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The Epidemiologist

Dr. Linda Bell on COVID-19’s impact, being in the spotlight, and how we can slow the virus

  • Updated
John A. Carlos II

Dr. Linda Bell speaks during one of Gov. Henry McMaster’s COVID-19 press conferences. Photo by John Carlos

For nearly three decades, Dr. Linda Bell has toiled in the realm of public health in South Carolina.

But for the last four months, she’s become a regular in living rooms across the Palmetto State, at least on TV screens.

Bell, a Texas native who has worked with the state Department of Health and Environmental Control since 1993, has been the state’s epidemiologist since 2012. She directs 140 people in the department’s bureau of disease control, and serves as South Carolina’s liaison to the Centers for Disease Control and Prevention.

And, as the novel coronavirus pandemic has continued to hold the nation and South Carolina in its grasp, Bell has become the face of the state public health agency’s fight against COVID-19. She has been a regular at Republican Gov. Henry McMaster’s frequent televised news conferences, and is often called upon during those sessions to present the scientific facts of how the virus is affecting South Carolina, and offer recommendations on how to slow the spread of the disease. For instance, Bell has been an ardent advocate for people wearing masks while out in public, even as McMaster has resisted a statewide mask measure. She has even publicly lauded cities and counties who have passed ordinances requiring masks in public.

Bell and other public health officials are now grappling with the steep rise in COVID-19 cases across South Carolina. While the coronavirus seemingly hit a plateau in the late spring, cases have unquestionably skyrocketed since Memorial Day weekend, with SCDHEC now routinely announcing more than 1,500 new cases on any given day. Hospitalizations because of COVID-19 also have climbed precipitously in the Palmetto State. Consider this: On June 1, there were 450 COVID-19 patients occupying hospital beds in South Carolina. By July 12, that number had grown to 1,472. Also, data from The New York Times show that, if each of the United States were a country, South Carolina would have had the third-worst per capita COVID-19 outbreak on the planet between June 28 and July 4, with more than 2,300 cases per million residents over that timeframe.

Bell recently hooked up with Free Times for a long chat on a number of topics, including her disappointment in South Carolina’s rising case counts, her thoughts on the role of young adults in helping slow the spread of the virus, the pressure that comes with her sudden moment in the state’s spotlight, and much more.

This interview has been edited for clarity and length.

Free Times: Obviously, we’ve seen case numbers and hospitalization numbers rise in South Carolina. How much does that concern you, and what can we do about it?

Dr. Linda Bell: It concerns me deeply. It is so disheartening to see those dramatic increases follow a period where we were optimistic. It appeared we had reached a plateau, and we were optimistic that we had reached a point where we might realize a downward trend for a prolonged period of time. That was really our goal with disease interventions and the closures and all of those measures. So, to have the disease rates climb so dramatically after Memorial Day is completely disheartening. And, with continued increases from one day to the next, it’s really alarming that this is occurring.

As to what we can do about it, there are some very basic tools that don’t rely on high technology, they don’t rely on access to care, they don’t rely on any of the other things we generally consider for disease control measures. They even actually don’t rely on testing, per se. But, if we could adopt the widespread use of masks throughout our populations, that is how we can make a significant difference. It has worked in other jurisdictions and other countries and it has made a dramatic difference, that really can happen quite rapidly if there is a very high uptick of that very simple, low-tech measure.

Does it frustrate you to see images where masks are not being used, or where social distancing is not being observed and folks aren’t taking those simple steps?

It absolutely frustrates me. But it also leads me to question what it is that we, in public health, could possibly do differently to stop those kinds of behaviors, when we see these public images of people gathering on the beaches and at these recreational activities. There are many pictures of activities in bars where there are large groups of young people who are in very close proximity to each other. You can scan those crowd scenes and see that not a single person in those environments has on a mask and that none of them are practicing physical distancing.

I don’t even think “frustrating” is the word. It brings some different emotions in me. But, one of them is to question how we could possibly do this differently. What are the messages we can convey about the risks? About the effectiveness of those simple measures, of physical distancing and the use of masks? In those populations, what are they missing in terms of not just the risk of exposure, but the impact that this is having on the population, where we continue to see deaths in our communities from [people disregarding safety guidelines]? These are preventable deaths, these are preventable hospitalizations. Even those who may only become mildly ill, even with the impacts of that we are realizing some of the young people will take a prolonged period of time to recover.

What role can young people — and I’m talking about teenagers and those in their 20s — play in helping beat back this virus?

That population group is driving transmission now. In the weeks and months prior to Memorial Day weekend — which I sort of consider our watershed for this disease transmission — the majority of our cases were in individuals over the age of 50. Beginning about a week after Memorial Day to the present time, the majority of our cases are now in people who are 50 and under, and really significantly in that 20-30 age group and older teens. That’s the message they need to hear. It is those groups that are driving this epidemic throughout our populations.

The other message I want [younger adults] to hear is that there is really a significant impact that they could have in turning this around quickly. It is our responsibility to make sure they are aware of the risk and that threat [of COVID-19]. It’s really in their hands to do something about it. Young people now can be so socially conscious about other factors — the environment, social issues — they can take it in their hands to make a difference in this pandemic and in our populations.

John A. Carlos II

Dr. Linda Bell stands beside Gov. Henry McMaster during a coronavirus press conference. Photo by John Carlos

I know you are originally from Texas, but you’ve been working in South Carolina for a good while now. What’s it been like for you living and working in South Carolina?

It’s been wonderful. This is home now. I’ve been in South Carolina for about 26 years now. I came here from Texas by way of Atlanta, where I worked at the [Centers for Disease Control] for a brief period of time. South Carolina has a number of benefits. The quality of life, the cost of living, and the relationships I’ve developed here. My husband [cardiologist Dr. Myron Bell], his family is from South Carolina.

I’ve worked in public health for my entire time here. And that’s been a great reward.

But, throughout the course of my public health career, we have struggled with, in many respects, a lack of attention to public health. I think it is only when we don’t do certain interventions that public health becomes a more prominent issue. I think many, many people nationwide are recognizing the role of public health in protecting people from ongoing disease threats, from chronic disease threats, for putting things in place to make sure that people have access to vaccines and screening and all sorts of things that prevent diseases in communities. It’s only when we don’t do that that we have the worst example of the current circumstances, with this pandemic that is like nothing that many of us have seen in our lifetimes.

Public health and epidemiology have been your life, and now we are faced with this widespread pandemic. What’s it been like, in your field, to have this incredible moment to kind of go up against?

We have seen a number of disease threats over the last few decades, some that have been alarming to the public. Everything from the concern about Ebola in this country — though I would remind people that there were really only [a handful] of cases of locally acquired Ebola in the United States, despite a widespread almost panic about the risk — to the H1N1 flu pandemic to Zika. So, those stand out to the public. But we’ve also been through smoldering pandemics, like the HIV pandemic that has threatened lives for decades and decades. And we continue to work on things like that, along with health disparities and health inequities.

But, with this particular pandemic, with COVID-19, it is the duration and the magnitude. We’ve been fighting this for months now, longer than any other epidemic that is acute. So, in contrast to, say, the HIV epidemic. To have a public health workforce who has fought this hard and this long to see it go in the wrong direction, despite every effort we have made to use the tools available to us, it just saddens me deeply. It makes me continue to ask, “What more can we do?” It’s influencing public policy, I think. We have these limited tools, and unless those are shored up by widespread support from decision makers and policymakers to help us get the population to adopt these measures, then I’m very concerned that our disease trends will not go in the direction they need to go to save lives soon enough.

You have been known in medical and governmental and media circles for a while, but I think in recent months you’ve now become known to Joe and Jane Public. For instance, my mom talks about what “Dr. Bell said” all the time. What’s that been like for you, to go from being known in certain circles, to being on TV every week?

If I could pick one word for that, I would say “weird.” [Laughs.]

It’s unexpected. And in some ways, it seems undeserved, the attention. I would have to credit so many more people who are behind my comments to the media, who are doing the work to collect the information, to identify people who are at risk, to test them, to provide guidance to all the state agencies and businesses. There is an entire workforce of people behind the words that I’m saying, to put me in a position to provide that information to the public, and hopefully inform.

I’ve even heard people say, when you speak to the state in these press conferences, that it gives them comfort, to hear the facts from you. Do you feel any pressure, carrying out that message?

I do find some pressure in wanting to make sure that what I say is accurate, that it’s true, that it’s not confusing. With some of these concepts, different things can be confusing. So, I want to be clear and understood by the vast majority of people, so that it’s in simple language, and I try not to skirt any issues. At the same time, you only have a moment in time. There are times when I wish I had been more clear or expanded on something, or where I missed an opportunity to better educate. So, I do feel that pressure that I want to make sure I say the right thing, that it is accurate and helpful, and that it is useful in people changing their behaviors, and putting them in a position to take control over their risk of exposure and risk of complications. It is important to me to make a difference with what I say, and I do feel some pressure in trying to make sure I do that, and I often second guess my messages.

John A. Carlos II

Dr. Linda Bell speaks during one of Gov. Henry McMaster’s COVID-19 press conferences.

As we’ve reported on COVID-19, one of the continuing curveballs we’ve gotten from those in the social media sphere is the idea that virus cases have gone up simply because there’s more testing. But that’s only partially true, right?

That’s a great example of a concept that requires more explanation. People may believe, “Well certainly you are going to find more cases, because you are testing people.” But there’s part of that where we have to look at additional information to understand that we can test tens of thousands of people, and the percent of those people who are positive was only 2 percent, that would mean one thing. But if we test tens of thousands of people and 20 percent of them are positive, then that tells us an entirely different story about what we are finding. So, when we test more and more people, and we have a high percent positive, that tells us that we are looking at a much sicker population. That’s a great example where it’s not just looking at one number, out of context. You have to find a way to convey that there is more information out there and there’s more to interpreting those numbers than just a simple number.

I also do try to convey that it disturbs me when people just look at the numbers, because I like to say that for each case that is reported, for each death that is reported, that it’s somebody’s son, somebody’s grandmother, somebody’s wife or child. We’re not just looking at numbers. These are people’s lives that we can save, and we may be running out of time to save additional lives or prevent additional hospitalizations and illnesses. It’s not just about the numbers and data. It’s about public health and people’s lives.

You recently discussed that high case numbers, a high incidence of COVID-19, can, for lack of a better word, overwhelm efforts in contact tracing. Can you explain that?

A tried and true disease control measure that we use is to investigate cases of infectious diseases that are reported to us, so that we can find out the potential source, learn the potential risk factors, and we can also do an intervention to prevent additional disease transmission. Prior to a widespread pandemic, we can do that pretty effectively, when we have a relatively small number of cases of a variety of conditions that we follow up on.

But as our case numbers have crept up, if people can appreciate that, to conduct a case interview for every single case — to do a disease intervention, to potentially learn about the source and make recommendations to an individual about what they can do to prevent spread, and identify all their contacts so that we can reach them and make recommendations that they take measures to prevent spread — it becomes a really daunting task if you look at doing that for a few hundred cases. But over time, we are looking now, from one day to the next, at doing that for over 1,000 cases each day. If each case has from three to five, or more, contacts, that ends up being thousands and thousands of interviews each day. Not only does it become overwhelming, but it is also no longer an effective way to prevent disease transmission in a community.

Once we reach a point where there is widespread transmission, attempting to implement disease control measures around a single case are less effective than population-based measures like restrictions on activities or the widespread use of masks. We reach a point where we can only implement effective disease control measures at the population level, because we’ve lost our ability to prevent transmission around single cases.

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