Interview with Dr. Rocco Armonda:
Perspective on the COVID Crisis and Response
Rimal Dossani, MD
Rocco Armonda, MD
Rocco A. Armonda, MD, (Col ret, USA, MC) is director of Neuroendovascular Surgery and Surgical Co-Director for the Neuro-Intensive Care Unit at MedStar Washington Hospital Center, and Professor of Neurosurgery at Georgetown University Hospital. Following neurosurgical residency at Walter Reed Army MEDCEN, he completed a fellowship in Cerebrovascular Surgery and Interventional Neuroradiology at Thomas Jefferson University. During his 31-year military career, he was awarded the Bronze Star for service, the Legion of Merit, and the Army Medical Proficiency ‘A’ Designator for excellence in both clinical and academic medicine in 2009.
How would the military have responded to the COVID crisis?
The military would have intervened earlier with public health measures as a priority over immediate economic concerns and in the final analysis, society would have been better for both the economy and public health as well as military readiness. In military medicine, we are taught that non-combat loss due to disease is often greater than combat losses. In some conflicts this was as high as a 6:1 ratio. Infectious diseases among a confined population is a common scenario in the military and is a critical part of the “threat assessment.” Battle days lost to disease can incapacitate an army and has happened throughout history. Combat power is preserved by a healthy, resilient fighting force. In the civilian sector, this translates to public health measures to limit the spread of the virus. This is not going to be a popular decision, and that’s where leadership must flourish. In a time of crisis, asking people to make a sacrifice for the benefit of the entire population is what we are trained to do in the military. It is obviously more challenging to enforce this in the civilian population. Making the sacrifice to stay at home, socially distance, and wear a mask when in public is in the best interest of the society. The critical role of logistics planning from test kits, PPE, to ventilators and ICU resources could have been optimally coordinated as the military would for a mass casualty scenario. To paraphrase Gen. Martin Dempsey, the former Chairmen of the Joint Chiefs of Staff, “A rookie talks about strategy while a professional plans for logistics.”
How would you evaluate the leadership response to the COVID crisis?
In my opinion as a private citizen, there were a variety of leadership examples both good and bad on all levels of the government. The delay of a coordinated, centralized and early federal leadership was contrasted by the heroic efforts of Governors and Mayors to protect and provide for their citizens. In particular, the examples of Gov. Cuomo, Baker, Newson, Hogan, and others to fill a void from the absence of a central coordinated federal response was remarkable. Unfortunately, they are limited to state resources which at the time had to compete not only with each other but also the erratic intervention of federal agencies. To enact an efficient COVID response, the President should have immediately used his authority under the War Powers Act to declare a national state of emergency, mobilize our industrial capabilities, enacted widespread testing utilizing the World Health Organization (WHO) kits, coordinated the tracking of cases, mandated a national lockdown, and prioritized personal protective equipment.
In countries like Taiwan, New Zealand, and South Korea, early decisive action through measures like widespread testing, international travel restrictions and social distancing were able to limit the number of deaths and infections. As a result, these countries had much fewer deaths per capita than the United States. The President on the other hand refused the early counsel of his experts, deferred responsibility for a central coordinated immediate response and focused on affixing blame rather than adopting a strategy to protect our society.
Has history repeated itself given the context of the great influenza in 1918?
Many examples from the Great Influenza of 1918 resonate today. It is interesting that some of the most famous doctors of that era were infected by influenza including Drs. Cushing, Welsh, and William Osler who would expire from the disease. The early first wave concentration of cases in the spring of 1918 from Haskell County, Kansas to Camp Funston to nearby Ft. Riley, Kansas followed the pattern of a zoonotic to human infection. Contact contamination with a concentrated population of military recruits led to further dissemination. The military response was thwarted by efforts to get more soldiers to European battlefields, resulting in significant infection spread in Ft. Devens, Massachusetts in particular, and subsequently to other military training bases and civilian sites as soldiers returned from WWI. One of the most dramatic national outbreaks occurred in Philadelphia in October 1918, a week after hundreds of thousands gathered for a “War Bonds Parade.” The following week, daily death tolls exceeded those of WWI battlefields, and a shortage of caskets was notable in Philadelphia.
The worldwide spread of the disease with death tolls approaching 50 million and 675,000 deaths in the US during the second wave presents an ominous warning for us today. As many as 14 million deaths were reported in the Indian subcontinent alone. This would be equivalent to 1.2 million deaths given our current US population. Failure of a coordinated federal and international response, with community spread, lack of abiding public health measures with the gathering of large public groups, and local, national, and international politics continue to threaten citizens today in a similar fashion.
What is the role of the military in maintaining civil order?
The active military and national guard are not a police force. Outside of an extreme crisis and martial law, their training is not specific in maintaining civilian order and their use in the wrong situation can lead to confrontation and escalation of violence. They have been used in emergencies to protect peaceful protests, maintain order and avoid confrontation between aggressive and violent opposing groups in unique situations. The military should always remain an apolitical force. To do otherwise is to corrode the professionalism of the US military. This oath is sacred. It is to a set of principles not a party nor person, it is to those ideals set forth in our Constitution; including freedom of the press, of assembly, of religion, of equal protection under the law regardless of race, color, or creed. As stated by the former secretary of defense Gen. Mattis, “We must reject any thinking of our cities as a ‘battle-space’ that our uniformed military is called upon to ‘dominate.’ This becomes critical now as we are at crossroads of both a pandemic and increased racial tensions where violence needs to be avoided and understanding and compassion should be enhanced.
What is your hope for neurosurgical leaders as we prepare to navigate a new norm in healthcare?
Neurosurgical leaders should be open-minded, invite new ideas by encouraging younger investigators, and question our assumptions. We should especially look at the most vulnerable populations, who experience healthcare disparities due to socio-economic and racial prejudices. This is particularly seen with civilian penetrating brain trauma as well as spontaneous intracranial hemorrhage, stroke, and delayed presentation of aneurysmal SAH. Neurosurgeons should stay engaged in improved community awareness, education, and prevention. Our role in community health needs to be emphasized and should shape the educational mission of our national organizations.
Additionally, the model for our national meeting should be reexamined. Gathering a few thousand people in one city for a neurosurgical meeting may not be prudent in a time of pandemic, financial crises, and other public health priorities. Such meetings will potentially expose thousands of people to the virus when there are excellent alternatives through the internet and live webinars to further the educational and leadership mission. Some of the best talks I have heard recently have been on Zoom. I have recently interacted with biomedical engineers and diverse professionals virtually, where previously these types of multidisciplinary interactions may not have been possible. There are a number of online international symposia that we can all learn from and use to teach others who are less likely to be able to travel abroad.
How have you applied decision-making learned in your military career to your neurosurgical career?
My military career has helped me seek the counsel of others, critically analyze my complications, recognize excellence and sacrifice of others, and avoid commercial bias. As a leader you must set the highest standards; don’t ask others do to something that you don’t already do. Sharing the burden of call, crediting others with success, and taking responsibility for complications are essential. Ideally it is best to avoid procedural complications by discussing treatment plans with your team, seeking different opinions which you may have not considered. This type of “war-gaming” consideration allows alternatives, contingencies, and worst-case scenario discussions. Additionally, the military prohibited relationships with industry. I have adopted the same in my neurosurgical career. I have zero disclosures. I am willing to use a variety of medical devices as it best serves a patient. The crisis has also allowed us to reexamine funding needs. It is critical to reassess our relationships with industry and ensure that we remain neutral and unbiased. Ideally, we should not have any fiduciary relationship with the medical device industry.