Indo-Pacific Health Leaders Series: Dr Josephine Herman, Secretary of Health, Cook Islands

Welcome to the third episode of our Indo-Pacific Health Leaders Series. Today, Australian Ambassador for Regional Health Security Dr Stephanie Williams speaks to Dr Josephine Herman, Secretary of Health in the Cook Islands.

Dr Josephine is a physician who holds a Masters in Public Health, a Diploma in Obstetrics and Gynaecology and a PhD in Epidemiology from the University of Auckland.

She was appointed as the Secretary of Health for the Cook Islands in June 2018 and is currently the vice-chair of the Pacific Heads of Health.

For more information about the Indo-Pacific Centre for Health Security, visit our website https://indopacifichealthsecurity.dfat.gov.au.

Connect with us on Twitter via @CentreHealthSec and @AusAmbRHS.

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Enjoy,
Contain This Team

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Dr Josephine Herman  00:00

There are countries outside our borders that have lost so many lives. And for us, we need to be grateful for what we have, and figure out how we can continue to maintain and protect the country.

Dr Stephanie Williams  00:13

Welcome to Contain This brought to you by the Indo-Pacific Centre for Health Security. I'm Stephanie Williams, Australia's Ambassador for Regional Health Security. Today I'm continuing a special series of podcasts with Indo-Pacific health leaders. In this series, I bring you frank conversations with leaders in the Pacific and Southeast Asia, about how they are facing current challenges making decisions amidst uncertainty, planning ahead while dealing with a current health crisis, and how they as individuals adapt and adjust their leadership style during this large event, COVID-19. Today, I talk with Dr Josephine Aumea Herman, Secretary of Health for the Cook Islands. Dr Josephine is a physician, who is a fellow of the Australasian Faculty of Public Health Medicine, the New Zealand College of Public Health Medicine, and the Royal New Zealand College of General Practitioners. She also holds many regional leadership roles in health, such as the president of the Pacific Public Health Association. She was appointed as Secretary for Health for the Cook Islands in April 2018. Welcome to Contain This. Dr Josephine, you're the Secretary of Health in the Cook Islands. Not all of our listeners would understand the Cook Islands. Could you tell us a little bit about your home?

Dr Josephine Herman 01:35

Kia Orana, Stephanie. I think the Cook Islands is a small paradise, hidden away in the South Pacific Ocean. Fifteen little islands, population 17,000. And Rarotonga is the main island, where 70% of the population live. Huge reliance on tourism for the economy. And apart from that, just friendly faces, New Zealand citizens. We are part of the Realm of New Zealand. We have some 60,000 Cook Islanders living in New Zealand, and about 20 to 30,000 living in Australia. 

Dr Stephanie Williams  02:23

As Secretary for Health, you are responsible for the COVID-19 response in the Cook Islands and the health system more broadly. The early days, if we think back to early 2020, were characterized by quite a lot of uncertainty about what this pathogen was, what it was doing. How did you deal with uncertainty in your position of advising government on what the best responses was going to be?

Dr Josephine Herman  02:51

At the time when we started beginning to receive information about the outbreak in China, I think at that time, for us, we understood that we were quite distanced from it. But we were very clear about the fact that Ebola and other threats that have come our way in recent times, have always had that potential for pandemic. And for us, the big one for us was making sure we focused on assessing the information that was coming in to us. And we were looking for information. We wanted to make sure it was accurate. And from a reputable source. And then we looked on social media, we looked at BBC, CNN, more global news areas was also important. And there were systems in place for WHO to communicate directly with our minister and myself. And of course, we had connections to the New Zealand Government. And apart from that, we were also paying attention to other countries that were nearby, China, we're talking about the Philippines, most of Asia, really, we were watching what's happening in those countries and using technology to help us.

Dr Stephanie Williams  04:16

Can you tell us a bit about the team around you when you say we looked at all of these places? How did you resource that?

Dr Josephine Herman  04:25

In our country, it's a small, small population, a small team, and much of them not necessarily familiar with pandemics. None of us are and also the public health risks and the processes involved in the risk assessment. But what I found over time, is that you sometimes have a workforce that don't necessarily have the required qualifications for public health expertise, however, they have the know-how, they know the people, they know the context in the community. And in public health, if you know your community, and you have good leadership, you'll know what to do. And I think for us, watching from afar, it was really important for us to understand the severity and also understanding the epidemiology of the illness, we were always thinking it is going to be a pandemic. We were listening to every other commentator that was on the news, we were looking at the timelines and the speed of transmission. And when we, the first time we heard about a case outside China, that was that was alarm bells. For us, okay, this is not very good. 

The other thing, of course, was assessing the risk to the Cook Islands, that's always been our priority. We are highly connected to global travel. And we have 20 plus flights a week at that time, we now have only one flight a week from Auckland. And we're open to LA, Sydney, French Polynesia, as well as New Zealand, of course, and it was like, okay, we have open borders. What's the risk for us? Given that, you know, it was quite clear that this was going by plane or aircraft. And then the other thing we did, you know, in terms of looking at all the uncertainties, we were assessing our infrastructure, our systems, did you know I have the manpower, the human resources to respond? And just really looking at our level of emergency services to stand up. We are a fragile health system. And I've been in the role just over two, almost two years when this happened and was like, gosh, let's let's have a look. How are we positioned right now before we can actually advise government? 

And then part of the role I've had, which is really important in terms of the preparedness plans for this during this moment, time of uncertainty, as part of my work coming in, as Secretary of Health wants to restructure the organization, at executive level, to make it more flat, and encourage more robust, clinical and efficient decision making in particular. In small countries, it's not easy for you to have many management roles, you really need to have be a jack of all trades and have clinical competencies. Because you don't have enough or much room to employ so many people to do one role, you pretty much have to do many roles. And even your executive must also be multi-tasked and multi-skilled to work across the system. 

The other thing about this, I think during that time of uncertainty was the speed when we stood up our our health response, that was on the 22th of January. And by five days later, the National Health Emergency Task Force was called. And we were we were briefing cabinet from then on. And these were daily briefings, they were tiring. And, you know, COVID hadn't even reached outside of the world. But we knew we needed to move as fast as we could. And I think early in the piece, what was very clear for us, we have about a 90 bed hospital. And we don't, you know, it was clear that it would be difficult for us to stand up ICU capability. And we were very clear that if we were going to protect our people, we needed to make sure our public health processes were robust and primary care as well. So this was really all of the thinking that was happening in a matter of days and weeks that we have to run through very quickly.

Dr Stephanie Williams  08:59

You talked earlier about if you know your community, you can lead well in a public health response. Can you tell us a bit about how you've worked with the grassroots community councils in the Cook Islands as part of your public health response?

Dr Josephine Herman  09:16

It goes back to the restructuring of the organization prior to COVID-19 landing on our doorstep. And in that restructure we made sure that we had a Community Health Advisory Committee that was advising directly to the Secretary of Health role. And in that Community Health Advisory Committee, we had we had representatives of government and community groups, especially around Rarotonga where the majority of the people live. We had the traditional leaders, arikis, represented as well as the Religious Advisory Council. It's the Cook Islands, we have three pillars of society, Government, Religious Advisory Council and our traditional chiefs. So they are represented there. And this committee was already established prior to me starting but had not had regular meetings. One of the things we did as soon as I started was that we would meet four times a year. So by the time COVID arrived, the briefings to them was quite was established, the relationships were established, and the connections to the people. 

The second thing that happened here was that we already have a Disaster Risk Management Act. And through that process, they've established what we call Puna, or many districts on Rarotonga, as well as the outer islands. So that infrastructure was already in place. And all we had to do was stand it up. Now, these Punas, they are like mini islands, they know their community, which number 1000 to 2000 people, they know everyone in there. And so it was just having that system already there and standing it up and saying, okay, we have an issue. This is how we have to do it, and making sure we had sort of reached all facets of society. And if you have a look at our national health response, strategy, emergency response strategy. In it, you had the NGOs, you had the development partners. You also had the Religious Advisory Council, the traditional chiefs and we included youth as well, to make sure that the voices of the youth were heard. So that's really how we ensured we could canvass the whole whole of society, the whole country as part of our national response.

Dr Stephanie Williams  11:54

Josephine, it's September now. If you're thinking about the current situation, what do you see is the biggest challenge in the immediate future? We've been going for nine months, but as at today, what are some of the challenges you're facing?

Dr Josephine Herman  12:00

I think, the challenges we've faced as well as what will continue to be, I think a big one for us is our smallness. If we could have a word like that. We have to cover so many facets of public health and clinical medicine, we cannot ignore the fact that we still have an NCD [non-communicable disease] epidemic that we have to deal with. So we still need to make sure that the hospital can respond to people presenting with strokes, heart attacks, cellulitis, and other problems with appendicitis and so forth. Or one of our elderly, older persons or older folks falling and breaking their hip, we still had to run that. And so coming back our smallness, it's really stretched us in terms of the workforce. And I think the big risk for us has been the risk of fatigue.

And what we've been doing as part of the restructure was to call in the help of our diaspora. And that's been an important part for us, we have many Cook Island specialists, and friends of the Cook Islands health system overseas who have helped us from a distance. The other thing, of course, the NCD epidemic. That's that's one of the challenges. We're trying to manage COVID and protect the country against COVID. And we still have to manage NCDs that are turning up on our doorstep, so huge. And the other one, of course, is mental health. The fear of the unknown. And what we've had to do with that has been to ramp up our mental health services, we have a clinical psychologist, we've employed more counsellors and assistance because for us, it was very clear that people needed to understand that it was okay if they felt scared, worried, concerned, and to give them tools or skills to help them get through it.

Then, of course, dealing with the social and economic impact, as much as we focus on health, if we're not assisting in that space, health just gets under more pressure. And, you know, I know our government was quite generous in terms of assisting our people with free power, for example, and ensuring those that had been stranded in New Zealand, for example, could return home. Those stranded in the Cook Islands are still stranded, which is an ongoing concern for us but that's because of border restrictions with New Zealand's border. And then those that have been unemployed because of the hospitality industry, tourism. That's been also an issue for us.

What's been very clear throughout this process, though, has been the point of being kind and compassionate, and finding ways to look after each other. There were times right at the beginning when some families and Puna districts were giving land to those to migrant workers so that they could plant and feed their families. So, you know, there's been quite a bit of generosity across society across the country, to help others in need.

Dr Stephanie Williams  15:56

In your position, you have had to turn up every day, as a health leader in in a small place. We see that happening for our public health leaders across the Pacific and globally, a very small number of people coming every day to lead health responses. How do you yourself keep going? What are your strategies for endurance in this pandemic?

Dr Josephine Herman  15:56

I think this is everybody's challenge. Even now, 300 strong workforce turning up every day to give our best. And I think what's been clear is that thing of hope, we will get through this. And we'll find a way we'll figure out how to get through this. And using every facet of our minds to figure out how we can make things better for everybody. You know, we've gone COVID free since the 16th of April. And so I was very clear with this, that when we did that, we must focus our efforts on the border. So there's been so much work done at that in that space, as well as looking at the disease transmission patterns in New Zealand, which is the only border we're opening up to. But I think the other thing, in terms of longer term really has been around service and our commitment to our people. You know, you see your people and you think I've been trained in this, we've been trained in this, and we've been given this role as heavy as it is to do the job so we must keep going. Because it's worth it. And that feeling of perseverance, and, and we've had some very good feedback from the people out people. And so it keeps you going and keeps you motivated. 

And at the end of the day, sometimes things could be worse, there are countries outside our borders that have lost so many lives. And for us, we need to be grateful for what we have, and figure out how we can continue to maintain and protect the country. Risk has been important. Lots of sleep. And many of us don't, we work very hard. And we're the worst people when it comes to trying to get sleep. And then we've tried to encourage our workforce to try and do that. But it's been very difficult with manpower. But I think in terms of the prioritizing of our health workforce, health priorities, it's always been about the border. 

And in May this year, when we released our easing border restrictions, plan and had a border matrix to help guide us. This is actually informed our whole process around how we can put in place exemptions for travellers returning home. What we've found is that we've got patients that go to New Zealand for care, they need to come home, their support networks are in the Cook Islands, and bringing them home, we've found ways to do this. So first time we did this was May, June, where we repatriated some 260 people who had been caught out by the sudden border closures. And then we had eight quarantine free flights since 19 June, where they were able to leave Auckland and come straight back into the Cook Islands. We had some prerequisite requirements for them prior to flying. And then recently and tomorrow we'll receive our third cohort of passengers coming in, who will undertake supervise quarantine in the Cook Islands on Rarotonga. And so we've figured out how to minimize the risk, mitigate the risk as much as possible to zero if not, you know, minimal to zero and allow travel to continue. But currently there's an outbreak. There's a large cluster in Auckland. And that's pushed us into a space where we put in place supervised quarantine. So just to summarize, it's really about what we're doing at the border that allows us to let our people come home.

Dr Stephanie Williams  19:47

Dr Josephine, thank you for your time this morning and for reminding us that putting people in the centre with a big dose of kindness and a sense of optimism about that we can get through this together will be important in the COVID pandemic. Thank you very much.

Dr Josephine Herman  20:03

Thank you. And if I may say, I just want to acknowledge the government of the day. What I found, looking at other systems, health systems around the world, is that those countries that have had very strong leadership and governance, and taken on board the recommendations of public health specialists and health systems have done quite well. And I must say, our government has been very good in this space. And I think the second thing is that has been really critical has been the ability for us to stay engaged with our community. I have weekly meetings with our Puna and their representatives and the outer islands, just so that they are from, you know, they're aware of what's going on and what processes are in place. We're not perfect at all. But we're getting the job done. And we've tried to remain open to constructive criticism, and try our best to improve as we go along. And what's been clear for us right on, right from day one was always to take our people with us, take the whole country along with us, because to think that the whole system can do this alone is a big failure for any system, and we've had our people along with us and for the health workforce, we've always been clear. We're here to serve our people, and we'll do our best to protect our country from COVID-19.

Dr Stephanie Williams  21:40

Thanks, Josephine. Just a really good story. Thanks to you and your all your team in the Cook Islands.