On this month’s episode of the Healthy Intersections Podcast, Samy Anand from the Medical Care Section recaps last month’s blog posts and preview’s June’s issue of the Medical Care journal. Some great articles to check out for your summer reading list.
Next, Lisa Lines, co-editor of the blog and podcast, interviews Dr. Pia MacDonald, an infectious disease epidemiologist. Clocking in at over 20 minutes, the interview dives deep into what we can learn from the COVID-19 pandemic in terms of bridging gaps between public health practitioners and academics – and much more.
Listen here or via your favorite podcast streamer – we are on Spotify, Apple Podcasts, and more.
Transcript below (lightly edited)
Samy Anand: Listeners… Summer’s here! Hope everyone is still doing great! This is Samy Anand, MC secretary-elect with the summary of May’s offerings for Healthy Intersections! (yes, you heard that right!). Lisa will explain more on this so stay tuned!
In the first part of May, we had two great articles discussing viewpoints in Dr. Michael Fine’s book: Healthcare Revolt. The book explores the themes of healthcare being a marketplace and not a system that is in place to help people. The authors offer viewpoints on what should be done to implement better systemic change and who should shoulder that burden… i.e., is a revolt needed, and when is the best time, and what is the best strategy? This is a topic that brings up constant discussion in the healthcare and public health communities so head to the blog to read it and provide your own insights! We want to know what you think!
Jess Williams has written about Medical Care’s new peer review mentoring program that will match interested students and early career researchers to experienced reviewers. Mentors and mentees, head to the blog for more information and to sign up for this program!
We finish the month with author Cynthia Miller with a post on “Diabetes cure or diabetes management?” which explores the new proposed solutions: high intensity care and lifestyle change as primary management for diabetes. As the diabetes burden continues to significantly rise in the US, and more because of COVID-19 lockdowns and the “new normal,” she explores the feasibility of the various options proposed.
Let’s look at the June MC journal offerings…I want to highlight just a few:
Our own MC team members have worked on a beloved commentary that we are offering the full text for readers for FREE on the MC journal endorsing the single payer health system reform. Medical care has always been a strong supporter of this topic so please take some time to read this. It’s a great read!
The journal also has articles on COVID-19 trends, racial and ethnic differences in hospitalizations, a RCT on cognitive behavioral therapy for long term opioid patients, and an applied methods on measuring inconsistency in quality among patient groups to target quality improvement.
Head to the journal and blog to read more!
Now on this month’s episode, we have Lisa Lines, co-editor of the MC blog, interviewing Dr. Pia MacDonald, a noted infectious disease epidemiologist at RTI.
Cut to Lisa =)
Dr. Lisa Lines: Hello, listeners. This is Lisa Lines, senior health services researcher at RTI International and one of the co-hosts for the Healthy Intersections Podcast. And yes, that’s right, listeners, we have renamed our podcast! The idea is that this podcast is at the intersection between medical care and public health, just as the journal and blog are. And we’re really excited to also feature some excellent interviews and conversations at that intersection.
Today, we’re delighted to have Dr. Pia MacDonald, a senior director and senior research epidemiologist at RTI International, with over 25 years of experience in epidemiologic research and public health. Dr. MacDonald, thank you so much for sitting down with me today.
Dr. Pia MacDonald: Thank you for having me on your show.
LL: As an infectious disease expert, you’ve been very close to the action, so to speak, when it comes to the COVID-19 pandemic. What has that been like for you?
PM: It’s been a whirlwind of feelings and emotions. And I would say, I’ve been, at times, terrified. I’ve found it very depressing. It’s been heart-wrenching. There have been feelings of being invigorated, but at the same time feeling hopeless, and other times hopeful, and all in between. It’s felt a lot like a grief cycle in terms of various phases of the pandemic, as well as my own feelings about where we were. So there’s been denial, there’s been the anger, bargaining, depression, and acceptance, and then a lot of back and forth among these over the past 2 years. But I will say I feel like that grief cycle fits well in terms of where I’ve been, but also where I’ve seen collectively as a society we’ve been. And then I would also say that I’ve learned a lot, and I hope I’ve grown a lot, too. I’ve learned a lot about myself, I’ve learned more about public health, about leadership, politics, government, and then much, much more.
LL: Wow! That’s a lot. It certainly has been an unprecedented time, and you know, like many of us, I’m wondering, has life in the US changed forever because of the pandemic? Or do you think things will go back to relatively normal someday?
PM: There’s a lot of things I think that have changed. It’s hard to tell how long they’ve changed. Many people keep reminding me that, while I’ve seen so many important shifts, a lot of people tell me, well, we forget very, very quickly as a society. So who knows how long it’s going to last.
I would say, though, that there are shifts taking place in society. Examples of that: what is the workplace of the future going to look like? Similarly, in response to what we’ve learned about COVID, I think we’ll reconsider the design of schools and workplaces in the future, in terms of being more intentional around air circulation and ventilation and crowding. And then similarly, as SARS-COV-2 has become lodged as an endemic disease, we’re going to see more and more people using personal protective equipment like N95 [masks], and they’ll be visible not only for preventing SARS-COV-2 but also the flu, influenza.
So those are just some of the ways that things are changing in the near-term future. But in the long-term future, I think it’s hard to tell. I think as a collective, people and society, we’ve become way more aware of how interconnected we are with the globe in terms of disease spread, and there’s been many, many people who have become what I call armchair epidemiologists, and really learn to look at data that I’ve spent many, many years looking at. But they’ve become very good at looking at data about COVID cases, hospitalizations, and immunization rates. I think that has led to us as a society becoming more educated and trained to pay attention to disease, and how that impacts on our communities.
LL: Yeah, you know, we had a blog post recently about that very thing. One of our contributors wrote about his patients and how they have a lot more knowledge in the community about public health, and maybe it’s time for us, now, with this increased visibility, to take advantage of that and not allow public health to go back to the background, but really keeping it … top of mind.
PM: I’d love to see that moving forward, that’d be my dream.
LL: Yeah, I mean, I think a lot of us in public health feel the same way. I’m wondering, what is your biggest fear about the next phase of the pandemic? What should our listeners be worried about at this point?
PM: In my own community, and even in my own family, I think that pandemic fatigue is real, and it’s as if we want to wish away all these waves that keep coming. But really, it’s clear that the variant waves will keep coming. And already, now, at the end of May, there’s a new wave in South Africa, and that’s been a place for us to look at what our future a few months [later] could look like. So right now we see, there, the B.A.4 variant being out-competed by the B.A.5 variant. And that likely indicates what will be happening in the United States in a few months. Right now, we’re in the B.A.2.1.2 wave, and we can see in the out-months, potentially, a B.A.4 or B.A.5 wave coming. I think [the important thing] is just making sure that we’re all aware that these waves will keep coming, at least for the foreseeable future, and understanding how that does impact us.
The very important thing that we keep learning with each of these waves is that immunization and staying up to date on the boosters is extremely important in preventing severe illness and death. I mean, it is very important to be vaccinated that first time, but it is also important to consider continually getting the boosters when they’re offered to us.
LL: I think a lot of people are so tired of it all that they they’ve just given up, and I think that’s, you know, the point about coming waves and being able to see them coming. We’ve got to pay attention to the hidden cases. With many, many tests happening at home now, feels like we’re kind of flying blind.
PM: Yes. But we’re learning more and more about, okay, now that we’re testing at home, how reliable are the tests? What does it mean for me in terms of changing my day-to-day behavior if I’ve been exposed, if I need to test over the next few days after being exposed? But again, what we need to keep mind is that with each of these variants, we need to re-examine: Do our tests work to detect those variants? Do the many mushrooming brands that are available at home all work equally [well]? Are we using the test kits according to the manufacturers’ instructions? Because there’s still so much variation, not only the tests, but also in the way we’re using them, individually, that they’re not a gold standard.
The best we have right now is the PCR test administered in a clinical setting. Rapid test kits that are in the homes are very helpful. But they are not an answer for knowing, definitively, if I’m at risk of passing the virus to others. And there are many reasons behind that. But I would also make sure that listeners keep in mind that with each of the new variants, we need to understand what changes about the epidemiology of the virus and the epidemiology of the disease. We have to ask ourselves, every time there is a new variant, do our therapeutics work? How well does the vaccine work? How well does previous infection provide antibodies [from] protect us? And there’s a continual need to develop and hone our therapeutics, as well as advance the vaccines so that they stay abreast with how the virus is changing, globally.
LL: In what ways is this like the Spanish flu pandemic? And in what ways is it different, so far, from your perspective?
PM: Yeah, I think that’s a really interesting question and one that, you know, there’ll be books written about, I think, in the future. One of the most obvious ways, to me, that they are similar, is that politics have played a role in the response. We’ve also seen lot of variation, regionally in the United States, as well as globally. And I think at the time kind of the Spanish flu, there was similar misinformation out there. Hard to understand the disease, the new virus. How is it transmitted? And because there were so many unknowns at that time, there was a lot of opportunity for misinformation.
Those are some of the similarities. And then, some of the ways that they’re different are very, very important as well. Therapeutics, vaccination, and medical care have advanced immensely since then. One of the problems with flu, or influenza, is that it is a viral infection at first, but the sequelae can be bacterial in nature, and at that time there were no antibiotics. And now, similarly, there can be sequelae that are bacterial with SARS-COV-2, but we do have antibiotics now.
We also have antiviral therapeutics. We also had, within one year, effective vaccines to mitigate severe illness and death. So, those are some very significant differences.
Another thing that is different now, though, is the speed of information–and that’s the social media, and more interconnectedness of people and news, and all that kind of stuff. Seems to me that there’s a deep polarization [around] prevention measures that we know work, such as masking and vaccination. The politicizing of that has been very, very unfortunate. And I don’t know that that was the same around the time of the Spanish influenza.
LL: Jay Varma recently published a take-down piece in the Atlantic called How Public Health Failed America. He specifically points a finger at us, and people like us: university-based physicians, epidemiologists, and virologists, “opining about what the government should do without fully understanding or communicating what is feasible, affordable, legal, and politically acceptable for public health agencies.” What’s your perspective? Are academics totally out of touch?
PM: Like Jay Varma, I’ve also worked in state-level and Federal-level public health. I’ve also been on faculty at the University of North Carolina, in the Department of Epidemiology, Gillings School of Public Health. And also, now I work at RTI as an infectious disease epidemiologist. I feel very fortunate to have had that experience in applied public health at the state, at the local, and at the Federal levels.
I think there’s a lot about our public health infrastructure and system that very different from what the public thinks it is and what academic researchers think it is. I resonate with what Dr. Varma is saying in that article. So, for example, legally, local health departments and how they operate–in terms of what data systems they can use, what information they can share–all of that is governed at different levels and differently across the United States. And that’s something that has incredible ramifications for anything that we try to do nationally, for example, with data.
There’s also the fact that infrastructure has been so critically underfunded for so long. Piling on money solves one problem, but it doesn’t solve the local capacity to expand their staffing, expand contracts, expand data systems, things like that. It’s just, money is not the only constraint to expanding their ability to do response work.
I think there’s many factors that that he highlights that are indeed accurate from my perspective. And I would say some of the benefits from this time are that more academics have gotten more aware and worked closer with public health. There have been many examples across the United States of state health departments turning to their universities to help them with disease modeling, or contact tracing or genetic sequencing, or other things, and that that really has nicely bridged those entities.
But, generally speaking, there’s a lot of university-based positions and epidemiologists who have never actually practiced public health and understand what that system and infrastructure looks like.
LL: So the point, really, is that the separation, this artificial separation between public health and medical care or health care. We’ve got to find better ways to actually bridge those gaps, those gulfs. And our healthcare system sometimes feels like a slow-motion train wreck.
So, let’s end on a high note: What gives you hope for the future, in terms of US healthcare and public health?
PM: A few things. One I alluded to just now, and that is academics who have started to work more closely with state and local and Federal health departments. And vice versa. I do think each of those entitites benefits a lot from that collaboration, so moving forward, I’d love to see an investment in that linkage and making that linkage permanent. So funding academia and funding public health entities to work together on collaborative projects and initiatives, thereby educating new people for the workforce as well as bringing new infrastructure, technology, tools, and knowledge into the public health system–not only from a workforce capacity/ pipeline aspect, but also, it’s a transfer of knowledge back and forth to advance each of them, right? So the academic researchers may be inspired to focus more on research that has public health applications, and then public health be more inspired by some of the more innovative and futuristic tools that are being developed in the research setting and having them applied more in public health. I’d like to see a fusion of those entities moving forward.
Similarly, I think there is growing appreciation of universal health care coverage and interoperable and flexible data systems, for example, electronic medical records. So, we in the United States are benefiting greatly from the fact that the United Kingdom has universal healthcare coverage as well as electronic medical records. A lot of findings about SARS-CoV-2, as well as the new variants, the epidemiology and the clinical features, all these things are coming from places that have integrated systems and universal health coverage like the United Kingdom. I think we’re seeing the benefits of that, and recognizing domestically that there are major challenges when there’s not a lot of cohesion in both the medical care infrastructure as well as the public health infrastructure.
I think electronic medical records will help both entities–healthcare providers as well as the public health infrastructure, to bridge those better so that electronic medical records can be used for public health to improve our ability to prevent and respond to population-level disease threats. And that is coming with the data modernization initiative and the amount of investment in that from a Federal perspective.
The other piece I would add is that there’s been really exemplary public-private partnerships that we’ve seen in this response. For testing, where the state and local health department infrastructure struggled in terms of being able to pop-up testing sites… In some states, others have taken that piece on and done a lot of data sharing with the State, so that they were both benefiting from doing that work because they were working in partnership. They could ensure that the data from the testing went to the state, and then the state could ensure that there was testing available all over the state, or where it was needed most at that time. There have been a lot of new public-private partnerships in the overall response. And that was just one example. but I think there’s been many more, and all of those give me hope that the next time we have to do this, which we will, that we’ll be better prepared. We’ll have more experience working together, both the public-private, but also the academic, public, and everyone in between.
LL: Well, that is a hopeful note, and I really appreciate you taking the time to sit with us today, Dr. MacDonald, and I hope that you get some time off to rest and recharge. And just thank you so much for all that you do.
PM: Thank you very much for having me, and I look forward to future discussions.