30. Doers and Thinkers: Three Health Experts Weigh In

Contagious Conversations  /  Episode 30: Doers and Thinkers





Claire Stinson: Hello, and welcome to Contagious Conversations. I'm your host, Claire Stinson. Every episode we'll hear from inspiring leaders and innovators who make the world healthier and safer for us all. Contagious Conversations is brought to you by the CDC Foundation, an independent nonprofit that builds partnerships to help the Centers for Disease Control and Prevention save and improve more lives.

In this episode, we're changing our traditional format to bring you a collection of speakers from this year's Aspen Ideas: Health festival in Aspen, Colorado. The annual event brings together innovative thinkers and doers from the world of health, medicine and science to address the world's biggest health challenges.

Recently, Dr. Judy Monroe, the CDC Foundation president and CEO, and Pierce Nelson, vice president of communications for the CDC Foundation, traveled to Aspen to take part in the event and spoke with several key participants there: Dr. Patrick Breysse, director of the National Center for Environmental Health, Agency for Toxic Disease Registry at the Centers for Disease Control and Prevention; Dr. Marlene Wolfe, assistant professor of environmental health at Emory University: and Dr. Karen DeSalvo, chief health officer at Google. Each shared their unique insight into public health protection challenges the world faces today.

Let's start with Dr. Patrick Breysee, director of the National Center for Environmental Health, Agency for Toxic Disease Registry at the Centers for Disease Control and Prevention. As the health impacts of our changing climate become more apparent in communities around the world, Dr. Breysee shared his thoughts on how climate and health are related, and what we can all do to address this threat.

Dr. Judy Monroe: It's great to be here at Aspen Ideas: Health with Dr. Pat Breysee. We're going to talk today about climate and health. So Pat, we're just hearing a lot about climate and health these days. Can you talk to us about why that is, and what's the linkage between climate and health?

Dr. Patrick Breysee: Yeah, there's a direct link between the factors in the climate that are changing today and impacts on health. Some of them are very obvious. When there's drought conditions or an increased wildfire risk, wildfire risk increases air pollution. Air pollution is a risk factor for a variety of cardiovascular diseases. Having communities in close proximity to wildfires and breathing wildfire smoke directly impacts your health.

Another example is extreme heat, something that's gripping the country today. People go into the hospital for heat related illnesses all the time. They don't necessarily think that's a climate change issue. But of course, when you realize the extreme heat events are getting more common, the extreme heat events are getting more strong, of course it becomes climate related. But we need to help communities, we need to help people and policy makers make that link so they think about extreme heat as a climate health event.

Dr. Judy Monroe: And so, as we make that link, then what do we need to be doing?

Dr. Patrick Breysee: Probably the first and foremost is we need to talk about it, like I just said. We need to acknowledge it. We need to bring it up when we talk to people about it. We need to make sure our healthcare providers are aware of it. We need to make sure our policy makers, health departments are aware of it, and everyday people we meet in our lives are aware of it.

So, in my life I've experienced an evacuation from a hurricane on a vacation. I lost my vacation. We all talked about that because we know hurricanes are more common. My parents have a house on the ocean that no longer has a beach in front of it. That's a climate change.

So, we need to talk about these things. We need to acknowledge it. We need to talk about it because the climate is changing. These effects are real. They're happening now. But the good news is there's a lot we can do to make sure that those effects are minimized. We need to learn to adapt to the changing climate that's happening now.

Dr. Judy Monroe: Yeah, and speaking of adapting, I mean, we all live in communities. So, can you talk to us a little bit about specific things communities are doing?

Dr. Patrick Breysee: Oh, there's many things. So, that's a great question. So, probably one of the most important things I'd like to mention is that there are impacts that are not equally distributed across society. We know that disadvantaged communities are at greater risk for these impacts going forward.

So, when you talk about extreme heat events, for example, we could focus on inner city environments where there's elderly people without access to air conditioning, and we can set up cooling centers. That's something we could do. We know it works. It happens.

Urban centers are at higher risk because the urban heat island effect. In the middle of a city, particularly a city that doesn't have a lot of green cover, it could be ten degrees hotter than in the suburbs where people live. And so, the climate is the same, but the temperature impact at that moment is drastically different. And you put on top of that susceptibility because you're elderly. You put on that susceptibility because you don't have the resources to have air conditioning. That's where we're seeing the disease. That's where we're seeing the hospitalizations. That's where we're seeing the deaths. We could focus on that. We know how to fix that.

Dr. Judy Monroe: Wow. So, shift a minute to the private sector. What should the private sector, and that then includes individuals and organizations, obviously corporations, what can they do? How can they lean in and really help?

Dr. Patrick Breysee: So, at the CDC, we talk about building climate resilient communities. By community, I mean the broad sense of the word. That includes the private sector. And so, we can't address this just from the federal government alone or even from state governments alone.

We know that, for example, last year there were 20 weather related events that had each one of them over a billion dollars in damage. That's $20 billion in damage last year. Now what happens to those people when they don't have electricity? Well, they can't go to work. What happens to those people when they get sick and they have to evacuate? They can't go to work. So we have employers now who can't get their employees to work. We know that if there's power outages, factories can't run.

And so, the business sector has a huge role to play in this. And we need to talk to them and we need to have everybody step up and everybody be at the plate. And we need to build this multi-sectoral, this multi-agency public/private approach to addressing these issues if we want to be successful. Everybody has to buy into it if we really want to make it work.

Dr. Judy Monroe: Well, thanks so much. Fantastic information. We all need to come together to work for climate and health. And we're very privileged to be here thinking big ideas at Aspen Ideas: Health.

Claire Stinson: Such an interesting perspective on some of the most pressing issues facing public health today. Next, Dr. Marlene Wolfe sat down with Pierce Nelson to discuss a lesser known public health tool, using wastewater surveillance to monitor COVID-19 levels in communities, and how that technique can be used to help mitigate the health impacts of climate change.

Pierce Nelson: I'm Pierce Nelson. I'm here today with Dr. Marlene Wolfe at the Aspen Ideas: Health festival. We're going to talk about wastewater surveillance. Wastewater surveillance has been around for a while, but it's been applied in a new way during the COVID-19 pandemic. Can you explain wastewater surveillance, how it's been used during the pandemic, and how effective it's been as well?

Dr. Marlene Wolfe: Yeah, so wastewater surveillance, or the idea of looking for pathogens that cause infectious disease in the environment, is not a new thing, but we have had this amazing moment of renaissance of the technology and a lot of development that's happened during COVID where we have realized that we can use this now in a way that it's so much broader than we had thought before.

So, this classic example, and for environmental microbiologists like myself, something that we've been used to seeing is the idea that enteric viruses, or viruses or bacteria that cause disease in your gastrointestinal tract, and then that are transmitted by that process, that fecal/oral process, that those would end up in the wastewater and be in the environment and be able to be tracked. That's something that we had an idea of before.

Polio is a classic example of something that has been used, has been tracked through wastewater surveillance in the past. Because we know that it is excreted in your feces. That's part of the transmission route. And so, it seems quite clear that looking for it in the wastewater would be a good way to see, is this disease in the community?

And for polio, that is a challenge because you don't necessarily see clinical cases at the beginning of a polio outbreak. There can be a lot of silent transmission. Be very difficult to isolate and stop polio transmission. So, being able to look at the wastewater and say, ‘Well, we see polio there,’ would give you a head start on intervening before you have really widespread outbreaks in the community.

So, that had been seen before. It's been implemented across the world. But when the COVID pandemic started, we were looking for some way as environmental microbiologists and engineers to contribute. We noticed right away that there were reports of the SARS-CoV-2 virus that causes COVID being shed in the feces of people who are infected.

So, when you're infected with a virus, it can come out in all kinds of bodily secretions. And so, your feces is one of those for COVID. We thought looking in the wastewater would be a good place to be able to see if there was the disease in the community in the case where we had limited testing available at that time.

And what we found is that even though we think of this as a respiratory virus, it is shed in our feces, it is trackable in wastewater. And now we've had two years of development of this and really robust evidence that the levels of that virus in the wastewater track really closely to the number of cases in the community.

And so, we are able to now supplement the information that we're getting from clinical testing with this information from wastewater. And that has been especially important recently as we see more and more people are using antigen tests. Those tests aren't being reported. And so, we're actually getting a clearer and more accurate picture of what the disease burden is in the community through wastewater testing.

And because our eyes have been opened to how widely this technology can be used beyond the classic examples of polio in the past, we have now been able to extend that into other pathogens that we want to track to understand the disease burden of things like influenza and RSV and many other things that we're working on in the community. So, the sky is the limit now with using this to understand population level health and burden of infectious disease.

Pierce Nelson: Yeah, that's really interesting, too. And it's become more of a forward looking type of measurement as well. Health equity is a topic that we've heard quite a bit about during the COVID-19 pandemic. Could you talk a little bit about whether technologies like wastewater surveillance can be used to address health equity issues in communities?

Dr. Marlene Wolfe: Yeah. I think that, again, we see wastewater surveillance as being complimentary to a lot of our existing surveillance systems that try to measure how much infectious disease we have in our communities specifically because they often capture populations that are not captured by those traditional systems.

So, if we have COVID testing, for example, and that's clinical testing, and you need to know that you're infected or have symptoms, you need to seek out a test. That test has to be available to you. And then you have to follow up and get the results of that test and have that reported to public health. There are certain populations that are underserved by the healthcare system, that have had more trouble accessing tests that we have different levels of resources.

And we've done a great job rolling out COVID testing across the country at this point. It is much more widely available than it was at the beginning of the pandemic. Right? But you still have inequity in how people have access to that testing information.

And the majority of the United States population is on sewer networks that feed into wastewater treatment plants. And so, we can take one sample, and it represents the entire community. And you don't need to know that you're infected. You don't need to have access to a test. You don't need to have a way to pay for that test. And you will be represented in that sample.

So, clinical testing is always going to be important for diagnosis and treatment of individuals who need support. But in terms of understanding what is our community level burden of disease, this is one way that we can make sure that we are counting groups that have historically been undercounted when it comes to COVID, and again, other diseases like influenza. Make sure we really have the full picture.

Pierce Nelson: So, how can wastewater surveillance be used to monitor health threats from climate change? And when you look ahead, what are some of the opportunities to apply technology to monitor and help mitigate the health effects of climate change?

Dr. Marlene Wolfe: One thing that I don't have to explain to people as much now as maybe I did two years ago is the very salient threat of pandemics in the world today, partly because of climate change. We're seeing an increase in the number of infectious disease outbreaks in the number of emerging infectious diseases that are causing outbreaks, and part of that is driven by climate change.

And so, one of the things that we see with COVID, for example, is we had amazing technology very, very quickly after there was this new virus emerging that everybody... what is it? What is it? We had a sequence for it very quickly. Right? We had a test we could do. We had the ability to target sections of the genome and do a test. And that happened much more quickly than we could roll out individual testing all across the country and all across the world. The basics of that is the same way that we look for these pathogens in wastewater.

So, we are going to be able to use, now that we are building these platforms for wastewater testing across the country and across the world, we're going to be able to use that platform to then easily pivot and say, ‘Okay, the next thing that's coming, we're going to be able to quickly test entire communities, entire populations of up to millions of people with less than a gram of solids from waste water.’ And so, that gives us the ability to very efficiently pivot to new threats, which is really important with the changes that we see with climate change.

The other thing is—I mean, there are many, many things–but one other thing I'll point out is that there's going to be a lot of movement with climate change. We're already seeing that. Right? Human migration has been a part of what's happening with climate change. And so, our populations and mobility have changed drastically. And this enables us to really count what's going on in an individual place regardless of who's there. We're capturing who's there now.

So, when you have people who are displaced and are moving, and you want to make sure they're counted even if they're not in the official systems of that new place that they are, they are unofficially contributing to the systems of that place. And so, I think it gives us an ability again in thinking about equity that we're serving the entire population that is contributing to the sewer network in an area without bias about who they are or where they came from.

An important foil to that is that, of course, not every place has networked sewage. And so, that is a challenge. But at the same time, the idea of environmental monitoring for these pathogens applies even to places that do not have networked sewage. And so, there's a lot of ongoing work to make sure that in the ways that we don't solve health equity issues with... we solve a lot of health equity issues with this, but there are others that we're just continuing to innovate on making sure that we have that population level environmental surveillance of just about anything we can think of.

Pierce Nelson: Well, thanks. It's such an important topic. We appreciate you joining us at Aspen Ideas: Health, and thanks for joining us on this episode of Contagious Conversations.

Dr. Marlene Wolfe: Yeah, thank you for having me.

Claire Stinson: Such a unique approach to helping communities stay healthy. Finally, Dr. Monroe sat down with Dr. Karen DeSalvo, the chief health officer at Google, who discussed some of the challenges facing public health today.

Dr. Judy Monroe: I'm Judy Monroe, and I'm here with Karen DeSalvo today, and we're at Aspen Ideas Health. Karen, thanks for joining us today.

Dr. Karen DeSalvo: Thank you, Judy, for having me. It's great to see you.

Dr. Judy Monroe: Yeah, great to see you. So Karen, you've worked in health and public health for a number of years now and in a number of capacities. Talk to us about how you see the state of public health as a profession today.

Dr. Karen DeSalvo: I still think it is one of, if not maybe the most honorable way to approach health. And the last couple of years for the public health workforce has been exhausting and difficult and dangerous. But they've also stepped up and been heroes in a way that I am not surprised, but I do hope that they're taking the opportunity to find a way to build up their capacity and resilience. Because they know as well as anyone, their work is never done. And we really count on them as essential infrastructure.

Dr. Judy Monroe: Yeah, we really do. The country owes a debt of gratitude to our public health profession. So, it was just this week that the Commonwealth Fund released a report with recommendations for building a public health system that addresses ongoing and future health crises, advances equity and earns trust. And you served on the commission and had a 90-day turnaround. I think this was a really fast commission. And so, at a very high level, what kind of difference do you think these recommendations coming out of the Commonwealth's recommendations will make in the nation's public health system?

Dr. Karen DeSalvo: Yeah, the report, I'll say, we're very proud of. We moved swiftly because we know that time is at the essence, that there are decisions that public health leaders are making at the national, state and local level, and that their private sector partners want to make to be able to work with them.

We sought to think about how the federal level of public health needed to strengthen its ability, in fact, really significantly alter the way that it organizes itself so it's a better partner to states and locals, and also to the private sector. That there had to be more clarity of leadership of decision making, but also understanding how the data infrastructure workforce, how the healthcare enterprise would be of a strong support and partner.

Very importantly, for folks to know in this report, we built upon the knowledge and recommendations of prior reports like the National Academy Report we did in January about a year-and-a-half ago, prior work from my life, Public Health 3.0. So, what we would hope is that people would see that there's iteration in building and learnings from COVID, but a really hard lean that we can't just incrementally slowly make change. That it's too important for the public's health for us not to take advantage of this moment and create a movement to see that we have a modern public health infrastructure.

Dr. Judy Monroe: Yeah, I couldn't agree more. We really need a movement. So, let's talk about funding for a minute. Consistent and sustainable funding has been a significant issue for public health for years, and the Commonwealth report, again, highlights this issue. This report, like others, highlights the need for funding, but ties funding for jurisdictions to expectations to meet standards for protecting their community. So, talk to us about that linkage.

Dr. Karen DeSalvo: Judy, these are two things that I care deeply about because for a whole host of reasons, it's increasingly important that we fill the gap in resource needs to provide the foundational capabilities for public health, that every day public health is able to promote and protect everyone everywhere, no matter the color of their skin or their zip code. So, these are surveillance and preparedness and communications foundational capabilities that are well spelled out, but haven't had the resourcing that's necessary. Rather, it's boom and bust or categorical funding for a special program.

So, this is the Public Health Infrastructure Fund, $32 a person a year to provide foundational public health capabilities. That accountability for those funds could be matched up against a public health accreditation board, for example, accreditation module for foundational capabilities that would allow the taxpayers, the business community, Congress, the CDC, to understand that the department's not just good because they say they are, but because there is an external body doing it.

You know that I was one of the first health departments in New Orleans to become accredited. We were very proud of that. We are now reaccredited through our second iteration. I found it as a leader to be a way to drive vision, to drive quality improvement, to really energize our partnerships, and codify who owns what accountabilities in the community. I hope people will continue to think that this is an opportunity for public health not only to have resourcing, to promote and protect individual public health everywhere, but also to step up our opportunity for public health to be more transparently accountable.

Dr. Judy Monroe: Really important. Yeah, and you did some great work in at NOLA.

Dr. Karen DeSalvo: With your help, honestly. I mean, anyway. Well, that's another podcast, but...

Dr. Judy Monroe: Yeah, that's another ... we were all learning together, too.

Dr. Karen DeSalvo: This is such a critical thing that we have in the report and that I think we see in other similar public health reports. It's what we do together as a society to create the conditions in which everyone can be healthy. And I'm at Google now, and we've been partnering with public health and with the CDC Foundation throughout the pandemic that needs to continue. Right?

And all the private sector needs to be at the table. Because whether you're in the public health seat or another seat, everybody's got to bring their stuff in to make it the best. We say in Louisiana, it's like making gumbo. Everybody brings their ingredient and puts it all together and it makes this delicious meal that's great for the community. And now more than ever, I think we all need to be willing to step up. And I hope people we’ll see that kind of thread in the report as well.

Dr. Judy Monroe: I love that. So, going with the gumbo image here, one of the recommendations in the report was the addition of an undersecretary for public health at the U.S. Department of Health and Human Services. Sounds like maybe the master chef here for making the gumbo. But talk to us about that decision and from your perspective what's that key recommendation all about?

Dr. Karen DeSalvo: What we are essentially saying is that we have sufficiently disarticulated the public health functions at the federal level over the course of the last many decades, HRSA, NIH, FDA, CDC have all increasingly gone to different corners. And those important agencies don't have always the same level of coordination, whether it's programmatic or discretionary monies or budget or authorities.

And the assistant secretary for health is a role that could provide those functions, and in history has. A secretary could choose to augment the assistant secretary. We talk about that in the report. There are potentially other ways to maybe redefine that role as an undersecretary strengthening the authorities that have, frankly, diminished over time. I served in that role, and there's a lot of good that can be done.

But on the other hand, when the rubber meets the road, it's really helpful to have someone that the secretary and the White House knows is going to be thinking about not only in crisis, but every day how those different divisions of HHS not only partner together to be efficient and effective, but how they work across government. So, we really wanted to call out this need for there to be an elevated role, whether it's through an elevated ask or a new role that Congress might need to create to see that the right authorities were in place.

Dr. Judy Monroe: Really, really, really interesting. So, I want to shift here as we close out to talk about a really important issue, and that's lack of trust. Folks talk about how things get done at the speed of trust. There's a lot related here to experiences with racism and discrimination, ideological opposition, misinformation. So, how do we restore trust in public health?

Dr. Karen DeSalvo: To be frank, this really breaks my heart what has been happening in the last couple of years. I have so many friends who are brilliant, evidence based, caring public health leaders, and were questioned in ways that I never imagined I'd see in my lifetime.

And public health, this is one of the things that we do, I think, best on a regular basis. It's work with community and build programs with, not for. Really think about inclusion and the importance of being consistent and reliable and following through and not over promising. And so, those are just the basic ingredients. Whether you're doctoring or public health-ing, you just need to be real transparent, consistent and present, and acknowledge what can be done.

I think the difficulty in this day and age is that disinformation in particular flies very quickly through the ether, more specifically through the internet. And the responsibilities that we all have, including the tech sector, the other potentially important partners like the marketing and advertising, and folks who have very creative ways of thinking about how to get people to understand truth.

We're all going to have to put our heads together to make sure that we're elevating high quality information and using public health as the lead voice in that for their communities and using their message, but also really working together to get in front of harmful mis- and disinformation. It's not anything that any one sector can do alone. And I really know that this is going to be important, again, not just for trust for public health, but for trust in institutions and in science.

Dr. Judy Monroe: Yeah. It's so important. And it breaks my heart as well. I mean, we both have practiced medicine. The trust that patients give to physicians was humbling many times. And then, I know certainly as my experience as state health officer, I ended up having a lot of trust by the public. And so, to watch what's happened in recent times is just heartbreaking.

Dr. Karen DeSalvo: It's interesting. Look, people who are in public health practice know that when you come on the radio or television, you say ‘The water is not safe to drink, don't drink it,’ you want people to trust you and not do that. Right? One of the ways that we do that is we're in community a lot in public health. And the pandemic kept public health from being able to be in community because it wasn't safe to have gatherings.

And so, I do have optimism that as public health can get back out in community and have those town halls, those coffees, see people at the grocery, all that reality that the trust will begin to improve. And I have to be optimistic about it, because I just don't see how we have health in this country without having strong public health.

Dr. Judy Monroe: Yeah. I couldn't agree more. Thanks so much for joining. And it's been beautiful here in Aspen this week.

Claire Stinson: Thanks to all of our participants for taking time out of the Aspen Ideas: Health event to share their unique perspectives. And thanks for listening to Contagious Conversations, produced by the CDC Foundation, and available wherever you get your podcasts.

Be sure to visit cdcfoundation.org/conversations for show notes. And if you like what you just heard, please pass it along to your friends and colleagues, rate the show, leave a review and tell others. It helps us get the word out. Thanks again for tuning in and join us next time for another episode of Contagious Conversations.