From Darkness to Opportunity: Reimagining the Future of Public Health

Host Mati Hlatshwayo Davis, MD, MPH, FIDSA, and former CDC director Demetre Daskalakis MD, MPH, explore the current state of public health. They discuss how political pressures and weakened infrastructure have left the system vulnerable, and how this moment could spark a public health “renaissance."

Transcript

Mati Hlatshwayo Davis: [00:00:14] Hello and welcome to Let's Talk ID. I'm Doctor Mati Hlatshwayo Davis, recently stepped down as director of health for the City of Saint Louis and a current member of the IDSA board of directors. I am beside myself because joining me today is my spirit animal. I just can't say enough. I think when I first met him, I told him he was the Beyonce of ID week when we first met. And guess what? It still holds true today. Joining me today is Dr. Demetre Daskalakis to reflect on infectious diseases, public health, trust and equity, amongst other things. And honestly, whatever else he wants to reflect on at this pivotal moment in our field. Very briefly, Dr. Daskalakis is widely recognized for his national leadership in HIV and sexual health, and for his service in public health leadership roles. Over his career, he's worked at the intersection of clinical care, community engagement, and health policy. He has led major national efforts in HIV prevention, vaccine strategy, and harm reduction, and most recently served as the deputy coordinator of the White House National Mpox Response and as director of the Division of HIV Prevention at the CDC. His work has consistently, consistently centered on equity, inclusion, and a deep commitment to the communities most affected by infectious diseases. We are honored to have you here, my friend. Thank you for joining us.

Demetre Daskalakis: [00:01:46] Thank you. It's my honor to be here with you, Mati.

Mati Hlatshwayo Davis: [00:01:48] So to begin, I'd like to step back in time before moving into the challenges of the present. You have been a leader at the intersection of HIV medicine, LGBTQ+ health and public health for many, many years. Looking back, what moments or experiences most shaped your understanding of how infectious diseases and social justice are linked?

Demetre Daskalakis: [00:02:14] Such a difficult question to pick one moment. I feel like my answer is when I was doing HIV testing at bathhouses in New York City. Some of the encounters that I've had with people in that testing room that really sort of showed to me where sort of risk and stigma intersect, and how it creates the perfect environment for infectious diseases to fester. It's not like some big moment, like being at the White House or some big moment at CDC or at the New York City Department of Health. But just the most influential thing was being in the room and meeting someone who I remember saying to me, I can't get tested for HIV because I'm not from this country and I'm scared. I go here because I don't want anyone to know that I am gay or have sex with men. And just to see, you know, how stigma interplays with infection in a way that reminds me of one of my sort of infectious disease life mentors, which was Dr. Bob Moellering, who was the chief of medicine at Beth Israel Deaconess when I was there. And one of the things that he said that made me answer your question the way that I did about being some of those interactions with men at the bathhouse, getting tested for HIV, was that Dr. Moellering taught me that axiom of infectious diseases, locus Minoris resistentiae, the site of least resistance. And I remember him teaching that it's not just, you know, the place in the body where the infection seeds, but it's also the place in society where the infection seeds to, you know, honor that memory of that important learning from him. I can't say that it's something big, like in some big venue, but it's the sort of small moments with the patient in a room where I was like, I'm giving you a service, I'm teaching you about your HIV status. And it's important because I'm not bringing the stigma that's blocked you in other places.

Mati Hlatshwayo Davis: [00:04:17] Honestly, it shows in the way that you show up. I love that answer because we see you on national stages now. I just think there's very few leaders that are touching people, but more importantly, that can make that link between our field and real people in society, right. And you do that so well. It makes sense to me, now that I hear you go back in time talking about the fact that for you, it started with real people in real community. And I always say, if we do not continue to ask the question, how do we compel a person to take one pill, one vaccine, one X. Despite the billions of dollars we spend on research, what are we doing it for?

Demetre Daskalakis: [00:04:57] Yeah. You know, people say to me a lot, you're a really good communicator. I just find it so weird because telling a doctor that they're good communicator, when all that I actually do is talk to, like, audiences the same way I talk to my patient. It's just second nature. You know, just part of what I do. And so I think it's really interesting that, you know, for me, like when I think about my big moments, like, I can totally talk about some of the things that I've done that have been pretty visible. But in terms of the things that have been inspiring. I mean, I can give you stories from when I was doing my oncology rotation, not even an ID, where I learned this valuable lesson from a bone marrow transplant. Attending Dr. Joyce at Beth Israel Deaconess Medical Center. Shout out if you're listening, but I don't think you listen to ID podcasts. But I remember in the HIV space, like the moment of seeing a really sick BMT patient and going, wow, this is a lot like a really sick AIDS patient. And I remember her saying to like our cohort of residents that were rotating through OMD, which is what it was called at Beth Israel Deaconess when I was a resident. You see the patient and you're looking at them from your lofty height down, and I'm looking at them from like where I've seen the darkness up. And so, like, you're seeing this BMT patient is, like challenging. Why are we doing another BMT? Why are we doing all this? And I see hope there. And what you see is like no hope. And so I always feel like those are the moments like that's the stuff that's influenced me. Like in terms of how I approach the work that I do. It's not so much an accolade or, you know, having to go up against a politician.

Mati Hlatshwayo Davis: [00:06:27] I will say to you, though, as much as I love the humility behind, this is just what I do. I would counter a little bit and say that communication is an expertise and you are an expert. And I think that if we were more serious about that, especially in academia, instead of calling it what I feel like I was gaslit a lot with, which is a soft skill.

Demetre Daskalakis: [00:06:47] Oh no. Totally not.

Mati Hlatshwayo Davis: [00:06:47] Some of the hardest times like Covid and the things that I think we're reflecting on now may not be where they are. You are truly an expert. And I think we need to see more of that expertise and model it. Which is why I'm so grateful that you do put that, because it can be a draining thing to give so much of yourself. The way that you communicate is not just abstract. It's very personal as well. Right? And you don't owe us that, although we're very grateful. But it is an expertise.

Demetre Daskalakis: [00:07:12] I mean, so I 100% agree with you, but I think that it's an expertise that physicians need to have. So I feel like that's mainly less undercutting, like my ability to communicate and more making the point that the energy that we have when we sort of, you know, do those infectious disease histories of our patients that every other person fails to get the information, but because we can connect with the patient, we all of a sudden like learn something. And that tends to be the linchpin that gives you the diagnosis. Like that's like the same skill when you're talking to like a room full of folks trying to sort of say to them what real data are around, you know, antiretroviral therapy, antiretrovirals for prevention, or like, you know, Covid vaccines. It's the same skill.

Mati Hlatshwayo Davis: [00:07:53] Okay, so I mean, Captain Obvious here, but we are living through a time of deep mistrust in institutions and these growing political attacks on public health or the very intentional dismantling of public health. From your perspective, how has this erosion of trust evolved in recent years, and what did you observe from within the CDC about how that climate affects our ability to respond to infectious diseases, threats?

Demetre Daskalakis: [00:08:21] Yeah, I think that's a really it's going to be a long answer. I think that there are things that definitely public health did wrong. People in infectious diseases. And I sort of think back to what it was like during the beginning of the Covid pandemic, when I was the incident manager in New York City during the very beginning.

Mati Hlatshwayo Davis: [00:08:37] God bless you.

Demetre Daskalakis: [00:08:38] Yeah. No, I, you know, January 2020 through November 2020, I was the "incident commander" is what they called them in New York City, the incident commander for Covid 19. And I remember there was this moment where people who were policymakers, like politicians, like people in that world, were asking us as scientists to be more absolute in our statements so that we could create more trust. It felt better for us to not put the confidence interval around what we had to say, but rather to be more absolute. You know, whether it's, you know, Covid vaccine prevents infection, period. Whether it's masks prevent this period. Like I think what happened is, you know, public health those lives sort of like below as like the connective tissue of so much of what happens in health care. And like, no one ever thinks about the connective tissue. Think of like the big organs. You don't think about the connective tissue, but like really that connective tissue is the blood that pumps through the entire organism. But you don't really think about it. And so, you know, I think what happened there is that, you know, public health all of a sudden became really visible. I was on a podcast with folks from the MAHA movement, and they had this really interesting moment where they were like, I never even thought about the federal government or public health. It was always invisible. And then Covid.

Demetre Daskalakis: [00:09:54] And so all of a sudden you're elevated and then, you know, we're used to sort of saying, well, you know, this is a model and there's all this uncertainty about it. And, you know, the number is six, but the confidence interval is between 2 and 10. And so it's the kind of thing that we're used to talking about. But that's not how the folks that wanted to do the talking points and speak publicly wanted you to talk. And I think that, you know, having to respond to sort of that environment, I think that people became pretty comfortable being more absolute in some of the words that they said, which meant that that sort of aspect of risk communication wasn't done adequately. And I think that the result of that is that people can say, you didn't tell the truth. And also science changes. Science changes at a pace and social media moves faster than that. And also the receipts. My favorite thing is the receipts where people say, look, on March 2nd, you said this, and then on October 5th, you said that.

Mati Hlatshwayo Davis: [00:10:51] Yeah.

Demetre Daskalakis: [00:10:52] And it's like what you said on March 2nd must be a lie, because science changes at a tempo that's different than the speed of the medium that is now being used to transmit it. You know, that's part of where the trust gap began, which is that we didn't do great with risk communication. We could have done better. And now there's this accelerated fashion of getting information where it's moving faster than the speed of science and faster than the speed of normal scientific communication. So that's what I think really started it. You know, the trust gap, I think, means that you lose large swaths of the population, like there are people who are in the movable middle about things that you're going to work on, and you can impact those. But there are people who are, you know, of the school that they either think everything is whatever they say we're going to do, or I'm never going to do any of that. And I think that, you know, the doubt that has been created, that trust gap means that our people in the middle are getting a little bit smaller, and the people at the edges are getting louder. Not that much bigger, but way louder because of the trust gap.

Mati Hlatshwayo Davis: [00:11:57] I feel so affirmed.

Demetre Daskalakis: [00:11:59] [laughs] Um, that's what I'm here for.

Mati Hlatshwayo Davis: [00:12:01] I feel so affirmed. And, you know, when I was leading efforts on behalf of Saint Louis's Health Department, I think that the feedback we got was similar. But I will also say that a lot of us leaders, leaders who had to enforce things like I had to announce the first case of Omicron, I had to announce shutting down schools for X amount of time. Right. Things that I would never really willfully say is a great idea.

Demetre Daskalakis: [00:12:28] Totally.

Mati Hlatshwayo Davis: [00:12:28] But I do think that maybe there isn't as much of an appreciation for the abundance of caution during times of uncertainty.

Demetre Daskalakis: [00:12:34] Right.

Mati Hlatshwayo Davis: [00:12:35] We should have pivoted faster. But I will never apologize for the abundance of caution when dealing with population health and with the most vulnerable amongst us. Again, we did not pivot fast enough in the beautiful way that you said that I'm not even going to try to reproduce. Our risk communication was inadequate, right?

Demetre Daskalakis: [00:12:55] Yeah, I mean, I think that, you know, when you don't have Marty Blazer, one of my career role models, used to say to me when he was the chief of medicine in New York City, NYU. "Do you know what an expert is?" And I would look at him and I was like, I mean, someone who studies deeply in a topic and is able to discuss it and, you know, produces science around it or something like that. And he goes, no, an expert is someone who's able to make decisions with imperfect data. And so I would add one more line to that. Somebody who is able to make decisions with imperfect data and communicate why. And I think that when he said that to me in 2000 something and something that was probably right. I think in this era, it's not only I'm making this decision with imperfect data, but I'm telling you why I'm making it and the fact that my data could change. And so I think that that is an important piece of that experience. I mean, I have seen, you have seen, guaranteed people who are experts, who are paralyzed because of the lack of perfect information. And then what happens is that then the person who's really the expert, just like communication, not only in the micro piece but in the macro piece, is the one who's able to say, we have to make this hard decision with limited data. And I think that during the pandemic, there were hard decisions made with limited data, it was communicated with great certainty.

Mati Hlatshwayo Davis: [00:14:19] My spicy, hot take to round this out, though, is that not everybody should be at the mic. And I'm going to say this, I think sometimes we've rewarded in academia and ivory towers, those who have done incredible work, who are so well published and highly awarded, not necessarily need to be at the mic. This is not a soft skill as I heard throughout my career and was gaslit. This is, like we said, an area of expertise. Some people. It's also an IT factor that not everybody has and that's not fair. But you know what? I don't get to just traipse into labs and pick up pipettes and play with people's mice. Not everybody gets to be on the mic. That's my hot take.

Demetre Daskalakis: [00:14:54] Yeah. I mean, I think that that's right. And I also think one of the important things about, you know, being a leader in public health medicine, infectious diseases is also knowing how to use your experts. And that, I think, is, by the way, not to transition too much to the future. But when you have people who don't know anything and also don't listen to experts, this is the pickle that you're in today. So on the flip side, I mean, like I'm going to talk about my career for a second, which is I am an HIV doctor who trained in infectious diseases. I love ID, my identity was I am the HIV person. My career didn't do that. So I was pulled into disease control in New York City, where I was over all of the infectious disease sort of portfolio in New York. Like, what did I know really about Legionella? What did I really know? I read the book. I saw the movie. But that's about it, you know? Then all of a sudden, I was supervising very smart people who I did something crazy, I listened to them. And I learned. And, you know, after my, like, 20th legionella outbreak, after my 20th legionella outbreak, you know, I can out Legionella anybody. I know what happens. I know, like, what the cooling towers do. I know what the testing is like. I know what it means, and I know, like, what the interventions are like. I eventually was able to help guide policy because I listened to my experts, and I read and I listen. And many of those experts would I put them on the mic? Absolutely not. But some of them don't want to be on the mic. They want to brief their leader and they get their satisfaction out of a well briefing a leader who then is able to sort of speak in great detail because of the level of expertise they have at base. So I agree with you. Not everyone needs to be on the mic, but the person on the mic  best listen to the people that know all the things.

Mati Hlatshwayo Davis: [00:16:55] Best listen. It is bi directional. My frustration is sometimes I don't think we've done a great job of modeling that in our academic centers. I think actually we do a better job of that in the formal public health space and federal space. But if we're going to raise the next generation of leaders, it made my job really hard in a city to have to deal with the divide between academia and public health, the lack of bidirectionality. And quite frankly, we don't have time for it in an outbreak. And so what I've seen you do so well is exactly what you described, right? We all know that you're not the expert in all the things, but when you came to the mic, you came to the mic with your expertise, with the humility and having listened to your experts building that infrastructure and then being able to relay it in a way that the public could understand. It's going to take us years and years and years and years and years to build back. I believe that's going to happen on the ground and we need to model that bidirectionally.

Demetre Daskalakis: [00:17:43] Yeah, no, I agree. Yeah, I agree. Respect the experts, but also respect the experts in communicating.

Mati Hlatshwayo Davis: [00:17:49] So how do you think federal, state and local leaders can protect public health infrastructure and maintain this commitment to equity, when budgets are actively shrinking, priorities are actively not just shifting, but being eliminated? I have a follow up, but let's start there, because that's a loaded question in itself.

Demetre Daskalakis: [00:18:06] I think it's at the beginning of this is in our current environment, I think that it's going to be hard to do everything that we want to do. And so I think that that's like step one, which is like in a universe where there will be shrinking resources, we're going to really have to pick our battles. And that, I think, is something that people in medicine and academia and public health don't want to hear. I think that people in government are sort of more attuned to what it's like when you have to reprioritize and, you know, really not do some of the things that you think are important, not because they're not important, but because you have to do something that's more important. So I think that that's number one is that we're in it together, and that there has to be a clear sort of strategy for prioritization. Scary part is you're not going to get a lot of convincing information or convincing guidance from the federal government on the staff level, you will, as long as they're allowed to do it. But I do think that the onus of responsibility for a lot of this is going to shift to like the state, like substate level for many of the things that are happening. And so the other part is, your question was equity. I think that where you need to shift your language to be in compliance to ideology. Don't stop doing what you're actually doing.

Mati Hlatshwayo Davis: [00:19:22] Can I just say-

Demetre Daskalakis: [00:19:23] That's hard.

Mati Hlatshwayo Davis: [00:19:24] How hard that is.

Demetre Daskalakis: [00:19:25] It is.

Mati Hlatshwayo Davis: [00:19:25] But I so appreciate it. And I want the audience to pay attention. I gave this man one question, and out of an abundance of respect, and because it is who he is as a leader, he answered the question and he literally saved equity for its own. At a time where there's such a strong anti DEI sentiment, where this is personal for me because I'm watching literally my life's work and the communities that I come from being eradicated, I just really thank you for that. But it's hard, right?

Demetre Daskalakis: [00:19:53] It is.

Mati Hlatshwayo Davis: [00:19:53] Because I'll tell you that when I was going through my five stages of grief, you know, you sit on these boards or you sit on these collaboratives and people are like, okay, we got to start erasing words. And I was furious.

Demetre Daskalakis: [00:20:02] It's really hard.

Mati Hlatshwayo Davis: [00:20:02] And I thought it showed cowardice. And I wanted to leave those areas like. But then I had to grow up. Right. Because I realized that there has to be a means to an end approach. And I hate saying that. I'm going to tell you with every fiber of my being. But there has to be a strategy that says we can do the work whilst being in compliance. But what I think is important and that I'll ask you, is how do you let the communities that are under attack, the folks like me, who it's really hard to sit in a meeting and hear that we're scrubbing words that really define either you or your life's work.

Demetre Daskalakis: [00:20:36] Totally.

Mati Hlatshwayo Davis: [00:20:37] And that doesn't really build a trust in saying that you're going to do the work. But you said it and you said it so well. And once I got through my first three stages of grief with this [laughs] once I got through rage, that's what I've been telling folks. Can you talk a little bit more about that? But I wanted to thank you for centering equity and not trying to just package it or ignore it in the answer.

Demetre Daskalakis: [00:20:56] Yeah, I think, you know, it's because, you know, one of the things that I'm, first of all, a little like soliloquy on equity, one of my observations in dealing sort of at a pretty high level with what's happening in public health on the federal level, is that, um, there is a purposeful confounding of DEI with health equity.

Mati Hlatshwayo Davis: [00:21:16] Heavy on the confounding.

Demetre Daskalakis: [00:21:18] And it's not an accident. It is done on purpose. Right. So that there is the ideology of like in our hiring, there's like a desire to remove some of the things that we have traditionally looked at to create a more equitable work environment. You know, do things so that our workforce reflects more the people that we serve. My opinion is clear on that. Like, I think that that is a really important piece of what you do to sort of create a workforce. But that's not what I'm talking about right now. What I'm talking about is there is an effort to confound health equity with a mind frame around how to recruit jobs. And it is done on purpose because it's been put together into one mass, really, because there is a desire to not support people who are unlike the ideal that this administration is looking toward. And so, like, I wasn't shy in my resignation letter about my sort of belief that there is like a purposeful effort to ignore the weak and to erase people. Right? And by weak, I mean people who aren't advantaged to the same way that the people that, you know are surrounding some of our leaders now.

Demetre Daskalakis: [00:22:31] I think that there is a purposeful desire to confound a sort of work program with health equity so that poor people can be hurt. That's what's liberating about not being in the government right now, is that I'm calling that exactly as I saw it. Like I will never forget, like listening to the last Advisory Committee on Immunization Practices meeting where they were talking about the birth dose of hepatitis B vaccine. And someone out of their mouth on that committee said, this isn't a big deal for people from normal families. And I'm like, since when? Since when is public health about some weird, idealized normal family? Equity is about making sure that everyone has the best shot that they can get to achieving their most optimal health. That has nothing to do with DEI. That's not what they're saying. They're confounding it. The CDC website has a thing about DEI, and they use that to swallow up health equity and erase all of the work.

Mati Hlatshwayo Davis: [00:23:33] It's a purposeful branding.

Demetre Daskalakis: [00:23:35] Yeah.

Mati Hlatshwayo Davis: [00:23:35] And it does so much harm. But I appreciate you being honest about what is required to continue the work. That we can do the work. And I will say, as someone who does the work, that doesn't mean it's easy.

Demetre Daskalakis: [00:23:46] No, no.

Mati Hlatshwayo Davis: [00:23:47] Right. It's very painful. I mean, I'm on a very purposeful sabbatical right now. It's been really interesting bumping into people. Their minds sometimes cannot compute. Right. [laughs]

Demetre Daskalakis: [00:23:57] Oh, I understand. [laughs]

Mati Hlatshwayo Davis: [00:24:00] Those conversations have been interesting. But this is the work. And I think leaders like you are look to say it out loud so that we can accept that and move to doing the work.

Demetre Daskalakis: [00:24:10] Yeah. If I'm able to give people permission to focus on mission and less the words to keep the mission going, so be it. It stinks. We're so used to being able to say that I want all of my, especially in sort of the HIV universe. Like we want everyone to feel like they're seen and heard in the work that we do. It's an emergency right now. So if we can't make them feel seen and heard, we at least need to make them feel as protected as we can.

Mati Hlatshwayo Davis: [00:24:40] All right, let's talk about morale and purpose.

Demetre Daskalakis: [00:24:44] [laughs] It's great. I don't know what you're talking about. Everyone's fine.

Mati Hlatshwayo Davis: [00:24:50] [laughs] So, as impossible as a question as this is, how do we sustain morale and purpose when the work feels politicized and unsafe? And what personal practices or values have helped you stay grounded in your mission?

Demetre Daskalakis: [00:25:05] Yeah. So this is really, I think, two things or maybe more than two, but I'll start with two, which is that. And you answered the question by the last part of your question, which is you have to be grounded in the mission. One of the things that I have learned, which I think I've said before in a couple different ways, places that I've been, is that public health and frankly, infectious disease response. And response, I mean, broadly, right. Like, you know, the work that you do in a clinic, the work that you do in the hospital, doing consult. I call that all response because my brain's a public health brain. And so the three components of pillars that hold up response are implementable science, like something that you can do, political will and community co-creation. And right now all of those things are frankly, under attack, like they're trying to contaminate science with ideology. The political will is not to build. The political will is to destroy. Right. So there is no political will to lift up. And so that's what people are lamenting because their science is being contaminated by ideology or people are trying to. It's not succeeding and may succeed in veneer, but not in the depth. Political will is not one of sort of sustaining its of destroying. And then frankly, then the community isn't able to co-create because it's being attacked. And so first you have to say, I'm going to do the same thing to the folks that I work with and my environment that I do with my patients. And what do you do with your patients? It's called trauma informed care. You're right. All of this is happening. We're not making it up. This is a traumatizing period in the life of infectious diseases and a traumatizing period in the life of public health. So the first step there is have to acknowledge. The second thing is, in my opinion, we really like our institutions in public health and infectious diseases, right? I loved the CDC. In order to succeed here, we need to practice detachment towards institution so we can have more attachment to mission.

Mati Hlatshwayo Davis: [00:27:08] That's a hot take, my friend.

Demetre Daskalakis: [00:27:09] It is.

Mati Hlatshwayo Davis: [00:27:10] Not everybody's ready to receive that.

Demetre Daskalakis: [00:27:12] Well, it's been given. That is the answer. Like which is that, and I was talking to Mike Osterholm about this because I think he's doing something really interesting right now. You know, someone came up and asked him, like by creating sort of an alternative, like are you not feeding exactly into sort of what the mission is of the people who want to destroy public health? You know, he had a really eloquent answer. And then I followed up and said, listen, sometimes you need to lean in to the people who are trying to destroy you. And as they're destroying, take the opportunity to create. And so the thing that's going to come out the other end of this is not going to be the thing that we had before. I believe that what's happening with the state and local jurisdictions, what's happening sort of in environments like CIDRAP and the other things, the Vaccine Integrity Project and sort of the work to make sure that, like HIV funding doesn't go away. Is that like the community, right, it's the only thing that's left. There's no political will, and science is being compromised. The community is building its blueprint for when the pendulum swings and when the pendulum swings, we're not going to rebuild public health and infectious disease is to what it was like before. We're going to build it to where it needs to be in the future.

Demetre Daskalakis: [00:28:31] I'm just going to give one more image for people's heads, like think about the Dark Ages. So there was a classical period. So you had like marble columns. Then you have like the Dark Ages, which was like leeches and sadness and plague. Right. And then you have like the Renaissance that's like, you know, Da Vinci's Sistine Chapel, right? The Sistine Chapel has nothing to do with the Acropolis, right? It's something new, right? There's inspiration. But the thing that comes the other side of the Dark Age, you shouldn't try to rebuild the time before the Dark Age, because that is the reason that the Dark Age was able to come. And so that's what I think. I really do think that, like, the point of this is going to be that, you know, rather than trying to lament an institution like, oh, it's really sad that CDC is falling apart. The political will isn't for it to stay together. That political will is pretty strong. So we should be focusing on like the mission, which is to get ready for the Renaissance.

Mati Hlatshwayo Davis: [00:29:28] You better preach. So I'm going out of order of questions because they were doing great. There's no way to stick on script when you have Demetre, babe. But guess what, I came ready. I'm drinking my water. Okay?

Demetre Daskalakis: [00:29:39] I'm caffeinated.

Mati Hlatshwayo Davis: [00:29:40] I'm built for this.

Demetre Daskalakis: [00:29:40] It's going great.

Mati Hlatshwayo Davis: [00:29:41] I have had the opportunity to speak with a lot of the people that look up to you, that worked alongside you. We are right now in Atlanta, and I want to take the time to just on the mic, publicly show love and support to those who were in your city and you are literally not getting paid. And I hope you're getting a measure of community and being here with us during this time. Having said that, I've heard over and over and over again from them how much your resignation meant. And I'll be honest, I was kind of pissed on your behalf because people romanticizing trauma is something that I'm very familiar with.

Demetre Daskalakis: [00:30:20] [laughs] Yeah. 

Mati Hlatshwayo Davis: [00:30:20] Do you know what I mean? And so I'm quick to check people sometimes and being like, so what we're not going to do is romanticize my trauma, but let's call it what it is, and let's talk about the positive.

Demetre Daskalakis: [00:30:29] Sure.

Mati Hlatshwayo Davis: [00:30:29] So the first thing I said to you when I saw you last night is, I'm sorry and thank you. I think both things for me were important to acknowledge. You mean a lot to them. There isn't one that I've met who wasn't inspired by, who didn't understand why, but they had a question, a singular question that resonated. And that question was you left, how do we stay? And I think it's the follow up question to what you just said, because they're going to hear you talk about the fact that the CDC may not even come out the way it is in the future. So to me, I mean, are you saying like, what's the point in them staying then? Are they supposed to burn it down? Are they all supposed to walk? What is your message, your advice to them?

Demetre Daskalakis: [00:31:07] So first of all, I'll say one of the things when I was a director at CDC. So first of all, the people at CDC are amazing. Let me say that in a different way. The careers at CDC are amazing. I have a different opinion about the politicals. You know, it is a group of people that actually have no public health expertise that are running the premier public health agency for the country. I'm sure they're wonderful at hedge funds and battery companies, but they're not so good at public health. That was a read. So when I was there, I ordered online, yellow ribbons, and I distributed them to all of the center directors at CDC because our staff was being held hostage. So we know that. And everybody outside needs to know that the people on the inside from CDC, the folks that you loved, are still the people that you should love. They're working really, really hard in an environment that is discounting their relevance and their expertise. Staying is resistance as much as leaving. It is important to sustain yourself when you stay. Also important to decide where is the line. Some people may not find it. Some people may not be pushed in a direction where there's a reason to find it. Is it frustrating that your science isn't able to shine as brightly? Absolutely. But you have to do what's right for you.

Demetre Daskalakis: [00:32:34] And for me as my example like I went through some serious moments, you know, change the vitamin A guidance. So it's not about supportive therapy, but about treatment and prevention of measles. I held the line. It wasn't just me. Deb Houry. Everyone at CDC loves her, too. We held the line. Didn't do it. Add drugs that had no evidence to treat measles onto the list of drugs to treat. Held the line. We're able to do that. Mitigated the disastrous change in the Covid vaccine schedule as best we could. Held the line. My line was when I felt that there was no way to prevent ideology from being the only thing that ruled those space I was working in, which was vaccines. When I saw that there was no way to stay, I left. I knew my line already. I had already decided what my line was. And so staying there as much resistance as leaving, taking care of yourself. This is really important. Self-care is resistance. Don't forget what our lovely, lovely head of OMB said. He said, I want to make it so miserable to work in the federal government that every day that federal workers come in, it's going to be traumatic. How do you address trauma? Self-care. Care for yourself. CDC people really like to be over and above. It may be okay not to be over and above.

Demetre Daskalakis: [00:33:57] Do your job. Take care of yourself. Identify what your line is and if you're starting to feel like your line is coming. Think about your exit strategy. And this is important. Like permission to apply for jobs and to talk to people, to network, to make sure that you're ready when that moment comes. If it comes, it may never come. You know, I think that what's happening with CDC, you know, is USAID in slow motion. Things may happen. There may be more reductions in force. There may be more lawsuits that reverse the reductions in force. All of that can happen. And you have to also decide, is there a moment where, like the trauma, the risk that the benefit and pain ratio of the trauma is such that I don't need to be there anymore or shouldn't be there anymore? Or am I being asked to do something that is unethical or illegal, or something that I don't feel comfortable doing from the scientific perspective? Otherwise, just being there, even if all you do is keep lifting up your science and everyone ignores you. You have the paper trail that you've lifted up your science, right? And you can always say they made terrible decisions about X, Y, or Z. They didn't let this go out. Eventually the pendulum will swing. These will be pieces of information that will be known. And so staying there is just as much resistance as leaving.

Mati Hlatshwayo Davis: [00:35:15] The brilliance in your advice is that it's not just for CDC. I hope the trainees, the young faculty members, really anyone in medicine is listening. Gone are the days that the adage of you are stronger and you are better if you are consistent in stay. I'm so happy for people for whom that's the path that wasn't my path. And I've been wildly successful, and I think it took time to really understand. I take pride in the fact that I've role modeled how to get the dream job, or the new job, or build the pathway. I take pride that I role modeled how to do it well. I think my resignation was a huge point of pride.

Demetre Daskalakis: [00:35:53] Totally.

Mati Hlatshwayo Davis: [00:35:53] It was a different message, especially for my community. Right? The misogynoir that I started to watch unfold in this country from a national level, all the way down. Rest is resistance. Rest is strategic.

Demetre Daskalakis: [00:36:05] 100%.

Mati Hlatshwayo Davis: [00:36:06] Rest is also earned. And so I take us seriously the lesson in stepping down. And again, my reason for stepping down is multifaceted, but the portion of it that I genuinely am so proud of, and that I just came from Flavors of ID, where young trainees came to meet people from different sectors, and they all wanted to know, well, why did you step down and what are you doing? And I said, and I'm resting. And that was the period, right. And rest is resistance. Right. But rest is strategic too.

Demetre Daskalakis: [00:36:35] 100%. I mean, I go back to what I just said. I mean, like they're trying to attack the public health workforce. They're trying to make it weaker, they're trying to make it more vulnerable. And they're also trying to reduce interest in this area. It is a concerted effort. So every time that people used to see me go away for like a week or two days, whatever it was and say, I'm sorry, I'm not going to be on email, like talk to my deputy. People were like, this is really important that you're like making sure everyone knows that you're doing it. I think it's 100% right that the way to address trauma is self-care.

Mati Hlatshwayo Davis: [00:37:14] Yeah.

Demetre Daskalakis: [00:37:14] And like we are living through a significant trauma to our area that we love.

Mati Hlatshwayo Davis: [00:37:21] But the clarity of your message is not just rest as a part of leaving that this is your advice for staying.

Demetre Daskalakis: [00:37:28] Yeah.

Mati Hlatshwayo Davis: [00:37:28] And I've always said to people that there are multiple vantage points from which to have impact and to fight. There are people who do it from within, and there are people who do it from without. And I just love that your message centers both and affirms the very people who look up to you, who are so grateful for your leadership at the CDC, that there is a pathway from within and from without, but that you were clear in empowering them with that exit strategy if they so needed. Thank you for that.

Demetre Daskalakis: [00:37:56] I've got to just add one more thing, which is that everybody, whether they know it or not, is mentoring the people around them. And so I took that very seriously in my everyday work and also in my departure. You know, standing up for me was really important in showing that you could be brave. Show some moral courage in the wake of, I guess, whatever the opposite of immoral cowardice, is what I think I'm seeing, sort of from the halls of power. But yeah, I mean, I think that, you know, showing that you are taking care of yourself to the people around you, especially in this environment, gives them permission to take care of themselves. And that is an act of resistance, like it is an act of resistance-

Mati Hlatshwayo Davis: [00:38:39] An act of courage and an act of strength.

Demetre Daskalakis: [00:38:41] I agree.

Mati Hlatshwayo Davis: [00:38:42] Yeah. So my last question before I hand the mic over for you, for your last message and your last words, we get stopped in the grocery store, you and I, we get stopped in hallways. People want to know what's the answer? How do we fix this? How do we get better? So it would be disingenuous of me not to ask the ridiculous, but the question that's on everybody's mind. I'll couch it this way. If you were advising the next CDC slash or insert federal public health leadership team, what would be your top priorities to rebuild trust, strengthen the infectious diseases workforce and ensure that equity remains a central guiding value. You've touched on a lot of it today, but how do we wrap that up for folks?

Demetre Daskalakis: [00:39:23] Yeah, it is the impossible question. I kind of go back to what I started with, which is the people who are currently destroying public health and thinking that they may have a path forward in terms of how they may want to rebuild it, actually have no experience in large organizations or knowing how to do any work in those spaces. They're like, you know, breaking things that they don't really understand, thinking that if you break things up into little pieces and then throw it up in the air, it's going to land somewhere, and how it lands is how you're going to develop it. So that's not how you do this. So if I were giving advice to the next universe of trying to create this, I would go back to what I said at the beginning, which is you need to not focus on legacy institution. You need to focus on mission and design around mission.

Demetre Daskalakis: [00:40:07] CDC was built to respond to malaria in the South. So let's not forget. That's why it was built. It was not built by the South saying like, you know, let's build it up to create like a way to a strategy to address malaria. It was, they said, go down to the south and address malaria, discuss. And so what I would advise is take the destruction as an opportunity for creation. Like what does the state need? What does the jurisdiction need? What do the people need? What are the silos that we've had for years that we don't want to have anymore? That we can change because these other people that don't know anything have destroyed things. So I think that that's my advice. It would be like, don't try to recreate the past, don't build the Parthenon again, make the Sistine Chapel, do the Renaissance. Don't go back to see what the classic is, the Dark Age. It allowed for the Dark Age. So I would say like really think about like, who are your shareholders? Who does CDC serve? Who does public health serve? Who does infectious disease serve? That's where you start.

Mati Hlatshwayo Davis: [00:41:10] Can you do that in the absence of money? If all the money is being stripped away and the infrastructure is going. Can you do that?

Demetre Daskalakis: [00:41:15] I think that the answer is you have to do it as a seed to be able to do the next thing. So even if it's not perfect, even if it's, Mati, I'm going to go from like happy there for a second to just like not so happy. There is no way, given the destruction that we've seen or that we are currently living, that there will not be people who will be hurt. There will be health impacts on people. We should try to not have that happen, but I just don't think that it's possible. While this is happening, even if it's imperfect, the things that we're starting to seed by the ground up are going to be the things that become the blueprint for the future. Is the thing that's going to come from the ground up this month, going to be the thing that fixes it all? No, but one of those things is going to blossom into the next thing, and what's going to happen is it'll be funded some crazy way. Someone's gonna, like, throw together money from here and money from there to do the imperfect thing. A little foundation money, a little industry money, a little bit, who knows? And then it's going to be a model that seems to work. And then when the government loses their irrational desire to destroy and their authoritarians and eugenics strategies like the next swing of the pendulum will be, wow, this is a great idea, and this is what people need on the ground, so let's actually fund it to build it. So it's like these moments of ground level creation that are going to be the platform for the next CDC, the next HHS, the next sort of future of infectious diseases.

Mati Hlatshwayo Davis: [00:42:48] Y'all can't see me, but I'm over here silent clapping, silent snapping. Because I can't ask this question of everyone, but I can with you. Okay, this has been incredible. You get the last word because you are the reason we're here today. Anything you want to sign out with? Anything you haven't had the chance to say. The mic is yours.

Demetre Daskalakis: [00:43:09] Thank you. Don't give up. I think that's the main message. It's don't give up. Is it going to be easy? No. Are terrible things happening? Well, maybe terrible things happen. Unfortunately, yes. As we sit here in IDWeek, the one thing that the people who are destroying public health and infectious disease hate are experts who come together and get power. Sitting here in IDWeek, being surrounded by experts. This is their Kryptonite. Don't forget this is their Kryptonite. Any human who tries to put a wedge between their clinician and the patient are humans that should not be trusted. This is where the power is. And the power sometimes is in your clinic, one on one with your patient. But it's also in being engaged with folks that are your colleagues because they're Kryptonite, are people who know things and who understand data and science and who come together and say no. In Greek history, there is a moment where there was a leader. Little Greece was being attacked by a big place. That leader just stood up and said, "Ochi," which means no, there's a day that celebrates it called Ochi Day. All you have to do is say no with authority. Sometimes you'll win, sometimes you'll lose. In this environment, surrounded by all this brainpower and all of this vision, this is the Kryptonite that is going to undo all of the bad that's been started.

Mati Hlatshwayo Davis: [00:44:46] Thank you, my friend. This has been let's Talk ID, I've been Mati Hlatshwayo Davis and it has been a pleasure. Thank you so much.

Demetre Daskalakis: [00:44:54] Thank you.