of others. When it is go-time, leadership gives the order to execute the agreed upon plan and the team goes into action.”
As I reflect on my time in Washington State, one of the strongest elements – what gave my team the most maneuvering ability – was having a governor who, even though he had to operate in a highly polarized and politicized environment within the state and across the country, was willing to frame everything that he was doing as being able to serve Washingtonians and save the most Washingtonians from COVID-19. I pivoted off of that consistently and publicly. I used that everywhere I went – because it didn’t matter if you were a business, a university, a public entity, a private company, red, or blue. No matter who you were, you had to be for saving as many Washingtonians as possible.
And, how do you polarize that? If you were in WA State, you were a Washingtonian. Because when people would ask, what about the unsheltered? We could ask what we need to do to take care of the unsheltered – so we could save as many of those Washingtonians as possible. And when people would ask about counties where we had out-of-state workers, we would say, first off, let’s save as many Washingtonians as possible. Let’s also consider that these workers are now Washingtonians. I was honored to be a Washingtonian, too.