The Cost of Cutting Public Health (Pt. 2)

Judy Guzman-Cottrill, DO, Professor of Pediatrics at Oregon Health & Science University, and John Brooks, MD, former CDC medical officer, rejoin Mati Hlatshwayo Davis, MD, MPH, FIDSA, to discuss the impact of federal funding cuts, including the return of preventable diseases, the loss of mental health resources, and what can be done to protect the progress made toward health equity.

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Transcript

Mati Hlatshwayo Davis: [00:00:14] Hello and welcome to part two of The Cost of Cutting Public Health. Today we're taking a deeper dive to look at the growing threats of federal funding cuts and what these cuts mean for the future of public health. Joining me are two exceptional guests Dr. Judy Guzman Cottrell, an infectious diseases physician and professor of pediatrics in the division of infectious diseases at Oregon Health and Science University, and Dr. John Brooks, an internist and infectious diseases expert who served for 26 years as a medical officer and epidemiologist at the CDC. Together, we speak candidly about what's at stake and what we must demand from our leaders to preserve trust, equity and progress in public health. This is a conversation about truth, about resilience, and most importantly, about hope. Let's get into it. Friends, let's talk about health equity here. I think it's so important. And I think this, very clear and distinct reframing of DEI and what that's meant for these foundational and so critical health equity movements is not something we can gloss over. How do these layoffs and program cuts threaten the long-term progress we've made on health equity? Is it even important and why? And especially in communities that have been historically underserved and overburdened. What does this mean?

Judy Guzman-Cottrill: [00:01:44] We've taken a gigantic step backwards just in the past few months. A thousand steps backwards. You know, it is so hard to gain trust, but man, it's easy to lose trust. I still continue to be in disbelief that the term equity. Equity has become such a dirty word and it's so politicized. And I honestly think that our governmental leaders who do word searches for words, equity in grants and then cut those grants, they don't even understand what that word means. For my state, much of the population who are being negatively affected by these funding cuts because of equity are rural, white Oregonians who probably voted for the current president. And these people have challenges accessing healthcare. I want to also mention the day that it was announced that all of those billions of dollars were cut for infectious disease related programs across the country. HHS also that day discontinued about $1 billion for the Substance Abuse and Mental Health Services Administration. Mental health is something that is so important, of course, to all of us. You know, for me personally, you know, I have an adult son now, but when he was a teenager, he had a major depressive episode.

Judy Guzman-Cottrill: [00:03:07] And, you know, I'm a pediatrician. We were sitting in the emergency department of the children's hospital, where I am a professor, and I could not get the access to the care that my son needed. He was the most resource rich kid in that ED, with me being his mom, and we still boarded there for five days because we couldn't get access to an acute care bed. And now these funds were helping to support state level behavioral health programs all across the state. We lost five grants that helped establish the 908 mental health suicide crisis line. The folks that answer the calls and train others. These funds were being used to fill critical gaps in community substance use treatment prevention for communities of color, but also for rural folks, young adults and veterans. And the money's gone. The term equity just boggles my mind how it has just taken away so many critical resources for healthcare and especially mental health care. As I think about it right now for Americans.

John Brooks: [00:04:13] I really like how you're highlighting this mental healthcare and substance abuse aspect, because I think sometimes when we're looking at these cuts, we think about just what's affecting infectious diseases. But there's so many in the universe of factors that influence somebody's susceptibility or exposure to an infectious disease. Are these other parts of the human experience mental illness, substance abuse? And it's bad enough to lose these very proximal things for infectious disease prevention and treatment that we're seeing. But then these sort of other aspects that increase somebody's likelihood of encountering an infectious disease and being adversely affected by it are also being cut back. I really want to take issue also, I think something you alluded to, which is what do we mean by equity and what is wrong with trying to reconcile disproportionalities that lead to some parts of our society having inequitable access to prevention and treatment. When you start to make cuts in the efforts we're engaged in, to better understand how to reach consumers who we know are disproportionately affected, when you can't reach them and bring everybody up together, that hurts all of us. It hurts all of us because there's more suffering, more illness, increased risk of disease transmission. But if you really want to get mercenary about it, it's also expensive. A non-averted illness is going to cost dollars.

John Brooks: [00:05:36] We engage in research to understand our communities so that we can communicate effectively to them so that we can be trusted, and so that we can increase their access and uptake of interventions to prevent getting an illness or knowing where to get treatment for that illness if they've got it. I sometimes think of the analogy is, if I were to tell you that I have a product I want to sell, and I have a team of people who go out and decide how they're going to micro-target it to all the different flavors and smells of our society. All the different ways you can cut and chop our society by race, ethnicity, gender, geography. You know, you might say, well, that's a great idea. That's a great way to sell a product. That's what advertisers do in business all day long. If we want to increase the value and impact of our product, we kind of have to do the same thing. And it's a well-trod pathway that we're kind of following. And so to me, it's sort of speaking out of two sides of your mouth where you're saying, oh, you know, what you're doing is not really valid because it's doing equity. If we framed it, maybe we need to reframe everything as a business model.

Mati Hlatshwayo Davis: [00:06:40] Absolutely. And I keep trying to impress upon folks. Again, I don't like to politicize health and public health. But the bottom line is this viruses, bacteria, fungi, all these organisms, they don't choose, they don't see any of the things that we like to see and argue about and parse out. And even if you believe that you don't care or don't want to focus on one group. If you do not help that group, it will not just affect them, it will come to the rest of us. That's just the bottom line. So whether you don't like the word and it's now become this whatever DEI, health equity. The bottom line is this we have to protect the most vulnerable amongst us because it's the right thing to do. And even if you don't think it is the right thing to do because it will come to your door, it will. It always has.

Judy Guzman-Cottrill: [00:07:33] Absolutely.

John Brooks: [00:07:34] I'm going to speak now from my perspective in HIV, and this is what really frightens me about what's happening with HIV prevention in the country. You know, there's a proposal in this budget to completely stop all federal investment in HIV funding and to end the ending the HIV epidemic initiative that this president, which was a signature program of this president during his first administration. And, you know, many people may not appreciate that HIV is still with us, that it's still a problem and that it's extraordinarily costly. And as you've just said, there are successes that we may see reversed very quickly. One of the ones that really worries me the most is the elimination of mother to child transmission. Elimination doesn't mean it's completely gone. I mean, we haven't gotten rid of it like smallpox, but we've below a threshold defined as less than one per 100,000 births of HIV being transmitted from a pregnant person to their child. That's incredible. That was a couple of years ago. We achieved that threshold. This could be reversed with all of these cuts in HIV prevention that are planned to be coming. And it's obviously a lot worse when we're talking about sexual transmission and transmission through sharing drugs that could occur in the adult population. And it's just a matter of time till you see these numbers in all sorts of preventable diseases. If we're seeing it with measles, if we might be seeing it with whooping cough, I'm not quite sure yet what's relatable to cuts, but, you know, we're going to start seeing this.

Judy Guzman-Cottrill: [00:08:53] I'm the director of our pediatric HIV program at my hospital. I've been here for 21 years. When I first came in 2004, in Oregon, we weren't even screening all pregnant women for HIV. I felt like I had come out to the Wild West because I had trained in Chicago, and so. But fortunately, I found a couple other angry docs and we actually helped to change the law. So in 2006, it became law that HIV screening for pregnant women is standard of care. You don't have to get a separate consent form. We went ten years without a baby born with HIV in our state after we enacted that. And then, you know, I just kind of sat back with the nurse in my HIV clinic and we were just like, gosh, you know, things are so good. We haven't had any high-risk emergency phone calls of, oh my God, a woman just showed up in labor and she has HIV and hasn't been on meds. I tell you, I get that phone call now a few times a month for the past year. It's coming back.

John Brooks: [00:09:49] You may think that it's built into the system, that it's now law. It's going to happen. But what if the money that supports that isn't there? What if the people who do that are no longer funded? It may be the law, but it's hard to do.

Judy Guzman-Cottrill: [00:10:03] In real time. It doesn't matter what the law says.

Mati Hlatshwayo Davis: [00:10:06] All right, friends, what should we be demanding right now from federal leadership, academic institutions and local governments to ensure we do not lose the trust, the talent and the progress we have worked so hard to build?

John Brooks: [00:10:20] That is the million-dollar question. And although I think immediate answers are not easy right now, everybody is thinking about this. As things evolve, we're going to see how people respond and useful things that people can do. And I think, as Judy was pointing out, one of the most important aspects of this is what's going on at the local level and maintaining that local investment and trust, because really, like politics, all public health is local. You know, the federal government has gotten a bad rap. Okay, fine. You know, the state government may get a bad rap. Okay. I can deal with that. But it's that trust that we have on the ground with the communities that we serve that we need to first really address and build on. And that's going to be challenging with the cuts we've had. And if they continue. But that's really where I'd first focus attention. I think another thing that I've seen happening, and that I think has potentially been very successful, is raising up to federal leadership from academics and from local governments. They can raise up the federal leadership, examples of what's going to be lost, very specific examples of what's going to be lost or that could be lost. And the longer-term implications for that local government or for that local community. Because those are the voters in the local community who vote in the people at the federal level. And so building the locals appreciation of what's being lost by these cuts, which may seem very amorphous, but giving them discrete examples to use, can be very powerful.

John Brooks: [00:11:48] One thing I've seen that I thought was innovative were some hearings in Congress, both on the House and Senate side recently, where some of the folks who believe that these cuts are not useful and shouldn't be done, are inviting people to come in and give testimony. And that goes into the federal record. So it's available and preserves it for the time and going forward. So those are some of the first immediate things I can think of. I would also add that I would try to discourage people, although it's very hard right now from feeling hopeless. I think there's a lot we can do. And again, starting local is a place to look because at least, you know, as a culture in America too, I think we always think about our family first, and then we think about our greater circle of friends. And even just with your family and circle of friends explaining what's happening, describing by concrete example what it could mean for them, and not just kind of amorphously like, you know, you there may be measles in another state, but things like, you know, if there's a run on measles vaccine from an outbreak, you might not be able to get the booster that you need. And we've seen this in places like Texas. Those kinds of examples were really powerful.

Judy Guzman-Cottrill: [00:12:57] Well, I agree with John with all of that. Of course, local is always best. In fact, in my time of despair over the past couple of months, I've decided to. For me, I'm really narrowing my lens. You know, I mean, literally all of the federal and national stuff that I was doing for public health and infectious disease and infection control has been taken away from me. So I'm just going to focus on local issues. I, you know, I was recently nominated to serve on a board of directors for a local nonprofit that serves Oregon's HIV infected and affected communities. I feel like I might be able to make a difference by serving on that board. So, you know, these are examples that I think all of us can do right now. You know, our local communities need us. I think also we as leaders in our fields, we need to be mentors to the next generation. We need to build the army of new epidemiologists, infectious disease specialists, etc. people going into public health. You know, the young people aren't dumb. They're seeing what's happening. And there are a lot of them that are feeling engaged and want to do something just like all of us when we decided as young people to go into it. The next generation is following. We need to support them. We need to find them. We need to mentor them. And then also, I just wanted to say that I think because it's going to take a long time for things to kind of correct themselves. And I think we also need to be thinking outside of the box, so to speak. So the example that I always use is the trajectory of my career.

Judy Guzman-Cottrill: [00:14:27] So about ten years ago, I literally quit my job as the director of infection control and hospital EPI, because my goals were completely misaligned with the hospital administrator's goals. And I just said, you know what? I can't work for you anymore. But I love infection control. I love hospital epi. And I was quitting the job that I loved. So I took this huge, crazy risk and I started my own business as an infection prevention consultant. And I tell you, looking back now, this was the best thing I could have done for myself and for my career. This is actually how I found my way to become a public health person. And my tagline for the past decade is I have one foot in the hospital and one foot in public health. It has served me so well. Just like I'm sure. Mati, you, you know, being in your role and also still being at Wash U. I mean, you know, these types of outside the box ways of doing our work, I think are important. And when I think about outbreaks that are going to happen and how our public health infrastructure is dismantled. How are critical access and community hospitals going to respond to outbreaks and exposures when they can no longer rely on their public health partners? What about schools, colleges? All these places are going to need someone to help with their response plan. So for listeners who are ID docs, who are epidemiologists, public health workers, there's ways that you can do this, quote unquote, outside of the box, like I'm saying. And so anybody can contact me, I can help you do that. Because again, we need to create an army really, really quick.

Mati Hlatshwayo Davis: [00:15:57] I would say we have one I have two fearless leaders with me. This podcast is transformative. It is honesty. It is truth to power I will leave our listeners with this. Even in the hardest times. I stand by two things. Impact is local and we can still control our sphere of influence. I made the decision to leave academic medicine four years ago. I have led the Department of Health for the City of Saint Louis through a pandemic, multiple tornadoes, floods, measles, and now this moment. Each of us, from whatever platform we're in, are equipped for this. Let's lead with compassion. Let us listen and hear people. We have built trust before we can do it again. I am concerned, deeply concerned, but remain hopeful. Thank you both so much. We will see you next time.

John Brooks: [00:16:53] Thanks, Mati.

Judy Guzman-Cottrill: [00:16:54] Thanks so much for having us. Yeah, we'll get through this.