Medical geographer Paul Delamater, assistant professor in the department of geography and a fellow at the Carolina Population Center, discusses his research.
Jonathan Weiler: My name is Jonathan Weiler and I am a professor of global studies at UNC.
Matthew Andrews: And my name is Matt Andrews. I am with Jonathan Weiler, though in a different room obviously because of social distancing practices. I am a professor in the department of history at UNC-Chapel Hill.
JW: And Matt and I have both, for a few years now, had a podcast called “Agony of Defeat” which is about the intersection of sports and history and politics. And partly because of our experience with podcasting, we have been asked by the College of Arts & Sciences to launch this new series called “COVID Conversations” about, of course, the unfolding pandemic, and health and economic and social and political crisis we are all facing. And what we want to do is we want to spotlight the research and the work of some of our great faculty in the College of Arts & Sciences, whose work and research is relevant to understanding, trying to put in perspective, and make sense of the current pandemic. And we want to thank the College of Arts & Sciences, and especially Rudi Colloredo-Mansfield, the Senior Associate Dean in the College for Social Sciences and Global, for really conceiving of the idea and approaching us. We’re honored to be part of this project. And we also want to thank the chairs in the College of Arts & Sciences who have very enthusiastically signed-off on this project and have let us know of all the wonderful work that their faculty are doing, some of whom, many of whom, we hope will be part of the “COVID Conversations” series in subsequent weeks.
MA: Yeah and thank you very much to the College of Arts & Sciences for asking us to do this. Because Jonathan and I normally podcasts about sports, we literally have nothing to talk about right now. So, this is giving us something to dive into.
JW: So, our first guest in the series, and we’re so delighted to have him, is Paul Delamater. Paul is an assistant professor of geography here at UNC. He came to UNC in 2017. He received his Ph.D. in geography from Michigan State University. And Paul’s expertise is in, among other things, health geography, and spatial data science and analysis, and we’re delighted to have him. So, Paul let’s just kick this off with maybe just tell us a little bit about your background and how you came to study and be interested in the issues that have become the focus of your research.
Paul Delamater: Yeah, thanks for having me on Jonathan and Matthew, I wanted to say that first. This is a fun thing to be doing virtually at this time, spending this time kind of virtually together when we can’t be physically together. So, I started as an engineering student as an undergrad and wasn’t really enjoying my college career. And went one day to an open house because there was free pizza and I learned about geography and what is cartography and geographic information science and I signed up for a major like the next day I think because I thought it was such an interesting subject. It’s so broad the discipline covers a lot of ground. I did a master’s project that looked at land use and land cover change in the Ecuadorian Amazon and that was very interesting and very fulfilling. After that I started a Ph.D. and I got into this sub-discipline of health geography via a project about health care access and utilization in Michigan. This project was at Michigan State. And that was really where I found like my calling because there was just so much, so many interesting questions that have yet to be answered in this idea of what, you know, how can geographers help us understand health and disease and health care issues.
MA: Well Paul thanks for that, so great talking to you. That was gonna be the first question I was going to ask, which you started to answer a little bit. You know, I sort of grew up thinking that geography is like, what’s the capital of Slovenia you know, but obviously geography has broadened and you’re bringing in all these different sort of sub-disciplines into it. So maybe if you could talk a little bit more about what you see your role as a geographer at this particular moment. And then maybe a little more specific question is, how does geography then differ from Epidemiology in this particular moment?
PD: Yeah, those are great questions and I get them quite often because I do a decent amount of speaking about my research and people are always like what, why is a geographer here talking today about this issue about, you know, disease or COVID. And you know geography is the study of space and place, that’s one of the ways I’ve heard it described. It’s much more broad than kind of learning capitals and where things are on a map. When you start looking at how processes, whether they’re economic processes or disease processes like we’re seeing now kind of play out, there is almost always this geographic expression of things. And when we often look at the world, seeing it in a map is often extremely useful for us to understand what’s going on and making it real for us as people, you know, the idea of being able to look on a map is extremely powerful. So that’s, you know, that’s geography in a nutshell. It’s a really interesting field in times like this because geographers are also very broadly trained in the Natural and Social Sciences and so we often bring this ability to kind of think across disciplines and across different types of study when we are tackling a project like infectious disease outbreak such as COVID.
JW: Great thanks for that Paul. And Paul, so diving in a little more specifically to your research, I know one of the things you’ve worked on is vaccinations in California, and in particular, I guess sort of compliance and resistance to vaccination programs. So just briefly could you talk a little bit about that work that you’ve done and how you explore the questions you’re interested in exploring given your background.
PD: Yeah that’s been what I’ve been working on, this idea of vaccines and the idea of vaccine hesitancy of people who are actually unwilling to or aren’t comfortable with vaccinating their children. This started about 6 years ago, I was very lucky a professor at my prior institution George Mason University walked into my office and was curious. He said I have this vaccine data and I think there’s something geographic going on. And really this study is about, in the US, we don’t have any real requirements for vaccinating our kids other than, or vaccinating people, other than school entry requirements. So, when a child is born there are recommended vaccines for that child to get but no one’s making a parent have their child vaccinated. And so, we just started looking at this from a geographic perspective because what we found was this kind of behavior, this belief of hesitancy about vaccines, had a very geographic expression. And what I mean by that is, if you look at a map of something like the school-level vaccine exemptions, which are these exemptions from the vaccine requirements. If you look at that, it’s got a very geographic expression, where you see schools with high levels of these exemptions all located kind of near each other and schools with few of these exemptions or very high levels of vaccine uptake, all together. And a lot of that is based on demographics and socioeconomics because we as humans kind of organize ourselves into communities of similar type people. But what we’re finding is there is actually like a geographic expression to this. Some areas just have more of this hesitancy regardless of socioeconomic or demographic conditions. So, I kind of when I do this research I like to look at bigger, broader study areas like state level things, so I’m looking at like in general, how is this playing out in California? The other thing that’s really interesting in this is how legislation affects kind of people’s behaviors and beliefs.
MA: Are you seeing any links, and maybe in some ways this will be our transition to talking about COVID if that’s alright, are you seeing any links in what you see on the map when you’re looking at vaccine hesitancy and the laws about vaccinations or the recommendations about vaccination and what we’re seeing develop here? Either with regards to rates of infection, shelter in place orders, I mean, are there any broad correlations that you’re seeing so far?
JW: And just add to that list. What kind of hesitancy, or just around social distancing, whether that’s part of a government mandate or not?
PD: That’s a great question. I haven’t looked specifically at whether places that have shown hesitancy in the past have increased rates of COVID. But I think you know, thinking about this question, it would be important to think about moving forward. When and if a vaccine does get developed for COVID, whether people are willing to take that vaccine or give it to their kids. I’ve already seen some news reports about people talking about saying they don’t want a COVID vaccine. They don’t want to do it. They would rather not vaccinate their kid. They would rather they or their child gained immunity by having the disease, rather than having the vaccine. So yeah, so I think it’s something to keep in mind moving forward.
JW: And Paul, you shared an article with Matt and me earlier today. I guess I would put in the category of kind of maybe unanticipated consequences of this catastrophe we’re in, that a lot of parents whose kids are in the middle of a vaccination protocol don’t want to take their kids to the doctor to get vaccinated because the risk in their mind of exposure to the COVID virus makes it not worth it. So that’s sort of one of those unnerving consequences that probably most people wouldn’t have thought about until we were confronted with these extraordinary circumstances.
PD: Yeah, when I found that article this morning, I hadn’t even thought about that. And a student that I’m working with, she had brought something up similar. She’s hearing from people that she works with that vaccination rates are way down right now for our regular childhood diseases. And, you know, it’s a scary time. People don’t know what’s safe and where. It’s very hard to balance risk in these situations because there is a risk of leaving the house under our social distancing and stay home orders right now, but I’m sure parents want to protect their kids from things like measles and whooping cough. Hopefully the social distancing that we’re in right now will somewhat shield kids from coming into contact with other kids and passing those diseases around, but there’s always this chance you know. What should we do right now with these and worry that you know some people don’t quite have, don’t have similar resources or have the same resources as others. And there may be parents that it would be really hard for them to get their child caught back up on these vaccinations once this social distancing is done.
MA: So, Paul, I know you have a project that focuses on Michigan. Could you tell us about what you’re doing up there?
PD: Yeah, I’m working with some other professors and students at the University of Michigan. And the state requested that we produce some maps, pretty much of real-time coronavirus risk. And right now what we’re trying to do is, it’s an interesting thing because there are issues we are trying to balance as far as this idea of geographic resolution or scale, so you know at your very local region what your risk is but also balancing the ideas of privacy and people’s privacy and not wanting to kind of point out where people with the virus have tested positive because there has been a little bit of issues with that. And so yeah, we’re working really quickly right now. I don’t know if I’ve ever seen kind of the university steps to do a data use agreement and an IRB kind of work faster than this, because we’re talking days on things that usually take months to get put in place. And the end result of this is going to be a set of maps that we can show the people in Michigan of what their coronavirus risk is right now and over the last few days. And then again thinking about all of this we’re doing this all so fast, you know what kind of risk are we looking at for them in the next seven days or in the next couple weeks?
JW: And Paul, can you say a little bit more? Michigan has been incredibly hard hit. I think it’s just behind New York and New Jersey in terms of the most fatalities from the virus so far. And it’s one of the first places that we started to hear real evidence of systematic racial differences and who was getting the virus and mortality rates from it. Nobody should be surprised that there are racial differences, but could you talk a little bit about some of what you’ve seen in Michigan in terms of some of those factors?
PD: Yes, Wayne County and Detroit City is one of the most segregated places, you know, I would say in the US. There was the whole white flight thing that’s been happening there for 50 years. And you know, it’s kind of left Detroit, even though there has been quite a bit of reinvestment in the downtown and the city, you know, there are still some real structural issues as far as, you know the racial composition of Detroit and Wayne County. The other thing is there there’s a lot of underlying health issues in some of these populations that are socially disadvantaged. They have less access to primary care and less access to quality food sources. And so when a thing like coronavirus hits, you have a densely populated region of people with pre-existing conditions that make them susceptible to having worse outcomes, and so you get a situation like you’re seeing in Detroit, where there’s just a lot of cases. A lot of deaths and some, you know, because of how fast it hit, you know some breakdowns of the health care system. One of the things that’s happening in Detroit is they’re building a nearly thousand-bed field hospital to take care of COVID patients.
JW: Just to add quickly, Paul, to your point about pre-existing conditions. I know two of the ones that have been most commonly cited are asthma/lung related illnesses and diabetes. And those are two afflictions that, from everything I understand, fall disproportionately on black Americans, which seems to compound all of the things that you’re talking about.
PD: Yeah it’s, you know, there’s a lot of immediacy in people wanting to get these maps out and kind of understanding what’s happening right this minute because we’re in the middle of the pandemic, and of this awful situation, but I think that you know in half a year, in a year, and for many years, I think we’re going to be looking at kind of how COVID-19 affected people differently. And kind of why, you know the world was the way it was or what were some of the situations or scenarios that lead to things like, if you look at some of the death rates, it’s just shocking how many African Americans are dying in comparison to how many are actually getting the disease.
MA: Yeah when this started tearing through New York City, urban density you know, this became the buzz term, and everyone was talking about urban density but if you compare my understanding of what’s going on in Detroit to San Francisco. San Francisco seems to be managing the death rates because San Francisco is a relatively rich, dense place compared to Detroit, which is obviously an economically impoverished dense place. And so, Paul to go back to these maps that you’re making, what do you see, perhaps, as the most immediate effect of these maps? Can people then look at these maps and change policy? I mean, what do you hope to gain from the creation of these maps?
PD: One of the things that the state of Michigan’s most concerned about, and I think a lot of places are concerned about this right now is, are people social distancing everywhere and how much are people adhering to these recommendations not to get together, to stay 6 feet away? I have two dogs that we walk quite often now that we’re home very often, and so we’re out and about in our neighborhood a lot my wife and I, and we are continually amazed at what we’ve seen just on our few times out a day of you know, people just not being as careful as I think they could be. And we’re in a place that I think a lot of people are quite educated and you know, generally, are going to follow rules like this. And I think that it’s just hard you know, for a whole state to enforce any kind of social distancing recommendations and mandates just because, how are you going to you know, how are you going to police this? And the state just wants people to know that they are at risk, I mean I think that’s what a lot of people are thinking about right now.
JW: Right and I mean this sort of goes back to your work on hesitancy in compliance right and this is just a particularly dangerous, so much at stake, manifestation of that.
PD: It really is. And that’s a great point that you know vaccines are recommended, they’re required for school but you know parents can opt-out in some cases and social distancing is again, it’s a recommendation. It’s been mandated but how are you going to police this? And it’s, I think the difference right now is just the immediacy of it. That we’re you know, epidemiologists are trying to produce their models and everyone’s trying to look at you know, what’s going to happen if we end this at the end of April, at the end of May, at the end of June, and there’s just a lot of uncertainty right now. So, you know, I just I’ve been telling everyone I know just we gotta stay vigilant on it.
JW: This is “COVID Conversations.” I’m Jonathan Weiler, here virtually with my co-host Matt Andrews and our guest today Paul Delamater. Paul is a geographer who works in health geography and geographic information science and we’re talking to him about his work as it relates to the COVID-19 virus.
MA: I know one of the things that you study is this notion of herd immunity and this is a phrase that has obviously been in the news a lot recently, so you seem like the perfect guy to ask this. First of all, could you explain what the theory of herd immunity is? And then explain how it does, as you see it, does or does not apply you know as a potential strategy as we figure out what to do with this particular pandemic?
PD: Yeah, it was really interesting when I started hearing that some countries were thinking about implementing, instead of a social distancing approach, a herd immunity approach. So what herd immunity is, is if enough people either get vaccinated or get the disease, they get immunity to it. And what happens is, as you start building up like a critical mass of people who cannot catch the disease or spread the disease, what it does is it kind of like walls off the rest of the people who are still susceptible. So you can imagine if something like 90% of the people are not susceptible, they have immunity to the disease, then basically 9 out of every 10 people you run into you would run into, can’t catch the disease from you. If you had it, it would only be one. And what happens is, the way that contacts work among people is that, and how easy it is to transmit a disease, there’s this like critical percent of the population with immunity that basically it shuts off all those pathways and you can protect people who are not immune, even though not every single person is immune. So with COVID, that idea was that well maybe we can use the herd immunity model which is: let all the younger people, the stronger people, get sick, get immunity to the disease, and then shield the older people or the more susceptible people from getting it. Because they’re basically this group of people who are young, who get the disease and recover, build a wall like a big wall in our population such that it’s kind of like they block anyone trying to pass the disease from a person to an older person, right? The problem is you basically have to wall off, during this herd immunity building this immunity building stage, you can’t have any contact between the people who are kind of building the immunity and the people you’re trying to protect. And I think that’s where kind of this may have gone wrong or not been such a good idea because it’s just so hard like to wall off contact between say people ages 20 to 50 and the rest of the population.
MA: Well and it sounds like herd immunity makes no sense unless there’s a vaccine. I mean you said that you know people being vaccinated again, it sounds to me like that’s a key component to the concept of herd immunity, which we’re obviously lacking here.
PD: Right and that’s one of the issues with kind of implementing it is ’cause then you’re saying all those people to build up herd immunity, have to get the disease and pass through it on the other end healthy. And so that idea I think that’s one of the things that is a bit scary right now is, you know the disease is not, we’re not going to stamp out the disease completely in our social distancing period. COVID is going to be here for a while. We’re not really going to begin building a lot of immunity until we get a vaccine and so we’re going to have to keep up these practices for quite a while I think. Just to make sure it doesn’t kind of catch fire again because this is what will happen is we might tamp it down to like some embers but once we start you know, to lift the social distancing, you’re just throwing a bunch of fuel on it again and it can take off again.
JW: So, Paul, we wanted to talk to you about an article that you coauthored last summer. The lead author is Rachel Woodul, you’ll correct me if I pronounce it incorrectly, yourself, and Mike Emch, who’s a colleague of yours in geography. And before we ask you to talk a little bit more in depth about the paper, I actually want to read a couple of sentences from the abstract. I read this article last night and I got this like chill that I was in a science fiction story or something because. . .
MA: I did too, literally goosebumps reading this.
JW: So just to give folks some context, this article was submitted for review in November of 2018 and it published in July of 2019 and here’s part of the abstract:
“We constructed an integrated disease outbreak and surge capacity model to evaluate the ability of a region’s healthcare system to provide care in the event of a pandemic. In a case study, we implement the model to investigate how an influenza pandemic similar to the 1918 Spanish Flu pandemic would affect the population of the Raleigh-Durham-Chapel Hill metropolitan statistical area and the ability of the region’s hospital system to respond to such an event. Under varying scenarios for hospital capacity, we found that the population needing care would overwhelm the system’s ability to provide care in the case study1.”
So, it’s unnerving just reading that, but maybe you could tell us a little bit about how that’s, how you modeled what you did and what conclusions you drew and of course how that is relevant to what we’re going through now.
PD: Yeah that research came from a student, Rachel Woodul’s undergrad honors thesis, and she’s currently still working on similar work. She just passed her master’s thesis defense last week.
JW: Because we have awesome students at UNC, it shouldn’t. . .
PD: We really do, we really do.
MA: Yes, congratulations, Rachel.
PD: Yeah so, she was really interested in infectious disease modeling, and I’m really interested in healthcare and healthcare capacity, so when we were talking about projects, this kind of just emerged from our discussions. And in her model, we basically modeled an influenza pandemic that descends on the triangle region and modeled daily how many people we thought would get sick and where they might seek care and we know how many hospital beds every hospital has. And what we did was we modeled this as just the expected amount of people we thought would be sick and needing hospitalization. And because this is kind of an emerging area of research, this idea of surge capacity for healthcare, like how much, how many patients can a hospital take on, maybe more or less than the current number of beds they have. So, we tried many scenarios because we didn’t know exactly, we said, you know, maybe a hospital can hold 200 percent of how many beds they have. Or maybe it’s only three-quarters percent because there are still people who may be having heart attacks or strokes or broken arms that need to be in the hospital. So, we tried it out and we tested you know, this simulated pandemic and we found that in many cases it was going to overwhelm the hospital systems ability to provide care. Now I do have to say this is the caveat here: there was no social distancing in our model. Our epidemiological model is very straightforward. It was just the virus kind of comes, this influenza virus comes to the triangle and it just moves its way through.
JW: Yeah, and I know that speaking of social distancing, Mandy Cohen, who’s the director of the state Public Health Department in North Carolina, told a press conference the other day that according to their models, in a model in which we maintain social distancing I think through May, we’ll have something like a quarter of a million cases in North Carolina and if we don’t, we could have three-quarters of a million cases. So obviously the differences are absolutely enormous between maintaining those protocols and not.
PD: Yeah, and there’s a new report that came out from some scholars at UNC and RTI and I believe Duke was in there as well, that was looking at hospital capacity in the state. And I’ve actually recently linked up with those scholars and we may be trying to run our hospitalization model with some of their predictions of COVID in North Carolina. So, we’re interested, we’re very excited to be able to help in that way.
JW: Well, that’s amazing and obviously urgent work.
MA: So Paul, I’m wondering if you could talk a little bit more about this study that you did, and more specifically, you created this hypothetical pandemic last year or two years ago, and now we see a real world pandemic happening. To what extent have you found that your findings about what North Carolina was going to face in this paper that you co-wrote, to what extent are those findings being replicated by reality now?
PD: Well, that’s a great question and fortunately, you know, we haven’t to this point on April 9th, heard anything in North Carolina about the health care system getting overrun. I think that thus far, the state’s been able to keep cases and hospitalizations quite low. You know when we wrote the paper, we had no idea. I mean, there’s been a lot of books written about the coming global pandemic and things you know. I think people have been thinking about this, but when we were writing the paper, we were like thinking very specifically. What is this going to look like? Or what could this look like? We talked about it that, you know, we modeled almost a worst-case scenario with no social distancing or no vaccine available for this influenza pandemic that we simulated. So, you know, we’re seeing the efforts happening with social distancing, people working on a vaccine to try to get it finished quickly.
JW: Just to add one more thing Paul, and you can speak to this and correct me if I’m misspeaking, but from what I understand, the COVID virus is more lethal than typical influenza viruses. So, you may have modeled a worst-case scenario in terms of just people getting sick, but not necessarily in terms of death toll. To be to be sort of blunt about it.
PD: No, that’s a great point that you know, that’s something that Rachel and I have talked about, and that’s something she actually tackled in her thesis that wasn’t in the paper. And that was one of the ways she extended this work in her thesis. And I’m sure that you guys both heard, you know, when COVID started getting on the news and we started hearing about it and what it could do and what it could be, there was a decent amount of talk that it was just like the flu, that it was very similar to the flu. And I think what happened was, you know, at the beginning there’s just not a lot of information about these diseases and so you know the modeled expectations change on a daily basis or an hour by hour basis. And some of those first data that came out, it didn’t seem so terrible, but then we found out you know later that, yeah, this is a dangerous thing. This is, you know, it already has killed a lot of people and could kill a lot more and it’s really sad. And you know, this is one of those times where we’re lucky to have the healthcare infrastructure we do, and you know the people that are going out there every day and still going to work to care for patients.
JW: So that’s not the most encouraging note on which to end, but it’s an important one. And so, Paul Delamater, thanks so much again for coming on “COVID Conversations.” This was absolutely fascinating. We could obviously have talked for a much longer time, but we really appreciate your taking the time to share your knowledge and your insight with us.
PD: Thank you so much. It was my pleasure.
JW: And so, before we say goodbye, just a reminder: this is “COVID Conversations” and we want to let you know where you can find the podcast. There is a landing page, a website covidconversations.unc.edu. We are hoping and expecting that it will also be available on SoundCloud and iTunes soon and we will look forward to seeing you or speaking with you next time for our next installment of COVID Conversation. So, thanks so much and everybody please stay safe and I hope your families are well.
1Woodul, R. L., Delamater, P. L., & Emch, M. (2019). Hospital surge capacity for an influenza pandemic in the triangle region of North Carolina. Spatial and spatio-temporal epidemiology, 30, 100285.
Transcript edited by Kelsey Eaker.