I recently began corresponding on Twitter with Dr. Brian A. Brennan, an allergist in Sioux Falls, South Dakota. I was curious to know how COVID 19 was affecting his practice in a location that seemed remote from the New York metropolitan area, where ambulance sirens were interrupting our sleep with much greater frequency than usual. Then, overnight, Sioux Falls became a coronavirus hotspot with a major outbreak in the Smithfield pork processing plant, which, as we now know, supplies 4-5% of the national pork supply. After some pestering, Dr. Brennan agreed to answer a few questions. –Henry Ehrlich
AAC: Thanks for taking some time for our readers, Dr. Brennan. First some background. I looked up your credentials and saw that you trained in New Jersey and Washington, DC. Why did you choose to settle in South Dakota?
Dr. Brennan: I attended Purdue University as an undergrad so I had a taste of midwestern life, returned to my birth state of New Jersey for medical school, and at that time met my future spouse who was living in Washington, D.C. but whose family was from Minnesota. So after my Peds Residency at Georgetown we both felt that we wanted to move to the Midwest and I was fortunate enough to obtain an Allergy Fellowship position at Creighton University in Omaha. Life was so much easier in Omaha than in the D.C. metro. When we lived in D.C I spent about an hour and 45 minutes in the car every day, commuting. In Omaha, we were able to live in a lovely suburban environment right in the heart of town, on a Fellows salary, and my commute to work every day was 12 minutes. Our son had just been born, so that shorter commuting time gave me 90 minutes of my life back every workday. After that we knew that we would eventually settle somewhere between Omaha and Minnesota.
AAC: What is your practice like in normal times? What are the big seasonal allergens? It’s allergy season. Is your office still open? Is it business as usual or are you doing telemedicine?
Dr. Brennan: My practice is “bread and butter” allergy. As with all community allergy practices, every once in a while something amazing will come in, but usually it’s rhinitis, asthma, itchy skin rashes, and immune work-ups. Our seasonal allergens are pretty typical. In our part of the country it’s usually a short tree pollen season. Then into grass pollen season, which can be pretty heavy, a short break with pollens in July, and then into ragweed in August. The big difference between a practice in the agricultural Midwest and coastal practices is that outdoor mold is perennial here. Alternaria, a fungus, is our most troublesome allergen in general. Of course we have dust mites and pets as indoor allergens too.
Our office is still open, but patient numbers are of course way down, as it should be. We are mainly focused on keeping our asthmatics healthy and maintaining those folks with immune deficiency. We have been doing a fair amount of telemedicine, which is great for quick rechecks when patients are doing well. We have a fair number of patients who routinely drive 3 to 4-plus hours to see us, so telemedicine can be a blessing for them. I hope reimbursement levels for telehealth services continue to be reasonable in the future, so that we can continue to provide this important service.
AAC: I haven’t been in Sioux Falls for many years. Do you see farmers and ranchers? Do you have a significant number of Native American patients?
Dr. Brennan: Farming and ranching are still a large part of the economy of South Dakota. South Dakotans speak of our state in terms of “East River” and “West River,” in relation to the Missouri. Generally speaking, East River tends to be more pastureland and row crops (corn, soybeans) similar to Minnesota and Iowa. West River tends to be more ranching and grazing land, and looks a lot more like Colorado and Wyoming. Our state is also divided into 2 time zones.
We have a significant number of Native American patients, some who live in town and others from the reservations. We also have a significant number of Hutterite patients, who tend to have a very high prevalence of atopy. Their colonies in South Dakota have been involved in published research which seems to have revealed some insights into the “hygiene hypothesis.” (1)
AAC: How are asthma levels? I know that asthma is a significant problem with farmers because of use of chemical fertilizers and pesticides. Is that something you encounter in your practice?
Dr. Brennan: Farmers are at risk for all sorts of occupational lung disease, asthma and hypersensitivity pneumonitis being the most common. We manage these issues on an almost daily basis.
AAC: Can you describe your perception of the virus as it took hold in Sioux Falls? Did your patients express concern? Were they coming to you with their symptoms? Did you take extra precautions like face masks and so on? Did they?
Dr. Brennan: Once the virus was in Italy and Washington State, I knew it would be here eventually. Everything takes a while to reach Flyover Country, whether it would be popular culture, economic troubles, or contagion. I’m surprised to see the economic hardship of 2008 being compared to the downturn caused by COVID-19. 2008-2009 were barely a blip on our radar in the Upper Midwest. COVID-19 is orders of magnitude more serious economically. In general, things are more on an even keel here. We rarely boom, and we rarely go bust, but COVID-19 will cause significant economic hardship.
Medically speaking, I was wearing a mask to the office pretty much from the time there were any cases on the continent. Overkill at that time, but I have continued to do so. I was wearing an N95 at first, once our patients had awareness and were wearing masks themselves, I felt okay backing off to a procedure mask. But unfortunately this past week to 10 days people are getting the message that someone has given the “all clear” and we see patients wanting to come to the office again without masks. Mask wearing in my community peaked about 2 weeks ago, and it has started to trail off.
AAC: The Smithfield plant has become notorious. I’d like to ask a few questions specifically about that. First, were any employees your patients prior to the outbreak? I know that these companies pay fairly well, especially for the immigrant labor that is drawn to them, but do employees have health insurance? Were they prone to any particular allergies?
Dr. Brennan: Smithfield offers their employees a health plan from one of the two large health systems in our region. Because the clinic where I work is independent, we are able to see these patients and often do for allergic disorders. I’m not aware of any specific allergens in the Smithfield plant. I’m sure there’s potential for occupational asthma there, but we haven’t seen it. Because Smithfield employees are tethered by their health plan to receive their care from only one hospital systems in town, that hospital has borne the brunt of COVID-19 hospitalizations.
AAC: As someone trained in immunology, have you been consulted on the nature of this disease? How do you explain “cytokine storm” to your patients and to others?
Dr. Brennan: I haven’t heard of this specifically in Sioux Falls and I’m not sure if tocilizumab has been used here. As you may be aware our governor, following the lead of Mr. Trump, was promoting chloroquine and hydroxychloroquine quite heavily, and arm-twisted one of the health systems (the one that doesn’t have Smithfield patients) into doing a clinical trial. I’m wondering if that health system will even have enough numbers to show statistical significance.
AAC: Has the outbreak followed the pattern we have seen elsewhere, striking nursing homes and prisons?
Dr. Brennan: Yes, it has followed that pattern, although seemingly (so far) with less virulence in nursing homes and prisons. Smithfield was the primary hotspot where close working quarters and long shifts, along with hot physical labor, seem to have been the main risk factors. The idea that the home environment in which this primarily immigrant workforce lives is the primary risk factor for transmissibility is racist nonsense. This notion, promoted recently by HHS Secretary Alex Azar seems intended to deflect responsibility from the slaughterhouse industry, in what promises to be absolute blizzard of wrongful death lawsuits that they will have to defend. The government seems to have begun promoting an idea that meat-packing plants are some sort of irreplaceable municipal utility, like electricity, clean water and sanitary sewers. My feeling is that the federal government may offer the meat-packing industry blanket immunity from lawsuits under this rationale.
AAC: What is the civic attitude towards the public health challenge presented by the outbreak? The governor has been on the let-the-chips-fall-where-they-may side of the spectrum. And has Smithfield itself behaved like good corporate citizens after receiving all this attention? I have to say I was shocked particularly by one remark early on by a company spokesperson.
Dr. Brennan: I don’t know Smithfield well. My sense is that their leadership was following our state and federal governments and not taking the entire thing very seriously until it was much too late. Since then, they seem to have tried to deflect blame and were late to act. At one point they were offering significant cash bonuses to workers to avoid absenteeism, which in this working class community was essentially an incentive to come to work ill. Eventually the United Food and Commercial Workers Union (UFCW) stepped in and more appropriate action was taken at that point to safeguard the workers. I personally was surprised to learn that there was a union at Smithfield. This part of the country and particularly South Dakota tend to have very low union participation.
The civic attitude in Sioux Falls was pretty strongly in favor of staying at home, social distancing, wearing masks, and generally doing what the CDC recommended. Healthcare is by far the largest employer in our region, and one would be hard pressed to find anyone in our community who doesn’t have a close friend or relative employed by one or both health systems. So in general we have a pretty strong awareness of what’s to be done. That’s not to say that there isn’t a small but vocal percentage of the population here as elsewhere that feel the whole thing is fake news or a Chinese plot against the President or that they have an absolute God-given right to a haircut, the rest of society be damned. But in general, most people are behaving as if they are members of civil society, which is actually pretty amazing and awesome.
AAC: Finally, do you have any particularly thoughts on the future of this pandemic in your community and for smaller cities and rural America in general?
Dr. Brennan: My sense is that we’re going to get off easy. For whatever reason, whether it’s our willingness to voluntarily shelter-in-place, the seasons changing, something about the virulence of the strain we have in our region, or just lower population density, but so far the community is feeling that it wasn’t as bad as it could have been. This also presents a problem and a challenge, as people want desperately to return to their previous “normal” lives, but it’s clearly too soon yet. It seems unlikely that we will have adequate herd immunity from this virus until we have widespread adoption of a safe and effective vaccine. We’re not going to get adequate herd immunity through natural infection.
AAC: Thanks for your time. This story isn’t going away. I expect you will hear from us again one of these days.
Dr. Brennan: You’re very welcome. I’m happy to offer my thoughts.
Dr. Brennan is a Board Certified Allergy & Immunology specialist in Sioux Falls, South Dakota. In his spare time he enjoys gardening, home improvement projects, and neighborhood walks. Most winters he spends battling all manners of biblical upper midwest weather. It is his fondest hope to some day be able to retire to a warmer climate.
- https://www.nejm.org/doi/full/10.1056/NEJMoa1508749
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