Global Health Symposium: Lessons From Abroad on American Health

BOLLYKY: Good morning, everyone. Thanks so much for coming. I’m Tom Bollyky. I’m the director of the Global Health Program at the Council on Foreign Relations. It is my great pleasure to welcome you to our second annual symposium on health and international economics, this year entitled “Lessons from Abroad on American Health.” The standard pathway for decades in global health has been to adapt treatments and prevention programs from the United States and other wealthy nations to address the unmet health care needs of poorer nations. This symposium will explore the reverse situation, how practices from abroad can be applied to current health crises in the United States and provide a potential framework for analysis to help strengthen health systems and guide our public health investments.

Because if the last fifteen months has taught us anything on public health in the United States, it is humility. The United States has as much to learn on public health practices from our foreign counterparts as they have to learn from us. I will leave it to the moderators of each panel to make the necessary introductions of the speakers. But the first session this morning, Susan Dentzer will moderate, will be on mental health and addiction. The second panel, which will follow that, will be entitled “Global to Local—A Potential Pathway to Improve American Health in Future Pandemics.” And that will be moderated by Sheri Fink.

Just three quick notes before we proceed. First, I want to start by thanking Bloomberg Philanthropies for their generous support in making this symposium possible. Second, I want to acknowledge our partners and collaborators in this event, the Johns Hopkins Bloomberg School of Public Health. It’s been a terrific collaboration. I want to thank Josh Sharfstein and April Tong in particular for their help in organizing and designing this event. And finally, I just want to thank Sam Dunderdale, Samantha Kiernan, Stacy LaFollette from our meetings team who did all the hard work of organizing today’s event and making the rest of us look good, who had done very little.

So I look forward to the discussion. Thank you, again, for all being here.

DENTZER: Thank you very much, Tom. And good morning, good afternoon wherever you are to all of you who are joining us today. As we know, according to the Institute of Health Metrics and Evaluations’ global burden of disease study, somewhere between one in ten and one in nine of every person around the world suffers from a mental health disorder. That’s at least eight hundred million people. And of course, because we believe that these statistics are woefully underreported, that the actual burden of disease is woefully underreported and not well understood, we assume that the numbers are much higher. Depression alone is ranked by the World Health Organization as the single largest contributor to global disability. Basically 7 ½ percent of all years lived with disability, as was calculated in 2015, followed close behind by anxiety disorders.

And perhaps unsurprising to many of us on this call today, the U.S. turns out to be one of the most depressed countries in the world. It’s ranked third by the WHO in terms of unipolar depressive disorders just after China, which is ranked number one, and India, which is ranked number two. Again, we know that all of this is subject to statistical underreporting, in many instances, but that is our best understanding of the situation that exists. As Tom said, the U.S. may have a corner on depression, but it does not have a corner on how best to treat these conditions, nor is the U.S. immune from the fundamental social determinants of health that potentially predispose much of the population to mental health disorders of various types. And, of course, the subsequent behaviors that are often correlated with these behavioral health disorders.

So that is going to be the focus of our discussion today, as Tom said—what the U.S. can learn from other countries and how they are, perhaps in many instances, doing a better job of enabling their populations to live better and healthier lives by dint of having more support for mental and behavioral health. We’re going to hear first from Angus Deaton. And I will introduce the speakers as I ask them to give just a few moments of their topline thoughts on this subject. These are enormously detailed and important subjects but, again, if our speakers would confine themselves to just a few minutes of topline comments, that would be very helpful.

The first speaker will be Angus Deaton. Angus is senior scholar and Dwight D. Eisenhower professor of economics and international affairs emeritus at the School of Public and International Affairs and in the Economics Department at Princeton University. He’s also presidential professor of economics at the University of Southern California. His areas of research are in poverty, inequality, health, wellbeing, economic development, and randomized control trials. And as many of you will know, he and Anne Case are the authors of Deaths of Despair and the Future of Capitalism.

Angus, your work has focused most recently a lot on the situation in the United States with respect to what you both have termed these deaths of despair. Let’s talk about those deaths, those disabilities, and what appears to be driving them, as best as you research has been able to unearth.

DEATON: Thank you very much, Susan. And it’s a great pleasure to be here and to talk to this audience once again.

You talked a little bit about the social determinants of health. And, you know, we are primarily economists, though we worked on health for many, many years. And we are interested in tracing back this epidemic of deaths of despair—a name, which is not a political term but which seemed appropriate for something that looked, I mean, in many respects like self-inflicted harm, including suicide, accidental overdoses, and alcoholic liver disease. You could expand that if you want. But the key thing in our work that I think is extraordinarily important and is not as much emphasized in the epidemiological or medical literature as it ought to be, is that these deaths are essentially afflicting the part of the population that’s less educated. So we tend to divide people between people who have a B.A. and people who don’t have a B.A.

And the American economy has just not been working for people who don’t have a B.A. So suicides—which traditionally used to be thought to be higher among more educated people—the suicide epidemic which is, you know, driving us into the corner of countries, you know, in Eastern Europe that used to be the suicide capitals of the world, that’s almost—not almost entirely, but the rise is almost entirely among those who don’t have a B.A. The opioid epidemic, which other countries don’t have anything like to the same extent—in fact, the only country that has comparable death rates from drugs is my own country of Scotland. And they have a real problem there too.

But you know, these deaths of despair are really not happening in other countries. And so the other country comparisons, even though you say we focused on the U.S., very much in our mind from the very beginning, in the drafts in our first paper, compared what was happening to morality rates in the U.S. compared with what was happening in comparably which European countries. And this disaster is just not happening there at all. And it’s—you know, mental health is leading it, but life expectancy in the U.S. has been falling even before the pandemic, three years in a row. And once again, if you split that between people with a B.A. and people without a B.A., the decline is all among people without a four-year college degree.

We’re just treating them incredibly badly. And it’s not surprising that bad things are happening to them. Their marriages are disappearing. Their social life is disappearing. They’re not going to church anymore. They’re not connected to institutions. And for some reason, other countries are handling this better. And we think it’s actually primarily an American problem in which, you know, the educated elite and the owners of capital have been doing pretty well over the last fifty years, whereas people without a four-year degree have been falling off the end of the world. Thank you.

DENTZER: And just quickly, Angus, as you have pointed out, the social structures in many of these communities has been deteriorating. People are not going to church not just because some people are choosing not to go to church, but churches are disappearing as a force in the landscape that they once were as the faith-based institutions and other social structures, correct?

DEATON: Yes. That’s absolutely right. And also, you know, they are the targets of the pharma companies that are pumping out opioids and have sort of ignited the second-stage epidemic that we have now. And, you know, other countries just don’t prescribe opioids the way we do. And, you know, they used opioids in hospital settings. You know, if you have a hip replaced in Britain, you’ll get opioids. But they don’t send you home with hundreds of pills. And this explosion of opioids into the population with, you know, distinguished pharma companies like J&J turning Tasmania into a giant opium farm, those things are a failure of regulation and failure of politics in the U.S. A very good example of how money talks. Other countries just don’t permit this. And we do. And it’s a terrible failure. And it’s falling on the mental and physical health of less-educated Americans.

DENTZER: Vikram Patel, let’s go to you next. You are the Pershing Square professor of global health and the Welcome Trust principal research fellow in the Department of Global Health and Social Medicine at Harvard Medical School. You’re also a professor in the Department of Global Health and Population at the Harvard T.H. Chan School of Public Health. But also, very importantly, you were co-founding and you’re a member now of the managing committee of Sangath, which is an Indian NGO that won the MacArthur Foundation’s prize for creative and effective institutions back in 2008, and has really set a standard for how the public health system in a country such as India can be adapted in such a way as to provide support for those with mental and behavior health disorders, among other comorbidities.

Tell us about Sangath. Tell us about its approach. Why has it been successful, and why should it be a model for others around the world, including the United States?

PATEL: Well, thank you. Thank you for this opportunity. So, first of all, can I just say, I’ve been in the U.S. for just four years. And so I’m a—in a sense, a newbie here. I think Professor Deaton has been here much longer than me. But almost all my experience until I came to the U.S. four years ago was in India, and in a selection of sub-Saharan African countries, where I’ve had a very long period of mentoring colleagues—younger colleagues, who have now become leaders in those countries.

Since coming to the U.S., I discovered many important facts about the U.S., which I think I’d like to start with. The U.S. spends more than any other country on the planet on mental health. It’s, first of all, important to recognize that. It has more mental health professionals, spends more mental health dollars, it has more in-patient beds. In every single metric in terms of supply-side metrics, the U.S. outranks every other country in the world, by a long mile, actually. Just to give you an idea by how much, California as a state has more psychiatrists than the whole of Africa. New York City alone has more psychiatrists than the whole of Central Africa. So this gives you some sense of how much the U.S. enjoys—even though we’re very accustomed to hearing we don’t have enough resources. Actually, the U.S. is the most resourced country on the planet.

Now, in spite of this resourcing—and, by the way, you might ask, what do we spend all this money on? We spend it largely on mental health professionals because mental health care doesn’t really involve any expensive hospitals, technologies, procedures. It’s actually skill providers that account for maybe 80 percent of the expenditure on mental health care. Now, in spite of all that expenditure and some of the largest investments in research of the last four decades in mental health research, there has been no reduction in any of the metrics that one would use to evaluate the impact of investments in health care. For example, burden of disease as measured by DALYs, on suicide mortality rates, on incarceration of people with mental illness, et cetera. Every single indicator has actually worsened. This is even before the pandemic.

Just to give you one example, you know, Professor Deaton has spoken about suicide rates. Suicide rates in young Americans were on the uptick before the pandemic by nearly 50 percent, actually, in the decade just before the pandemic. In fact, its mental health indicators are the worst of any OECD country in the world. Now, you know, we all have our theories why that is the case. I have my own, having worked in many different contexts. I think a fundamental problem is the very narrow, binary, biomedical framing of mental health that drives every aspect of the mental health industry in this country. From the need to have a diagnostic code, which then triggers a whole range of, you know, interventions, primarily for reimbursement purposes.

The lack of attention in mental health programs to social determinants—and we heard a little bit about how important those are. The disempowerment and the lack of support to widely available community resources that people have historically accessed when they are in distress. And also twinned with that, the reluctance to seek help from mental health professionals, particularly in some groups in the population like young people who, you know, typically have a sense of invincibility and don’t like to seek help from anyone actually, other than their friends. But also low-income communities, people who come from historically disadvantaged communities. You’ll see much larger gaps in unmet—much higher levels of unmet needs for care.

So turning to Sangath very quickly, Sangath is just one of many innovative, pioneering organizations spread across Africa, Latin America, and Asia that have really sough to reach the last mile, offering quality care but very importantly quality care using resources that already exist in those communities. And as I mentioned earlier, by and large that means you do not have mental health resources. You’ve got to leverage what else those communities have. You know, such innovations, by the way, are not unique only to mental health, by the way. This also applies across many other domains of public health. And what Sangath has done is simply apply the well-trod route of using community resources for the specific area of mental health.

And two very—you know, two important examples of those innovations are, first of all, the use of widely-available community-based human resources to deliver frontline mental health interventions, including prevention as well as care. And secondly, the very active engagement of the community—in particular persons with a lived experience of mental health problems—in all aspects of mental health programs. And in doing so, I think what we really do is to change the narrative we hear all the time in the U.S., that we don’t have enough resources—which is really a euphemism for saying we don’t have enough psychiatrists or psychologists—to the narrative of how do we use the resources we have in ways that can transform lives?

And one initiative that I have launched, since I’d come here a couple of years ago, called the EMPOWER initiative is seeking to do exactly that. That is to bring the community health worker, deliver mental health interventions to the U.S. And we’re hoping actually to have our first rollout in Texas in the fall of this year.

DENTZER: And this, I think, probably ties in with a point that Angus made, that we were talking about earlier, that the social deterioration in many communities across the United States only fuels the non-virtuous cycle of people feeling abandoned by society, depressed, not having the social structures that you point out can give people a sense of meaning and wellbeing in their lives and create this kind of community resource support inherently. Is that also not part of this whole problem?

PATEL: Absolutely. I think what we fail to do in the U.S. is to embrace the notion that we already have rich resources in our community. We have very diverse approaches that mental health isn’t like tuberculosis, where you have to treat everyone with a course or regime of anti-tuberculosis drug therapy. Mental health is far more complex. It is deeply intertwined with one’s social world. And to try and reduce the approach to mental health care to an approach that works I think very well for infectious diseases, I think is actually missing enormous opportunities to leverage the diversity of approaches that could work.

DENTZER: Great. Thank you so much.

Sema Sgaier, we’re going to move on to you. You are cofounder and CEO of Surgo Ventures. I hope I’m pronouncing that correctly. You are also adjunct assistant professor, again, at the Harvard T.H. Chan School of Public Health. And just to say a couple words more about Surgo, and I hope you’ll tell us more, Surgo is a nonprofit organization dedicated to solving health and social problems with precision, and using all the tools available from behavioral science, data science, and even artificial intelligence to develop those solutions. You work in both the United States and in a number of low-income countries as well on a number of disease conditions, as well as social conditions such as housing.

So tell us about your work and your perspective on these issues that we’ve now had teed-up by Angus and Vikram.

SGAIER: Great. Thank you so much, Susan. So similar to Vikram, I’m also a newcomer to this country in terms of work. You know, my experience has been mostly in India and southern and eastern Africa working on a number of health issues from HIV/AIDS, TB, maternal health, immunization. And then most recently doing quite a bit of work in the U.S. on COVID and maternal health, and also starting to do work on mental health.

I agree with everything that Professor Deaton and Vikram said. And I just want to emphasize two points there. So going back to the social determinants, there is a reason why U.S. ranks lowest, not just actually in mental health and addiction but also in maternal health. There is a reason why the COVID response in the U.S.—you know, the pre-vaccine, you know, era of the COVID response hasn’t been optimal.

And one of the things that we’ve noticed—you know, we mine a lot of data. And so we’ve been looking at vulnerable communities when it comes to the impact of COVID, when it comes to impact of maternal health, and also when it comes to mental health. These communities actually overlap. So the social—the underlying social determinants that makes communities vulnerable to mental health are also the same ones that make communities vulnerable to, you know, maternal health, and make them vulnerable to COVID.

I think all of that to say is that we really need to expand how we are actually analyzing this problem. And really as Vikram and Dr. Deaton said very clearly, move beyond the very narrow frameworks of how we look at mental health. And what does that mean? It means really looking at housing structures, education, economic programs. It is really, really very broad from the underlying causes.

Now moving to the solutions, I think, you know, to highlight again what Vikram said, the solutions really need to be community driven. I’ll give you an example from one of my experiences. So I was managing opioid programs in northeastern India for many, many years—specifically around heroin addiction. And during that program, there was zero overdose deaths. And I was actually shocked two years or three years ago when overdose deaths in the U.S. were so high.

And the reason why we were able to actually have zero overdose deaths was actually really empower the communities around the drug users—actually their peers, their families, even the drug dealers—to have a simple, you know, antidote like Naloxone available anytime, anywhere. All to say is that we really need to—I think the big lesson from global health for me, when I look at the U.S. context, is how do we really leverage our social network, our connections, our peers to actually tackle these problems and really de-medicalize the solutions in some way.

So that’s my experience and my perspective, and I think very much aligns with Professor Deaton and Vikram. I’m happy to share more.

DENTZER: Terrific. And other than, as we’ve heard, of now the marvelous example of Sangath and what it has been able to do in India, are you aware of some other country programs that have taken a similar approach that could also serve as models for a more robust effort along these lines in the United States?

SGAIER: Absolutely. I mean, I think a good example is Zimbabwe, right? Zimbabwe has been using grandmothers—(laughs)—as, you know, resources in the community, for example, to provide mental health support to—you know, to young people in their community. I think we see a lot of examples beyond Sangath in the use of actually community members, including churches, including community-based organizations, including women’s groups, community health workers to really provide this kind of support.

I think the one thing to note is that almost every program in a low- and middle-income country, community health workers—which are not professionals, by the way; these are not nurses or doctors—are very much the backbone of the response. They are the link between the community and the health system. And they are the people that actually really make sure that, A, we are able to identify those people that are facing the challenge and diagnosed; and, B, provide them the services that they can and the immediacy; and, C, link them to the health service when and where needed. So I think there are many examples from around the world.

The other thing I will add is, we’ve been looking at diverse channels to reach communities, right? So also looking at a lot of the digital channels that are out there. And, you know, many new companies and startups that are coming out to really be able to provide that kind of outreach and support in privacy and be able to reach a much larger group of people than, for example, trying to get a person into a health center to be able to get the treatment they need. So I think we really need to expand our purview of what are the causes and also what are the solutions, and how do we get the solutions to people—to where they are.

DENTZER: Exactly. And the third has been one small bright spot in the pandemic. Obviously, in the United States, it’s been the greater use of telehealth. And the greatest growth has come in mental health services being provided via telehealth. Not that that isn’t the entirety of the solution, but obviously a piece of the solution.

So, Josh Sharfstein, let’s go to you now. You are vice dean at the Bloomberg School of Public Health at Johns Hopkins. You are also director of the Bloomberg American Health Initiative and professor of the practice of health policy and management. But you also have a lot of experience in the public sector, having served as secretary of health in Maryland, principal deputy commissioner at the U.S. FDA, and health policy advisor in the Congress as well. And you and your spouse also recently completed a very important book on the opioid epidemic.

Taking all of that into account, how do you view the situation that we have in the U.S., and that Vikram in particular identified? We know we have a U.S. health care system whose business model appears to be pricing itself out of the reach of much of the population. That has clearly happened in the case of mental health services. We have many, many psychiatrists and other well-paid health professionals, as Vikram said, who will no longer accept insurance. And essentially, making mental health care at that level the purview of the privileged at the expense of the kind of community-level resources that we do not fund necessarily through the health care system that could be so important in addressing needs.

So how do we get our way out of this, from a policy perspective, in your view?

SHARFSTEIN: Well, thanks so much for including me. And great question. I really appreciate the conversation. I’m taking from it that, you know, that it’s really important to think about three levels of response. One being the underlying economic and socioeconomic conditions that drive behavioral health. You know, it has a lot to do with prevention. And if you have a lot of inequality in an area, if you have more opportunities for people, you’re going to have more mental health and addiction challenges. And so you’ve got that base.

But then you’ve got a community health level that is very important for being effective in reaching people, you know, and both Sema and Vikram talked about that, about lessons that the U.S. can learn from other countries with community health workers. I certainly agree. And we see evidence in the United States of community health programs in both of these areas able to be effective but, as you said, very underfunded. And then the third level is the health care system and whether it’s focused on the right things. And I think for both mental health and addiction, there are some very strong critiques of our health care system. And even though we do spend a lot of money, is it focused on the right things?

The one area where I might have different sorts of data has to do with in-patient psychiatric beds, which I understand are actually much less in the United States than a number of comparison countries. I do not believe we lead the world there. And in fact, a number of in-patient facilities have shut down and there’s some significant concern among some experts in this field that that may be contributing to some of the suicide challenges. But in general, I do agree that most of the resources are devoted to things that are not actually the most important.

And if you look at addiction, we have a situation where in other countries it’s much, much easier to get effective treatment for, for example, opioid use disorder, than it is in the United States. And many hospitals, despite, you know, earning all kinds of hospital awards, actually don’t provide basic levels of addiction treatment. And so at each of the three levels, I think the United States falls short. The underlying economic issues, which have to be fixed by different social policies. Personally, I think the American Rescue Plan may be one of the most promising things in recent years in that area. And the support for families hopefully will bring down some of the incredibly high rates of depression and anxiety among kids and parents.

That middle level of community health outreach and, you know, the recent American Rescue Plan, then funding for hopefully one hundred thousand community health workers is, you know, an opportunity for the United States to take advantage of lessons from abroad, and rethink. Personally, I think the field of public health should be moving in the direction of community health. Here in Baltimore, during COVID the city opted to hire more than 300 community health workers from the most affected communities to lead the outreach and connecting people with resources and the tracking of infections and contact tracing and has actually done reasonably well—far better than you might have predicted based on our economic indices.

So I think, you know, for each of these there is hope. The health care system restructuring, which is where you started your question, may be the hardest part in the United States just because of how much momentum our current system has and how difficult it is. But even there, I mean, I think, for example on addition, we’re seeing more hospitals, more doctors recognizing how much the health care system falls short for people. And so I do think that you’ve got to work on all three, and there is a little bit of reason for hope in each of them.

DENTZER: Yes. As you say, bright spots certainly to be found amid the despair.

We’re going to open this conversation up now to those of you in the audience who are joining us today. So please feel free to go ahead and pose your questions. If you wish to direct them to a particular panelist, please do so. Otherwise, I’ll try to steer those questions to a panelist so we can get through as many questions as possible. So the floor is open.

OPERATOR: Excellent. Thank you so much.

(Gives queuing instructions.)

We will take the first question from Emmanuel d’Harcourt. And, as a reminder, please state your affiliation and unmute yourself.

Q: Hi. I’m Emmanuel d’Harcourt from Helen Keller International. Thank you very much. This is really stimulating and thought-provoking.

One question I had, particularly for Vikram or Sema who have managed community networks abroad, is I think there’s a lot of issues even abroad, in the sense that people have been talking really about—for hundreds of years about community health workers. But there’s really been a relative failure to scale, and the movement has been, arguably, co-opted by a small number of primarily U.S. NGOs. And so there’s a lot of issues operationally about what works and doesn’t work, about motivation, about compensation, about information systems. So I was wondering if you could comment about some of the lessons and what’s needed to be able to move this approach forward in the U.S., as well as internationally, for mental health and other purposes.

DENTZER: And, Vikram, since you are engaged in precisely that endeavor, please address that.

PATEL: So let me just, first of all, address the question about scaling up or community health workers more generally, because I think that’s a separate issue from scaling up community health worker mental health delivery. As far as the latter is concerned, I think you’re absolutely correct. But the reason for that is really because the science is also very recent. I can still remember ten years ago when I made a lecture somewhere about the use of community health workers for mental health care, there was huge pushback.

You know, and the pushback really came from the questions around safety, effectiveness, acceptability, and so on. And said, you know, this all works very well for maternal and child health—community health workers, that is—but, you know, mental health care is very, very complex. And you know, there is no proof of what you’re saying. So I think if today we can speak very confidently, it comes from proof. And the proof comes from a very large body of implementation, science—actually, a lot of it funded by the NIMH—that has demonstrated over more than 100 trials about the safety, acceptability, and effectiveness.

So what is the first part of the question? Has community health worker program scaled up in any way? Yes, it has. You know, India is the best example. There’s more than one million community health workers who are actually a workforce that is nominally employed. And I’ll come to the question of incentives in a moment. But there’s also hundreds of thousands of those more professionally employed community health workers. Most community health workers in India are actually incentivized, so it’s basically a fee for service with a basic honorarium and you can—you can add to that, according to what services you provide. But there are whole batches of community health workers in many countries, like in Ethiopia and elsewhere, where—in Brazil—you know, where you actually have these workers who are funded by the state.

So what we now have to do is to figure out: How can these community health workers in fact also embrace in their tasks a mental health care task? And I think there are very important questions about overburdening these workers, about ensuring that they incentivize appropriately, about supporting them—because mental health care work is also challenging. And, most importantly, I’ll say for us the most important challenge is making sure that the community health worker model doesn’t act as a silo. It isn’t preforming its role in a silo from the mental health system, but that there is actually coordination and collaboration so that no individual falls between the stools, either in the transition from community to specialized care, or in the reverse direction—that trajectory being entirely determined by their needs.

 DENTZER: Vikram, just a quick follow up, getting to a point that Josh raised about funding, where is the funding for the project that you’re embarking on in Texas coming from? What is supporting them?

PATEL: Well, our initial funding came from the Surgo Foundation that Sema chairs. I’m not able today to tell you where our scale-up funding is coming from, because there’s an official announcement on June the 15^th. But we work in partnership with local implementers. And in this case, in Texas, it’s the Meadows Mental Health Policy Institute, which has really been doing leadership work in Texas in bringing hospital systems together to implement evidence-based practices for depression. That’s their primary focus. And that includes, for example, collaborative care models, which is one of the best-established in terms of effectiveness and cost models of care for mental health problems, but sadly doesn’t get scaled up in most places. So they have had that mandate of working with hospital systems.

I’ll tell you one thing, Susan, one of my biggest anxieties when we launched this work was pushback from two groups. The first pushback was from community health workers themselves. You know, and saying, sorry, we’ve got tones of other things we are doing. By community health workers, by the way, here we are talking of a fairly diverse workforce. Some of them are social workers. Some of them might be community-based nurses. Others are actually called community health workers. And the second pushback was from mental health professionals. And I’ve been absolutely amazed by how much a sense of opportunity there is right now to think in different ways. In both of these communities, I have found nothing but just an open welcome to the idea, and a desire to engage.

For example, the curricula that we will be launching in the fall for depression—a brief psychological treatment for depression—for scale-up through EMPOWER is co-branded. And who? By the American Psychological Association. This is, of course, America’s biggest professional guild that is primarily intended to protect the interests of its practitioners. And here they are openly supporting taking one of their most important interventions and making it available to members of the community who are not members of the APA, and I think that’s a signal of really how much desire there is to change the narrative on mental health.

DENTZER: Yes, very much echoing what Josh said is a cause for some hope. Terrific.

Let’s go to the next question, if we could.

OPERATOR: Our next question will be from Michele Barry.

Q: Good morning. I’m coming from California and Stanford University.

My question to the group is how—it’s a question of existential threats such as climate change and planetary health has impacted mental health and despair. We’ve seen fertility rates dropping worldwide and felt—potentially due to despair about our planet’s future from young people and fallout also from climate displacement and migration. Has the mental health community adequately addressed these causes of despair? A little different from the conversation.

DENTZER: Well, I welcome our speakers today to tackle that, but I also want to give that for a moment back to Angus. I’m not sure how much the immediate concerns about global climate change are affecting a lot of the communities you’re talking about, but indirectly we know they will be affected. What would be your assessment of the—of the question that Michele posed?

DEATON: I think that climate change is enormously important. And I’m sure the effects of climate change, which don’t look like are being tackled very well, will differentially fall on weaker groups rather than on stronger groups and exacerbate the problem that we’ve got.

I just wanted to add one thing, though, which is before we get—you know, health care to me is not the solution to any of this; health care is the problem. You know, we’re spending 18 percent of GDP on health care, and as Vikram said most of that is being spent on providers, not on patients. And so we’re creating a lot of this crisis. I mean, health care, it costs pretty much the same to look after everybody with the result, but this 18 percent of GDP is crippling the people who earn the least because their jobs are going away, their wages are going down. This is what’s causing despair.

And so, for me, the problem is—(laughs)—is not how to cure despair. And we’ve wonderful things about that and all of that is good, but the problem is to stop creating it. And I’m afraid that climate change is just one of those things which will make this even worse, especially the way that American capitalism is currently organized.

DENTZER: Others of you want to comment on that question?

SHARFSTEIN: Well, I think the most direct impact is going to be through different types of, you know, weather-related events—natural disasters and the consequences that come from them. I’m including migration and, you know, dislocation. All of that just has immense impacts for mental health. That’s really just one dimension of the issue that Dr. Barry raises.

I would say I have a slightly—maybe slightly different view than Professor Deaton here, which is I don’t think the health-care system is entirely the problem. It certainly has contributed in different ways to the problem. But you know, there are people in every society that get mental illness, addiction. There are people who are pre-disposed to addiction and it exists in many places, and having a health-care system that actually can save their lives reliably is really important.

And so, you know, I think we need both. We need to be—have efficient health-care systems that actually provide the services that are really necessary for people, and we have to recognize the consequences of a, you know, very expensive health-care system that is one reason why we have in the United States really poor underlying conditions for health and the inability to invest in programs that could make some of these structural issues better.

DENTZER: I think that comment, Josh, gets us to a discussion about equity. And of course, now and over the past year in the United States we have surfaced the entire set of issues around lack of equity in our society, lack of equity in health, lack of equity in health care. And this issue of mental and behavioral health is front and center in that set of issues because we look back now and understand historically over the years the United States has been in existence different disadvantaged groups in the population have, obviously, been disadvantaged in terms of equity, and often they have been the same populations that, lacking in many other resources, also have probably experienced the greatest burden of mental and behavioral health disorders; we just weren’t paying attention to it or capturing a lot of data about it.

As we get into an era now where we are paying more attention to this, what do you think remains to be understood about the burden of mental and behavioral health issues, particularly on disadvantaged populations, vulnerable populations in the U.S.? Obviously, some of that is, as Angus said, very much related to education levels, but it’s also related to other social drivers of poor health as well. What do you think we need to continue to understand about that and the specific relationship to mental and behavioral health?

SHARFSTEIN: Well, I could jump in really fast and just say that the—similar to the concept that, you know, sometimes the health-care system has been the problem not the solution, our policies have been the problem in this area a lot and not the solution. And I think there’s a very strong and compelling argument that—particularly with respect to mental health and addiction, that there is structural racism embedded in policies around the criminal justice system, the education system, and others that have actually done just a terrible disservice to certain communities. And you can see that with the war on drugs, for example, and how that has criminalized addiction in some communities more than others. And you see that in the education system with the—you know, the essentially in some cases criminalization but certainly turning into a punitive—the behavior issues and other mental health challenges that kids experience—rather than helping them. And that’s done through policy, too.

I think that there’s a policy element to this. Not just the goal of community-level programs, but we really have to fix some of the policies that have been responsible for some of these problems and some of the inequities.

PATEL: Susan, if I may just—also just weigh in here, I wanted to add something. You know, I think—to me it’s very intuitive to say that if you live in circumstances that are associated with depravation or disadvantage that you will have a greater burden of mental health-related difficulties. I think that’s—it feels intuitive. So when we demonstrate this epidemiologically, I’m never surprised. It’s a bit like saying, you know, do people who live with violent partners have a greater risk of self-harm and substance abuse? Well, yes, they do, and it seems intuitive.

What’s a much more interesting question is, why do significant numbers of people—in fact, the majority, actually—who live in these circumstances, in fact, live fulfilling lives where they don’t fall into addictions, do not become depressed, and do not try to end their lives? To me, this is not the same as the opposite of risk. It’s really a completely different dimension of understanding protection.

And I was—you know, this was brought home to me a few months ago when I was teaching a class in Harvard with a colleague, Mary Bassett, who has been doing a lot of work on structural racism and its impact on health, and she came up with this remarkable observation that actually depression rates are lower in African Americans than they are in, you know, other groups in America. And you know, we asked the class, you know, this is counterintuitive, right, because African Americans have all these obvious disadvantages, yet at least in terms of population prevalence they seem to have a lower prevalence. And interesting things came out from out students. For example, could it be because of the close-knit nature of these communities that often live—segregation might have meant the development of social capital in ways that we might not have expected. Or does the church play a very important role? Et cetera.

All I’m trying to say is that this goes back to my earlier comments that mental health has to be viewed through a much broader prism than just medicine. If it is indeed the case that social networks—for example, through the church—are very powerful avenues for promoting mental health and resilience in the face of adversity, this is something that we need to acknowledge, embrace, and even support.

DEATON: Could I pick up on the policy point, Susan?

DENTZER: Please.

DEATON: One of the things that worries me here is the enormous influence that money has on the policy process. You know, so Britain has a thing called NICE—the National Institute of Clinical Excellence, or I guess it’s changed its name now—and they simply do not permit the use of drugs that are not very effective in terms of what they cost. So you have price control. All sensible health-care systems in the world have some form of price control. We don’t have that here because the pharma companies and the medical profession in general is very well connected up. They have a huge amount of money from the 18 percent of GDP that we spend and they will oppose to the death any form of price control.

The FDA two days ago approved a drug for Alzheimer’s, very important mental health condition. The manufacturer, Biogen, says it’s going to charge $56,000 a year per patient. There are all sorts of other costs that come with that, so a conservative estimate is it costs $100,000 a year per patient. There are perhaps a million people and maybe as many as ten million people who are interested, would like to have that Alzheimer’s drug. You multiply a hundred thousand by one million and you get $1 billion. If you multiply it by eight million, you get $8 billion. This money’s just going to go to the shareholders of Biogen and to the executives who work in this country.

This is a perfect example of how the medical system is predating on people with poor mental health. I can assure you that the British NICE will not approve this drug at anything like that sort of price structure, if indeed it approves it at all. We’re making things worse, and this is a detailed example.

Thank you.

DENTZER: Thank you, Angus.

Sam, I believe we have another question.

OPERATOR: We do. Our next question will come from Laura Fleszar or—(changes pronunciation)—Fleszar.

Q: Hi. I’m Laura Fleszar. I’m an MPH student at the Johns Hopkins Bloomberg School of Public Health.

So, as a Millennial, I’ve seen that there can be a sense of discouragement among my friends graduating from medical school, nursing school, or public health programs who are planning to work in the U.S. We enter these education tracks wanting to make a difference, but then we start to question how possible that is because of the health-care system in the U.S. Other countries seem to have a system which sets them up for success better. When and how do you think the system in the U.S. is going to change?

DENTZER: Well, we’ll turn to your own vice dean, Josh Sharfstein, who does see some rays of hope. Josh, do you want to expand on some of the points you made earlier about the growing realization of the health-care system and health providers themselves that they are falling short and want to continue to do better?

SHARFSTEIN: Sure. I was just adding up the numbers that Professor Deaton was talking about before. I think that there may be even more money that could be winding up going into Alzheimer’s treatment through this approved drug. I think it raises some very, very important questions for the health-care system.

And you know, as I said before, I think that the health-care system is, you know, an area that is very, very difficult to change. And you know, in my public health policy course that maybe you’ve taken or you will take, we get into that a little bit, why it is so difficult to change. And certainly, the political system is one reason why it’s so difficult to change.

You know, I wouldn’t necessarily say I would count myself in the most optimistic 10 percent of people that I run across on this. I do think that there are some reasons for hope, one of them being that it really is getting to the point that the system is unaffordable, and that pressure is causing some needed change. And you have places that are really switching fundamentally how they pay for health care in the United States for the first time, really looking for different types of solutions that are much better at aligning the health of a community with the payments for health care. In general, I think that’s the shift that needs to happen. We spend so much on health care without really much of a thought of what it creates in community health and in overall population health, and you do see some movement in some places to changing that.

In our own state in Maryland, the hospitals are paid on global budgets so it’s not fee for service, much better alignment with the overall health of the population if cases are prevented. Then the health-care system is able to, you know, take that—those funding, put it further into prevention, and we have very unusual investments in prevention happening in the state. And Vermont has done that at the state level. So the federal government seems quite interested in encouraging that kind of innovation.

I think it probably does take a crisis to cause a major shift in the health-care system, but I think that we may see more crises moving forward. I think COVID was one that really showed how brittle and unsuccessful the payment system is. And you know, I see some room for change; I just am not fully confident that we’ll get all the change we want.

DENTZER: I think, just to weigh in briefly here, we also have to look at, for example, the growing realization of a point that Josh made earlier, that we so criminalized the war on drugs that we ended up consigning many people, particularly Black populations, to prisons and jails for long periods of time. And we are finally addressing that by, for one thing, letting people out of prisons and jails—maybe not quickly enough, changing the sentencing guidelines for those crimes, and even decriminalizing a lot of that, and then finally pushing back against the private prison system. If we counted the prison system as a source of a supply of mental health care, which it is, we would grow the numbers even larger of the resources expended in this country on just warehousing those with mental illness in prisons. And so we’re finally seeing some movement away from that approach, albeit slow.

Sema, I want to give you a chance to weigh in here. What rays of hope would you cite to help give us a—give Laura and her colleagues a sense that there is, in fact, hope?

SGAIER: Sure, yeah. For Laura, I think—I think there’s hope because I think—I also see a lot of innovation actually happening outside of the health system. So if I was in Laura’s shoes, I would—I would really also explore where can I use my resources, for example, in up-and-coming technology companies, in—you know, in politics actually, you know, talking how important policy is. So I think there’s a lot a person like Laura, who’s—you know, who has that training, kind of can add.

But I also want to just say one last point before we close, which is around the data. You know, Vikram pointed out that, you know, there are communities that have overlapping issues and the underlying issues, and some are protective and some are not. I think one of the things we lack is really hyper-granular local data. Why is, for example, you know, a community that has all of the indicators around employment and economics, like, really low, but actually doing quite well when it comes to mental health, and another not? And I don’t think we necessarily understand fully, you know, how those different drivers interact and what are those protective as well as harmful, you know, underlying factors. So I would really argue around data.

And the other thing is around access to services. I don’t think we necessarily fully understand how the access to services is actually different across different communities and where there is low and high access.

So one thing I just wanted to make last point is the importance of data and the importance of going really granular to both understand the problem as well as think about the solutions.

DENTZER: Thank you so much, and that’s, Sema, utterly right, particularly since, as I indicated in some of my brief opening comments, we don’t really understand the full burden of mental and behavioral health disorders on our population in the U.S. and globally because of systemic underreporting and, of course, stigma, which is not a topic that we have already—that we have addressed much in today’s conversation. But obviously, stigma plays a role as well.

I want to thank our four wonderful speakers for this terrific array of insights—from surfacing some of the issues that we continue to face with respect to mental and behavioral health in the U.S. and the terrible consequences of that, including suicide; from the fact that we insufficiently credit communities in this country with the resources necessary and their capabilities in improving mental health; from some of the sterling examples that we’ve heard about Sangath and now the version about to be born in Texas that will make greater use of community health workers and others to provide those community level supports at much lower cost; and then, of course, the broader structural issues that we face in terms of structural racism, the economic climate in the United States disadvantaging so many communities, the enormous expenditures that we make on health care and how that may crowd out expenditures on some of the social and other supports that we think we need, et cetera. A very, very full discussion. We could go on and on and on, but we won’t today.

Again, I want to thank all of you and thank our audience for getting us off to a terrific, probing discussion today. Thank you.

(END)

FINK: Thank you very much and it’s such a pleasure to welcome everybody today to our global health—Part II of the Global Health Symposium. I’m Sheri Fink. I’m a journalist and a physician by training who’s been focusing on the COVID pandemic for the last year and a half. And I’m going to follow Susan Dentzer’s lead from the last—our last session by introducing our incredible panelists today one by one as they make their introductory remark. And just as a sort of introduction, CFR is hoping for us in this session to engage in a very lively discussion of lessons learned from past pandemics, both at home and abroad, and how we can use these lessons to improve health here and in the U.S. in the future. And we have a glorious assembled brain trust to help us today.

So let us begin with Dr. Joneigh Khaldun, who is the chief medical executive and chief deputy director for health currently at the Michigan Department of Health and Human Services. And I should just say that prior to this role Dr. Khaldun has had an amazing career that will bring a lot to this conversation. She spent time as the director and health officer for the Detroit Health Department. And as part of that work, the last time we spoke you were fighting the largest Hepatitis A outbreak in modern U.S. history. So bringing a lot of knowledge of working with communities to try to end, you know, an outbreak of an infectious disease, and many insights that you had that we spoke about at that time that I hope you can share with us today. And also Dr. Khaldun had former roles in the—as the chief medical officer in Baltimore, as well as a fellow in the Obama administration working on health reform. She’s also a practicing emergency medicine physician who still makes time to do shifts at Henry Ford Hospital in Detroit. And not sure if you’ve been continuing to do that during the pandemic, but you’ll bring—yes, OK. So some real insights from actually having that contact with actual patients.

So, Dr. Khaldun, maybe you could just start us off with, you know, I would—I would very much like to hear how your insights from the work you did in Detroit have sort of given you—given you an approach in your current role that has maybe really contributed to your ability to respond to the pandemic. And I think, you know, Michigan is very interesting because it has really the last wave—serious wave only just a month or so ago, of the pandemic. And so if you could talk about that. And also I know you’ve worked a lot and feel very strongly and passionately about addressing structural issues that lead to inequities. And that has been such a hallmark of the American experience with the pandemic. So please start us off. Thank you.

KHALDUN: Absolutely. Looking forward to the conversation with the panel today.

So Michigan was one of the hardest hit states very early on in the pandemic. We also saw significant disparities, again, like most of the country saw as well. In Michigan, 14 percent of the population is African American, but early on 32 percent of infections and 40 percent of deaths were in the African American, Black community. And we all really know the reasons for that, and that is just simply structural, systemic racism that goes back hundreds of years. My family, at least five maybe six generations of my family, are in Detroit or have been in Detroit. And you know, I spent time, as you mentioned, as Detroit’s health officer. So the interesting thing about Detroit that a lot of folks don’t realize is it’s 132 square miles. It’s the largest city in Michigan. It is about 80 percent African American. And it’s also the poorest major city in the entire country.

And so for people in Detroit, specifically Black people in Detroit, they’re more likely to live in poverty. They’re more likely to be unemployed or to work at a low-income job. We talk about access to housing—all of those things that during the COVID-19 pandemic we were telling you that you needed to do to protect yourself. So don’t use a ride share. Most people in Detroit, 132 square miles, don’t have a car. There’s no robust transportation system. How do we expect you to protect yourself? Can you actually work from home? Many people, including myself, had the privilege of being able to work from home, but a lot of people in the city did not. Of course, we talk about isolation. The CDC guidance said: If you can, use a separate bathroom in your home. Well, that’s ridiculous—(laughs)—when you don’t have stable housing. Not because of the color of your skin but because of these structures that have been put in place for hundreds of years.

So we were not surprised but certainly concerned about the disparities we saw in Michigan. And so we went into action. And again, the best public health—Sheri, we spoke about this years ago—the best public health is really when you bring public health into the community and not just do things to the community but bring them in so that they can help identify the challenges but also develop interventions and solutions. So we did that in Michigan. We launched a coronavirus task force on racial disparities that was not just a task force, but it’s really how we guided all of our policies and decisions when it came to equity and disparities around the pandemic.

So we distributed more than six million free masks. We implemented neighborhood-based testing, particularly in the Detroit metro area but also many other areas across the state, where we saw those inequities and disparities in cases, and deaths. We also launched a targeted multimillion-dollar communications effort really bringing in those trusted community members. And we actually saw success with intention and focus, which I think is really important. Intention, focus and, quite frankly, leadership at the highest levels. Michigan was actually able to essentially eliminate that Black/white disparity for our first surge in 2020 and our surge in the fall as well. And, again, I think it really speaks to bringing the best public health into communities, collaborations, and focusing on equity and disparities, which is really important and has implications globally.

FINK: Thank you so much. That is really an amazing and very important feat to take—to take note of. And a lot of lessons, I think, from your experience. Hopefully you are publishing lots of papers that the people who are listening to this call can get more insights into that accomplishment.

So we’ll go next to Tolbert Nyenswah, who we last saw each other in Liberia, in Monrovia. And just want to share with people, the members who are joining us today, how incredible your background is when it comes to today’s discussion. So not only are you a public health expert, a—I think your current role at Johns Hopkins is a senior research associate at the School of Public Health in the International Health Department, you also have a law degree. And most relevant perhaps for our discussion today is that when I saw you in Monrovia, you were leading the response as the incident commander, a large, you know, multinational response, to the biggest Ebola outbreak in history.

And I have often wondered what you’ve made of the COVID pandemic, and what your contributions, you know, from that time, your insights, how that has influenced the work that you have done with this pandemic—(audio break)—where communities really did—(audio break)—driving down the epidemic. You know, how did that—how does that—what does that teach us? What did that teach you? And how did you apply that here in the U.S.? So maybe you could start us off with some of those insights.

NYENSWAH: Thank you, Sheri. I remember those incredible days in Monrovia that you mentioned, that the entire world was frightened because of the Ebola epidemic that was taking place in West Africa. But to describe today, after a couple of years of the Ebola crisis, as you related, being capable to look at it in a sense that the world is again struggling to contain the pandemic. A few years back, during the Ebola crisis and after the Ebola crisis and other epidemics that took place—like SARS, like MERS—people, you know, were thinking during the outbreak, and television screens were carrying the dead bodies and the cases, that a lot of steady investment took place. We all thought that the world was at least near to preparing for the next outbreak.

But what has been seen right now is completely unbelievable to me, because in 2014—2016, during the outbreak, some of the (accord ?) that we were making to the rest of the world was, Liberia was a very, very poor country that experienced, you know, fourteen years of crisis. The other two most affected countries, Guinea and Sierra Leone, fell within the same fragile state situation. But now to see wealthy countries and developed countries having the same problem that we were facing in West African can tell me that—it tells me that, you know, the entire world is unprepared. The interconnectedness of the world, in terms of disease outbreak and all of that, it’s very, very incredible and unbelievable for me, who, you know, there with not only Ebola but Lassa fever and monkeypox, and other diseases of public health importance cause, you know, international disruption.

But most interestingly, United States—because the topic is about, you know, global to local and then how American health can be protected—I am surprised that during the early days of the outbreak, in March-April of 2020 in the first quarter and the early days of the outbreak, I was, like, watching it screaming. And could not believe, with the potential that the United States has, and working with partners with the CDC and NIH and other organizations in the field in West Africa, and to see the kind of struggle. But then I could see the linkage between the role of leadership in outbreak response as really being intertwined. There is no substitute for political leadership in outbreak response, is one lesson that we learned here.

And some of the things that we instituted in West Africa that turned around the outbreak, for example, the massive community engagement, you mentioned that you were in Monrovia. You covered the story of the West Point. West Point is a slum community with about 75,000 people congested—(inaudible)—areas. And the government imposed a quarantine and isolation on the population, populace, and deployed the military in there. Because they were using force, it did not work. We had to recalibrate, reinvigorate our efforts to put in place community-based initiative that curbed the outbreak in that community and other areas.

Once we did that we went to other countries in West Africa. So community engagement, case management, contract tracing, all of these public health measures, because we were dealing with a situation where there was no—there were critics. We didn’t have vaccines, like we’ve developed one now for COVID-19. It was almost like—(inaudible)—traditional public health measures can help in an outbreak. And this is why—and I think Emily will mention this, maybe you have a thought—on how we were able to mobilize, put together under our leadership contact tracing calls that helped the United States and the rest of the world.

But one lesson if we’re taking one from this composition, is the capacity and the leadership of the United States. You can never underestimate that globally when it comes to everything—whether it’s terrorism, whether it’s outbreak response, whether it’s preparedness, medicine preparedness, and disease control. When we’re struggling—(audio break)—provided the leadership of the United States. Deploy troops, deploy resources, the United States capabilities and disease response, then the rest of the world follow on West Africa. That’s how we were able to halt the outbreak there.

So the point I’m trying to make here, and reemphasize, is the U.S. leadership is very much critical. For us to protect the population of the United States, it very much starts with the rest of the world, especially the countries in low and middle-income economies. Thank you.

FINK: Thank you for those excellent points.

And I want to move next to our third esteemed panelist, also at Johns Hopkins Bloomberg School of Public Health, Emily Gurley, who is affiliated with the departments of both epidemiology as well as public health—international health, pardon me. And she has focused—you have focused, Emily Gurley, on—for decades, for a couple of decades, on surveillance and outbreak investigation, and particularly in the context of Bangladesh, and have focused on Nipah viruses and arboviruses. Your work has also focused, for a couple of years before COVID—I noticed you were working on a project about the emergence of diseases from bats. So as we have a potential for that bat to human spread in this outbreak, it would be very interesting to hear your thoughts on just those links between—and I know you focus a lot on the links—the ecological context in which humans live and experience viruses and outbreaks, the emergence of new and, you know, spillover events with infectious diseases.

And then, as Tolbert Nyenswah just mentioned, you’ve done a huge amount of work, both of you, on this course that I understand millions of people in the U.S. have taken on contact tracing. And it would be just great to hear your thoughts, bringing in that incredible history, on what the U.S. can learn for the future. And we really were not doing a lot of contact tracing in the beginning. Having spent time in Liberia looking at the work that Tolbert Nyenswah and just the many people in Liberia—not just in the capital, but also in, you know, many diverse parts of the country—they were going out and, you know, one-by-one that contact tracing, that word we all know now, was such an important part of turning the tide on Ebola. And it just seemed like we folded our cards very early in the U.S. And I’m wondering, you know, what are your insights into that and what can we learn from that in the future, and even now, when we’re at this phase of the pandemic where maybe it is again a little more possible to track individual cases?

GURLEY: It’s really a pleasure to be here today and to have the opportunity to talk with all of you. And I think you’re right, there are many lessons that we can learn here. I’ll start with the idea that the U.S.—the health of the U.S. population is directly linked to any zoonotic emergence anywhere in the world. And I think we know that very acutely now, perhaps in a way that we did not before. The threat has always been there, but somehow pandemics have never really touched, you know, the lives of most Americans—at least Americans that are living today. So I hope that this brings about a new realization of our interconnectedness, and therefore our interest in primary prevention of spillover events, which is going to be critical for us going forward.

I think COVID arrived in the U.S. in a time of a decline in our public health, both in terms of our physical and mental health and wellbeing—you know, before the pandemic life expectancy was in decline in the United States. You know, our existing epidemics of obesity, diabetes are growing. And along with that we also have been experiencing a decline in investment in our public health systems. So I think COVID really found ready ground of people vulnerable and unprepared. And so I hope we learn that lesson and turn it around.

It’s not just—(laughs)—that, you know, there wasn’t—there wasn’t the awareness about contact tracing—which is done actually in public health departments all over the country. This isn’t a new technology. But we didn’t have the bandwidth. There was no ability to quickly scale. Our surveillance systems were inadequate. The data systems underpinning our public health decision making in the U.S. are really abysmal. And I’m sure Dr. Khaldun can attest that, you know, you didn’t have the data that you needed in real time to make decisions. So I hope that we can turn around and make those investments where they need to be made, and improve our overall health. I think we can’t underestimate or ignore the fact that people with other comorbid conditions—which are, you know, sadly so common here—are at higher risk for severe disease from infections. And so we need to think about health as a whole. And that’ll help us going forward.

And I’ll say one more time that the context really matters. Transmission happens within a particular context, within given restraints, in a specific community. Prevention has to happen within that same context. You have to meet people where they are. One blanket intervention is not going to work everywhere. And it takes a lot of hard work to make those links and to do—to amend the interventions to fit what’s happening in your population, to have the conversations. That typically happens through public health, but without the bandwidth it doesn’t work well.

I think that in other countries around the world where I’ve worked—particularly those that don’t have the benefit of very strong central medical systems, they tend to rely more on community outreach and community health approaches than we do here in the U.S. And I think what we saw in the pandemic is the real risk of losing touch with that community pulse and those community links, and involvement in public health. I think contact tracing, as you mentioned, is going to be crucial going forward, particularly as we monitor variants and any possibly concerning changes in epidemiology from those variants. And I’ll leave it there.

FINK: Thank you so much. You all made such important points. And I think this—at a time when there are all these lofty conversations going on with multilateral institutions and with our own government in terms of planning for the future, trying to, you know, prevent, prepare for future pandemics, which we know are foreseeable, there’s a lot of talk of these large, you know, lofty—(laughs)—institutions and starting a new center for this and that. And you bring us back to the importance of tailored interventions to those, you know, labor-intensive, on the ground community relationship-built approaches that you just—there’s not a top-down approach for that. And these investments in, you know not just these institutions but people on the ground, and the public health workforce, and communities, and all of the work that you guys have been talking about. I think you’ve just really emphasized why that is so important.

And I would just ask one question of all of you, which is that, you know, I remember being in West Africa—this was actually in Sierra Leone not Liberia—and going to a village. It was rather late in the Ebola outbreak, which killed so many people, this massive outbreak that the world had never seen. And getting to that village and talking to people. And I’m sure, Dr. Khaldun, you’ve had this experience as a clinician. Where, you know, many months have gone on. There has been so much death. People had—you know, you’ve been shouting from the rooftops, everybody has, trying to raise awareness of what people can do to protect themselves. And yet, people still engage in behaviors in their lives. We shouldn’t—maybe behaviors is the wrong word. You know, in activities that put them at risk and don’t really seem to believe that they, themselves, could be affected until they’re in the hospital, until so many people in their communities are dying.

And I remember sitting down and speaking with somebody and—(audio break). And I’m—(audio break)—thought about, you know, what is that could—oh, I think we’ve just switched audio here. So I was saying that it seems like it’s a very universal human reaction. And I’m wondering, you know, what can we learn? And have you come up with any thoughts about how to just not experience that, to actually make an impact before people have to suffer and die in communities? And sorry if the audio didn’t work very well. And that question is for any of you. (Laughs.)

KHALDUN: Well, maybe I’ll, you know, emphasize the comment that Tolbert said earlier, which is the real importance of leadership. And the United States at the national level, from the White House, from the very beginning of the pandemic pretending that it didn’t exist or advancing non-scientific therapies. I won’t even repeat—(laughs)—what was mentioned early on in the pandemic. But I think unfortunately not only was there a lack of strong leadership and a unified scientific-based message coming from the top, you know, White House, I think that unfortunately it also caused this pandemic to become very political. And unfortunately, even what I’m seeing today in the state of Michigan, it’s—you know, along political lines are the people who really definitively absolutely don’t want the vaccine, or are saying it’s a fake virus, or whatever it is. And I think that could have been stopped early on. And I think it did cost us lives across the country.

GURLEY: You know, even without politics, which complicate many things, knowledge rarely equates to behavior in any kind of public health goal, right? Things that we do are determined by many factors, not just what we know or what someone has told us. I’m sure we can all think in our daily lives, even today, all the public health messages, all the things we should have done already today that we haven’t done. So I think that, you know, we have to take that into account. It’s not just about telling people. It’s about showing. It’s about really finding out what’s it going to take from their perspective to make needed changes. Or as—you know, or if this isn’t their concern, why? And getting down to the details.

I think the reality is also that there is a lack of trust. I mean, this happens more when issues become politicized. But there are many communities that view public health, academia, you know, the medical system as someone from the outside who may not understand what they’re going through. And so they’re less likely to listen. I think we need, again, those links with community and with people who are credible sources of information, because it’s not always Johns Hopkins University, for example,

NYENSWAH: So I think we—I think we are at the critical stage of the epidemic, what I could describe as the long tail of the epidemic or the pandemic, is that people claiming victory too soon that it is over. And actually, it is not over till it is over, to quote someone. That you have this thought that the outbreak is coming to an end, because of some normality coming in. Some like the vaccines are being distributed right now, but I don’t think we’ve reached a level where the herd immunity have been created that, yes, even if the United States is doing well with having shots in people’s arms, it’s not the same as other countries when we see travel has started again throughout the world. In Africa, there are increasing cases. India is reporting they’re having a boom in the number of—starting increase in the number of cases they’re reporting.

At this stage of the outbreak, risk communication is the magic bullet. You have to make sure that people are aware, like colleagues stated, behavior change and not claiming victory, as if the epidemic or pandemic is over. I have an experience where we were counting down on—because for Ebola you have forty-two days to incubation period before you declare Ebola-free. At least a week into our forty-two days we experienced a number of cases that took us back to a flare-up of the outbreak. This could happen with millions of cases that are still out there with the COVID-19 pandemic. And claiming victory very early would be an inconceivable thing to do. And so I believe we have to push harder and get the last case, vaccinate people, so that we can—we can stop this outbreak.

FINK: Thank you for those thoughts. And I spent some time on the African continent during this outbreak, actually witnessed—went to one of the places that has the fewest resources, Somalia, and, you know, saw a very community-based approach that was taking place there with, you know, far fewer tools but had been doing—(audio break)—than us in terms of mortality and, you know, morbidity. And now you’re right, we see, you know, that kind of—(audio break)—increase in cases. And then India, Nepal obviously have seen a vast increase in cases. So it’s very important to remember that it’s a linked world, and that this is really a global pandemic, and we are all—you know, there’s no end of this pandemic until it is over everywhere.

So now I’d like to invite participants to join our conversation with your questions. This meeting, as a reminder, is on the record. And the operator will now remind you of how to go about asking your questions.

OPERATOR: And our first question will be from Emerita Torres.

Q: Hi. Thank you so much for the discussion. My name is Emerita Torres. I’m the vice president for policy, research, and advocacy at the Community Service Society of New York.

Really great discussion, particularly around Detroit and the ability to address the racial disparities there, the data issues in real time and the communication risk points that were mentioned. You know, there’s been a lot of discussion around subnational cooperation and global cooperation. And I think, with regard to pandemics, this is—this should be a top-line priority, in terms of the lessons learned from cities, from states, from countries. You know, from Detroit to Monrovia, and the like. And so I’d be interested to hear your comments on venues by which, you know, this could take place, and things that you wish you would have been able to learn early on in the pandemic, both from a local perspective and a global perspective. Thanks.

KHALDUN: Should I start, from a local perspective? Thank you. Thank you, for your questions. You know, what I think—what I wish we had early on, and I remember when my state epidemiologist first told me that we were only going to be testing based on CDC recommendation—this is not to throw CDC under the bus, this is just the reality of the way it was—said that we were only testing people who were severely ill or who were hospitalized, I literally laughed and said: You’re kidding, right? And she said, no, they said we don’t have enough tests and that’s what we’re doing. I said, are you sure? And absolutely it was the truth.

And quite frankly, that—in, I think, it was February of 2020—I literally said: OK, well strap up, because this is going to be terrible. There’s no way you can only test people who are severely ill for a respiratory illness. Just, again, as an ER doctor, most people don’t get severely ill. They have mild illness. And we’ll never test them, and it’ll just spread like wildfire—which it did in this country. So I think—I hope that as a country we have learned the importance of these very basic public health measures, early testing, contact tracing, isolation. If we had done this very bread and butter public health things early on, we would have not seen the lives lost that we did. And so that was one thing that was—I don’t know if I learned it. I was certainly surprised by it and didn’t expect that response early on in the pandemic as a country.

FINK: Can I just—I want to jump here and ask, there’s been some debate about—Emily, since you’re the contact tracing expert on this panel—about whether it was feasible. Whether with a respiratory illness that you can use contact tracing successfully. And I guess we have the example of some countries that have done it, but what do you think in our context—contexts, plural—in the U.S., is it feasible? Could we, if Dr. Khaldun’s point, if the CDC had—you know, and if the private sector in our country had been able to churn out these tests at the level of, say, a South Korea, and we could have been test, test, testing in February, and, you know, applying—let’s say we had, you know, a robust contact tracing corps for the next pandemic. Is it possible?

GURLEY: So I’ll comment on that. I mean, I think the—I would say is what possible? I think that one of the major limitations of our response is that we never defined what we were trying to do, right? We’re never going to get rid of this virus, OK? But there’s a—so where are we—what are we trying to do? I think that timing is really important in these—in these kinds of events. So if we—you know, maybe it took us weeks to get more testing up and running and to get contact tracing going. Our loss in our ability to act is on an exponential scale, right, not linear. And so that—the initial time we lost was huge.

I’ve heard some people talk about contact tracing and say, well, contact tracing doesn’t work, especially if you have so many cases, right? Because, look, we still see transmission happening. And I think that’s a problem in our thinking. So if you want to know how well contact tracing works, the question isn’t how many cases do we have now compared to zero. It’s how many cases do we have now compared to how many we would have if we didn’t have a contact tracing program. And that’s not an easy number to calculate or conceptualize. And so I think a lot of people—you know, sometimes it’s a lack of imagination. You can’t imagine it even being worse. Well, it could be.

And we designed a whole course to help programs think through their impact, and to improve. But I think, from my perspective, I mean, there’s really no doubt that contact tracing had a big role to play here. Even when things seemed bad, they could have been even worse. And going forward, I hope we—I hope we keep that capacity—some kind of flex capacity around. We’re going to need it.

FINK: Did you want to jump in here?

NYENSWAH: Yeah, I think I cannot agree with Emily more about what was said about contact tracing. You have to start early. You investigate a case, you find it, you test it in your lab, whether it’s positive or negative, you trace their contacts. That’s basic public health 101. And in outbreak response, that’s one of the core tools that is available. We used it over and over from other disease, like HIV and AIDS, syphilis, and all of that, Lassa fever. And so the notion that with respiratory disease it’s not applicable, I really don’t see it hold water. So the fact of the matter is you have to trace those contacts. The reproductive numbers, that is the number of people that a contact may generate, with Ebola may not be the same as a respiratory disease, but it’s the number of persons that you put on the field there to do the contact tracing.

If we didn’t follow people at the point of entry, check them at ports, we would have had lot—a lot of cases spreading across the world to create a pandemic because of the Ebola situation. But tighter contact tracing measures and testing measures that were following everybody that made a contact with a case, that’s how we were able to minimize the number of cases that were coming out of West Africa into other countries. Those smaller cases managed to other countries, but that did help. And countries that started very early with the COVID-19 pandemic and managed to trace their contacts and limit the size of their outbreak significantly than other countries that didn’t do it well, (and the evidence ?) is really documented.

FINK: Yes. Right. Some countries—other countries can show us that it is possible, and that’s really important for us to look at going forward as models.

Next question.

OPERATOR: Our next question will be from Bodan Riskovic (ph).

Q: Hello.

I’m actually an M.D. How would—I have—the basic question I have, and I will share with you the scenario. How do we learn from those very specific mistakes or inactivity that we made? I spent the first six months on the pandemic on the Duke campus. And everything closed down. You know, North Carolina didn’t have huge numbers of cases. They had all the empty dormitories. They could have implemented testing, screening and contact tracing and provided dormitory rooms for the tens and hundreds of cases that occurred in all of North Carolina. And it was bizarre to see this health care facility and campus totally empty. You know, I used my iPhone to make videos of the campus and I would be the only person on the campus. They closed the botanical gardens. And here they had the capability of doing testing and contact tracing. And then when they opened up for this—you know, in September, they put all that testing to the benefit of their own students so they could have a basketball season. And they didn’t take care of Durham. You know, and this scenario repeated itself at the University of Illinois and Harvard.

FINK: Mr. Riskovic (ph), if you could please maybe ask the—

Q: Yeah. So the question—the question is: How do we learn from that scenario? Because I—

FINK: (Inaudible.)

Q: You know—

FINK: OK. I think the question was: How do we learn from that?

Q: Yeah. Yeah. I mean, our medical system went AWOL, literally.

GURLEY: Thank you. I’ll comment first. I think that in any pandemic there’s really no way around some period of panic and uncertainty about what to do. You know, there’s no way to have a pandemic and have everything go smoothly and well. That’s antithetical to what a pandemic is. And I think that in that early phase, there was a lot that wasn’t known. And so the default is often inaction, if there’s—if there’s no clear way forward. You know, how resources are allocated for public health purposes is something that communities have to—in the best-case scenario—come together and agree how to use well and best for them. But it has to be done with dialogue, right, which in many cases we didn’t have, we’re not that well practiced in. And again, we had what was the goal? We didn’t have a goal set for this huge enterprising project that we had, there was no set goal.

I think if you say, for example, in North Carolina, if there was a goal, this is our public health goal, this is what we’re trying to do, then it becomes much easier to talk about, what the appropriate use of public health resources is, because you have a shared goal. And we still really don’t have that many shared goals. I think we have one maybe around vaccination now, but we didn’t have it before. So that’s my comment.

NYENSWAH: Well, I think the best way to stop any epidemic or pandemic from—an epidemic becoming epidemic, or a disease becoming epidemic, is to prepare. There’s nothing more than that, building your surveillance system, making sure your data system is strong, doing simulation exercises, tabletop exercises, preparing as if to say the pandemic was already there. And having one plan, one program, one strategy in the early phase of a pandemic. Those are the things that can help to stop, because I’ve seen, as an example, the way Ebola treated us in West Africa. We were able to build back a little bit better. Now COVID is not as devastating as Ebola in Liberia, with the number of cases that are there. The way Africa have been dealing with Polio, with yellow fever, Lassa fever outbreaks in Nigeria and other areas on the continent, and preparing emergency operation centers, port of entries.

So those preparation were nothing that I think the global north, the countries in the United States and other areas, are not used to because of the—and for good reason. The diseases that you deal with in the United States, in terms of the burden of disease, are more, you know, noncommunicable disease that have potential pressure—diabetes and all of that. And in my case and other areas, in Asia and Africa, we’re still dealing with infectious diseases like Malaria, Lassa fever, Ebola, and all of these things taking place. So you have to have the system prepared, have one plan at the origin.

One other thing to speak specifically to the MD about Duke University, is that you saw different plans at the origin of the COVID-19 outbreak in the United States. The federal government was having its own plan, states government, jurisdictions, and city government in an outbreak responded. Country have to come together. I understand the diversity of the U.S., but the outbreak have to be managed by one plan, one strategy, one program.

FINK: Just pivoting off of that, could you just tell us briefly, to the extent that you’re in touch with some of your former colleagues in Liberia, how did they use, or did they use, some of that infrastructure that was built up, the approaches with the contact tracing and the community outreach? You know, was that employed with COVID? How much was it transferable from—you know, you talk about the importance of doing some preparedness. You had the real-life drill. Did it end up being useful experience for this pandemic?

NYENSWAH: Oh, yes. We reinvigorated and revitalized the integrated disease surveillance system for the country that was collecting priority disease and diseases of epidemic potential from every single health facility in the country and reporting back on a weekly basis to the national level. So when COVID struck that system was already there. All they needed was capacity to do some testing. That’s what I was mentioning. There will be a lot of new things in every pandemic, especially with a novel pathogen like COVID-19 that didn’t have capacity for testing and all of that. So the lead time will always be there, that will cause problems. But because of the systems, contact tracers that were trained, community mobilizers—(inaudible)—management team and everything that was in place, they were immediately able to stand up an incident management system that was used in Liberia and other countries in the region.

And in the DRC, Ebola outbreak was already going on. And countries within the DRC—Rwanda, Democratic Republic of the Congo, Kenya, and Tanzania, Uganda—bordering DRC were already prepared. And they were able to use those infrastructures and systems to get prepared. And one support that the U.S. did have to make a policy issue—since in fact we’re speaking to a policy think tank—is the global health security agenda is a very great USG strategy that the CDC, NIH, and other organizations are supporting out there. We need to make it a living strategy and document and tie it to our global policy so that we can prevent, detect, and respond to outbreaks earlier, before they reach the shores of the United States.

FINK: Thank you. That’s a great point. We have so much expertise and resources and funds that can promote some of those, you know, efforts in other countries, even though it is a bit ironic as we have done so poorly in our country when you look at morality, number one in the world, from COVID. But people who are in global health do stress the importance of that engagement from our country to promote better preparedness around the world.

Dr. Khaldun, I think you also wanted to weigh in.

KHALDUN: Yes. You know, I was just going to say I think what a lot of people didn’t understand—particularly I was having to deal with a lot of media requests—and still do, but early on—well, why don’t you have the information on where all the cases are? Why don’t you know their exact age, and how many people they contacted? Tell me about the outbreak, and how many outbreaks were there at schools? I think people don’t realize, it’s not that there are these people in government who want to hide things, and are lazy, and sleep in, and don’t care. We were using fax machines. I mean, fax machines are still a thing of U.S. public health. There are many local health departments who don’t have a single epidemiologist, didn’t have a single contact tracer.

Our systems don’t connect. Our public health data systems don’t connect to hospitals. So trying to pull that data in in a robust and disaggregated way to understand how the—how the virus was spreading, we just didn’t have that capability. And I hope, talking about lessons learned, we invest. Not just prepare, and plan, and tabletop—those are absolutely what we need to be doing, what we were doing, quite frankly, before the pandemic. We need to have people, people who are trained, people who can do the data analysis and communicate it as well. And we just simply did not have that.

FINK: Such a good point. So let’s go to another question from our participants.

OPERATOR: Our next question will be from Gary Goldman (sp).

Q: Oh, I didn’t actually have a question. Did I raise my hand? (Laughs.)

OPERATOR: Apologies. It looked like your hand was raised.

Q: I’m finding this all fascinating, but I don’t have a question. (Laughs.) Thank you.

OPERATOR: That was actually our last question in the queue, Sheri, so I’ll turn it back over to you.

FINK: OK, great. Well, we have about five minutes left. And I think we should end with some looking forward. I want to—I wanted to give the participants a change to ask their questions, but since I’d love to pivot off of the last thing you just said, Dr. Khaldun, which is, like, have we started to make some of those investments? Are there improvements? Are we off the fax machines? Are there better, you know, ties between our data streams? It’s such a fragmented thing. We even saw it with the vaccine rollout, the early bumps, how, you know, just the, you know, computer infrastructure to schedule and reach people was hit or miss. (Laughs.) That might be the best, most polite, way to put it. So are you seeing some improvements, so best practices?

KHALDUN: I would say yes. I think especially the public-private partnerships that have been developed and strengthened throughout this pandemic have been really exciting. We do have, quite frankly, a lot of money coming into health departments across the country. If you can get it through your legislation that’s a whole ‘nother conversation here in Michigan. But we do have a lot of money that’s being invested, at least today, in public health infrastructure and workforce.

I hope that that momentum does not die down, and we not only get the systems established but maintain them as well. Our immunizations registry in the state, you know, decades old. When it came out it was new, and it’s still great, but it’s decades old. And that’s what we were starting our pandemic with. So I hope we invest, and continue to invest in our public health infrastructure and workforce.

FINK: Thank you. We immediately got two questions right when they turned it back to me. So let’s go to one of those, please.

OPERATOR: Our next question will be from Carol Zafritis (ph).

Q: Hi. I’m Carol Zafritis (ph). And I’m with the—supervisor with the Fulton County Board of Health in Georgia.

You’ve talked a little bit about flex capacity. And you’ve talked a little bit around flex capacity. But can you talk a little bit more about it? Flex capacity and utilization of staff, tied to dollars, becomes a significant financial issue. There is—there tends to be an immediate thought towards employee, what’s their output, what’s the cost benefit. Can you talk a little bit about that and some strategies you might have?

GURLEY: I think I mentioned that specifically. And I’m not going to claim to have any strategies to solve the issue. Resources are absolutely there. You know, but there are other enterprises that have standing capacity, you know, for bandwidth, right? People who are trained in your community, who know about X, Y, Z, that you can call on, right? The military obviously has, you know, standing bandwidth capacity. (Laughs.) Other organizations have done it. I don’t know of great examples of public health in the U.S. that do it right now, but I think, you know, we need to be—we need to be thinking outside the box about how to solve these issues.

When we put together the course for contact tracing, one of the—part of the rationale was we need to train tens of thousands, hundreds of thousands of people. And most of those people will have no idea about what infectious diseases are or about what epidemiology is. And certainly not contact tracing. You know, even the public didn’t know. I don’t know, a radical idea might be teaching people about public health in high school or, you know, introducing these concepts in other ways in our society so that there’s a more of a general awareness.

FINK: Thank you. So we have one minute left. And I want to let our other two panelists decide whether to answer that or just give us, you know, your two sentences that—something you didn’t say today that you really want to leave people with. This is a very—you know, the people who are participating today have various roles in global health, in private industry, in government. You know, what is that one gem and pearl that you want to share before we sign off?

KHALDUN: I’ll say we have to continue focusing on equity and making sure people have the housing and the resources and the support so that when we do have these pandemics, they’re not disproportionately impacting marginalized and minoritized communities, and that we’re all, you know, interconnected. So I think just the focus on equity is really important.

FINK: Tolbert Nyenswah, would you like to have a last word?

NYENSWAH: Yes, thank you. So if I’m to put on my global health cap, I think the issue of vaccines in equity with the current pandemic. In the country with the virus right now, the rest of the world is no safe. There will still be—if you can even vaccinate over 70 or 80 percent of your population and reach herd immunity, there will still be susceptible population that will be affected. Measles is an example today. The United States had over 80 to 95 percent coverage when it comes to measle vaccines. And yet, there are measles outbreaks in the United States today because of importation from other countries and susceptible population that are not immunized. When we deal with vaccine hesitancy in the United States, and a lot of people are not immunized, we have to focus on the rest of the countries, give them vaccines, and let them eradicate the disease. Once the rest of the world have eradicated the disease, no country can claim victory. Thank you.

FINK: Yes. And the figures, for anybody who wants to look them up, are just so dramatically different. It’s like a less than 1 percent of people in low-income countries have received COVID vaccines whereas, you know, we’re looking at very high rates in our country. And thank you. Unless Dr. Emily Gurley has one more thing to say we’ll wrap it up here. OK.

So I just want to really thank everybody for joining today’s virtual symposium, and especially to our guests today—Emily Gurley, Joneigh Khaldun, and Tolbert Nyenswah. Thank you so much. And please note that the audio and the transcript of today’s meeting will be posted on CFR’s website. Thank you.

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