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Transcript:
Dr. Nahid Bhadelia:
Thanks guys for coming out. It’s definitely not August weather. But we appreciate all of you being here for the incredible stage for this incredible event, and some of the public health leaders who are leading voices within the infectious disease space. So, welcome to our hybrid event. This is Reflecting on One Year of MPOX Response. My name is Nahid Bhadelia and I an infectious disease physician at Boston Medical Center and I am the founding director of the Center for Emerging Infectious Diseases Policy & Research, which we call “CEID” for short because I had the brilliant idea of giving it such a long name. We're really thrilled to have you all here because one of the reasons that for hosting this event is that generally the end of a pandemic that we look at lessons for the next emergency. Over the last year mpox has become a pandemic within a pandemic. Even as cases get easier, globally the disease still continues to circulate at low levels. The purpose of today's event is looking at best practices to learn from the mpox response to apply to future infectious disease outbreaks, which are sure to surge given that we’ve seen an increase in climate change and changes to global populations. We need to identify the lessons learned and current gaps. Before I introduce our speakers, let me take a moment to tell you a bit about us. The BU Center for Emerging Infectious Diseases Policy & Research is a university-wide center that focuses on global health security. We focus on linking technical knowledge with policy decisions and how we can apply best evidence, affecting effective responses to infectious disease outbreaks. Out core mission is to build resilience against threats of emerging and epidemic, infectious diseases, worldwide, multidisciplinary public health and policy research global and local capacities, strengthening training and evidence generation, and community engagement. We represent nine BU schools. We have faculty, many of them are here actually today, nine BU schools and colleges, as well as external and international affiliates bringing in expertise from clinical, infectious diseases in that corner, virology - I see John Connor in the back corner there - epidemiology, data sciences, communications, law and global health policy. You can find out more about us on our website, including how to connect with us and how to support our work. Today's event is cosponsored by the Hariri Institute for Computing and Computational Science & Engineering part of a series of events under our collaborative and NSF grant generating predictive intelligence for pandemic preparedness on how we can improve our responses by predicting what might come next by knowing ourselves, our pasts, and our systems better. Among other things, we want to thank Hariri for hosting us in this wonderful CDS building. This new state of the art space features advanced ventilation and filtration including an open-air patio which you will see to the right of you once the reception starts. I also want to acknowledge some stakeholders in the audience today. Particularly, I want to thank BU President Freeman and Vice Provost Dr. Waters for your ongoing support and leadership here. I want to thank Commissioner Robbie Goldstein, who himself was part of the mpox response from the CDC side last year. It was a pleasure working with him, and now finally meeting him in person. Assistant Commissioner Fukuda, who I'm not sure has joined us yet. Our colleagues at BPCH, legislative offices including Representative Bill Driscoll, who's joining us. I want to thank you for your continued service for improving our health and safety here in the state of Massachusetts.
Let me introduce the event itself. We'll have opening remarks, and then about an hour of moderated panel, followed by Q&A that we’ll take both from in the room and on Zoom as well. The reception will then follow. These doors will open up, and the reception will be on the patio and next door. And now to what you've all been waiting for, which is really our distinguished guests. I'm not going to give them their entire bios, because if I did, I'd be taking over the entire. I'm just going to tell you that their full bios are on our website, and I'm going to give you just the briefest portion of what they've done in the last… combined I'm guessing a century of experience together.
Dr. Ashish Jha, who will be providing the opening remarks is the Dean of the Brown School of Public Health, and has been a Dean there since 2020. He’s a longtime leader on pandemic preparedness and response has led national and international analysis of key issues, including Ebola and COVID. He advises local and federal policymakers as well as private and public stakeholders. And until last month, as you know, he was also the White House COVID Response Coordinator under the Biden administration.
After that we're going to start the panel where we're going to feature a couple of my colleagues from the White House COVID Response team and Mpox Response team. Dr. Demetre Daskalakis, who is an infectious diseases physician, who until, well still - he's going to tell us about his new role - serves as the Deputy Coordinator of the White House National Mpox Response. Prior to his appointment, he served as the Director of Division of HIV Prevention at CDC, as the Deputy Commissioner for the Division of Disease Control, and Assistant Commissioner for the Bureau of HIV the New York City Health Department of Health and Mental Hygiene. He's focused his entire career on prevention and treatment of HIV and STIs as an activist physician with a focus on LGBTQ communities. And as we've just heard earlier today, once in a while helping face down pandemics.
Dr. Nikki Romanik is the chief of staff at the new White House Office of Pandemic Preparedness and Response Policy. A medically trained policy and partnerships professional, she has nearly fifteen years of experience, engaging with private sector partners, including as roles as the senior policy adviser, the White House ,technical expert at WHO, and multiple positions at CDC.
Céline Gounder who's an internationally renowned internist, infectious disease, specialist epidemiologist, CBS News medical contributor, fellow senior fellow and editor at large at the Public Health Kaiser Family Fund Health News. She is also a clinical associate professor of medicine and infectious diseases at New York University's Grossman School of Medicine, and, like me, she's actually a veteran of the West African Ebola response. A small thing you may not know about her. Additionally, she produces two public health sponsors podcasts, one of which just won a very big award. We're going to hear about shortly, American Diagnosis and Epidemic.
And last, but very much not the least, Ms. Adrianna Boulin is the Director of Community Impact and Engagement at Fenway Health, a local community health center focusing on providing healthcare for LGBTQIA+ people, BIPOC individuals, and other underserved communities. She also serves as the president of the Boston Pride for the People. She holds a Master's of Public Health from Northeastern University, and is interested in understanding and addressing issues at the intersection of social justice and health equity. As a peace and justice studies major, somebody after my own heart.
So, why don't I have Dr. Jha up to give his opening remarks, and then we'll have the rest of the panel. Thank you so much.
Dr. Ashish Jha:
Good afternoon, everybody. You can all hear me okay? Fantastic. Thank you, Nahid. And this is a super exciting afternoon and panel discussion. So, what I'm going to do is frame out high-level remarks thinking about mpox and thinking about mpox in the context of pandemic that we have with COVID. So, exactly fifteen months ago today, we go back fifteen months to May 17th, 2023. The first mpox case of the current outbreak in the United States was identified in Massachusetts, just down the down the street. That was the first case. Within two months we were at about 3,500 cases, which is a massive underestimate because of our inability to get testing going in the way that it really needed. We were missing a lot of cases. I remember on August 1st, exactly year and sixteen days ago, we hit 600 cases in one day. And on August 2nd, the cavalry arrived. Bob Fenton and Demetre Daskalakis arrived at the White House to run the mpox response. And here we are fifteen months or a year later, and we're going talk a little bit about what happened. How did we get from 600 cases a day to where we are now? And what I was asked to reflect on is, what are the lessons from COVID response that might have helped shape some of the mpox [response]?
So, I have six things that we learned. There are hundreds of lessons from COVID, right? So, I am not going to list all hundreds of them. But I'm going to pick six things that I think were really important for COVID that I think also, were really important mpox. And then we can talk about others.
So, the first is building a great, empowered team. Everybody talks about having a great team. So, what does that actually mean? So, first is the “empowered.” Having a team at the White House has a lot of value in signaling the importance of a response. And that symbolism also motivates and galvanizes the federal government in a way that is very, very hard to replicate. That team has to have deep expertise and not just deep expertise in the science of mpox and of public health, which Dr. Daskalakis had in large quantities, but also expertise in making the federal government run. And that was something. Bob Fenton had in enormous amounts. So, you want a team with broad expertise that can bring different things to bear. And then you want a team that's action-oriented. And this is a really important thing because analysis and all this stuff can slow things down. You want a team that is focused on getting stuff done. And this is where Dr. Nikki Romanik was unbelievably important as an addition. I often say that when Nikki has made a decision that she wants to get something done, you should not stand in her way. It will not turn out well for you. Having people like that who are focused on being effective and getting things accomplished is extremely important. So that, I think, is lesson one. If it's really important, you’ve got to have a well-empowered, expert team that can bring us a broad set of expertice to the problem.
The second is something that you all know, and I'm sure you'll will hear a lot more about which is focusing on trust, building trust with communities that are most affected. There are lots of ways of doing that. Having trusted voices, trusted messengers like Dr. Daskalakis, like Demetre, who has had a longstanding set of activities and engagement, and is deeply trusted in the community that was most affected by mpox. But it's also about leveraging the stakeholders and advocates. You know, what's interesting is often those stakeholders and advocates are actually initially are going to be quite critical. And it is very tempting when you're inside the White House to see them as the enemy, and it is always wrong to do that. And one of the things that Demetre and Bob and Nikki did extraordinarily well is took people who were being critical of the administration and took that energy and leveraged it action and for getting people moving.
The third is in some ways for me something that I've thought a lot about throughout the whole pandemic, which is the idea of applying scientific thinking. Let me explain what I mean by this. We all know the phrase, “follow the science,” which at this point has come to mean lots of different things to lots of different people. And often the science is unsettled, especially in a fast-moving pandemic or a fast-moving outbreak. The science isn't clear, the data isn't all in. But you’ve got to act. And their scientific thinking, applying what you know from other contexts, comes critically important. I think about the decision, one of the most consequential decisions that was made early in Demetre and Bob's tenure was the decision to switch from subcutaneous to intradermal vaccines. It actually totally changed our vaccine capabilities. It was a high stakes decision. And if you said, “Well, what's the evidence behind it?” There was one study from 2014. Is that a science-based decision? Well, there's one study. There was a lot of scientific thinking that went into it. I remember the amount of validation we did, the number of experts we called trying to think through “What do we know about intradermal vaccination?” “Why do we think this is going to work or not work?” So, you often hear things like, “well, what's the evidence behind this?” There are times when you don't have enough evidence. It would be great if we had large, randomized trials to guide us, but you often don't have that luxury. Applying scientific thinking. Applying knowledge from other areas can be extraordinarily helpful.
Lesson number 4 is the importance of using existing resources. So, when you get a new outbreak, by definition, it's not in your budget line. There's no budget that says “deal with mpox” because none of us, when the budgets were put in two years before, no one had thought we'd be dealing with it. It's always tempting to say, “well, let's just go back to Congress and get more money. And sometimes Congress is compliant. But you may be shocked to hear that Congress is not always perfectly responsive to the needs, the public health needs, of the Americans. And then you have two choices. You can say, “Well, if Congress hasn't given us any money, we're not gonna do anything.” That is a totally unacceptable choice. Or you say, “What resources do we have and how do we leverage that?” And what we found in the mpox response was leveraging COVID dollars, leveraging the incredible infrastructure that our country has of taking care of people with HIV. Because a lot of the populations affected by mpox are similar populations - men who have sex with men. And being able to use that infrastructure, that capability turned out to be extraordinarily helpful.
Two more quick ones, and I'll wrap up. Lesson number five I sort of think of, and it's a phrase that that Ron Klain often used, which is the phrase of “run past the tape,” meaning there is a temptation in the White House, there's a temptation in Washington to declare mission accomplished, to say, “We’re done. We've got this thing under control. Let's go out and celebrate.” You’ve got to fight that temptation. That, by the way, was a temptation. There was a lot of Congressional pressure back last April and last May of 2022 to do that with COVID, to end the public health emergency in April of 2022. To say, “It's over. We're done. Let's move on.” But the administration chose not only to fight that, but to actually choose a new COVID coordinator at that time. There were a lot of people when I showed up in Washington who were very skeptical that the country even needed one. But it is really important to continue the fight even as cases decline, as infections declines. First of all, viruses can surprise you. A lull can then turn into a raging fire. And second, there is important work to do, even as cases decline. I remember the same pressure in December of ‘22, with mpox. As cases declined, clearly we were in a better spot. There was a lot of pressure to say the public health emergencies going to be ending soon. I think it ended at the end of January. There's a lot of pressure to say, “let's just end mpox response in the White House.” We fought that temptation because there was important work to do. We knew that if we didn't get that work done, we could see another flare this summer.
By the way, everybody predicted another flare this summer. It didn’t happen. Why? Because these guys were on the job and prevented it. So that is really important.
Last, but not least, is building for the long run. You know there is a temptation to like, deal with the response. Run past the tape, get it all finished, done. Every one of these things gives us an opportunity. They're better for future ones. It's just an opportunity to make sure that if the virus makes a comeback, we are ready. That often means things like building up stockpiles. Regularizing people use the term commercialization, which is a term I personally hate. But turning vaccines into something that become more regularly available. The JYNNEOS vaccine has been really available only under the context of the mpox emergency. Making sure it's more widely available over time is very important like we try to do with the COVID vaccine. The bottom line is we want to regularize this for the long run. Because while mpox is in a much better place and while COVID is still in a much better place, none of us think we'll never see a flare. None of us think this thing is over. It will always be in the rear. So, having a long-term plan is really critical. So, let me just finish up by saying, you know, look, this has been obviously an extraordinarily hard three and a half years for our country. Mpox arrived right in the middle of the BA.5 wave that was happening with COVID. It reminds you that the lessons from one outbreak and one pandemic quite effectively to others. There's a whole series of things that Bob and Demetre and Nikki did to get the country to where they did. From my vantage point, there's a few specific things. All three of them, by the way, were very involved in the COVID response. It's not a coincidence. And the lessons from those responses, I think, were very helpful in shaping their response with mpox. With that, let me stop there and turn it over.
NB: This reminds me why I spent so many afternoons in Ashish’s office trying to get wisdom from him when I when I was there. Could I have the panelists come up and join us on stage?
So, I'm going to start with a very easy one. Ready? I'm going to ask the same question to all of you. What has been the major public health lesson you've learned from the mpox so far in your work?
Dr. Nikki Romanik:
I think the key takeaways for me during the mpox response: trust with the community is probably number one. I’d say community engagement. It was actually one of our main lines. I think because we made that a priority from day one - and I can't take credit for that because I came on around I think day fourteen. But because it was top priority and I think we were transparent. We were direct, and we had clear communication often as possible. I see some of the community that are now friends of mine because we talked to them so much. It’s pretty amazing. We also started a unique group: and equity mpox workshop. And it was the place where we got that's knowledge fastest because it's on-the-ground information. That workshop was specifically with a BIPOC group. And they told us their opinions, the good, the bad, the ugly, the criticisms, the recommendations. We decided if we're going to have this workshop, we should listen to them. So, a lot of the things that we did that were outside the box were recommendations that the network thought up. This guy over here did more videos than I think I've ever seen anybody do. Those questions came from that workshop. So, they were truly from people who needed a clear and concise answer what was going on. Outside of the box vaccines. We can't expect somebody to go into a health clinic that is stigmatizing to go get vaccinated, so bring vaccine to the person. So, our response focused on giving vaccines in vans and sex clubs and Pride events and sex parties, very unique venues. We're there reaching the people. And also, I think the community became part of our team. I remember one day we were sitting in our office. It was just the two of us next to each other in the same office.
Dr. Demetre Daskalakis: For a year.
NR: For a year, by the way.
NB: People probably think that the mpox response team has this big suite. It’s one office, two offices?
NR: Yeah, two.
DD: We called it a suite.
NR: I just remember one day I looked at Demetre as I got off the phone with this amazing, amazing advocate. I looked at him and I said, “You know this community is a part of our team. They are the extra person.” We had an extra desk at the time. They were the extra person. I also think that building on, as Ashish just mentioned, building on existing infrastructures and flexible funding was key to moving this response rapidly. If we would have waited for supplemental funding, we would still be waiting, unfortunately. So, having the ingenious and innovative idea of leveraging funding that already exists from multiple different buckets and engaging with multiple different agencies throughout US government, including HUD, I think that that was probably huge key takeaway, and that can be used in any response. And I think the last thing: endurance. By far, the game is not over because the cases are lower. The game is over when there's no longer one.
NB: Accurate! So, community engagement, trust, taking the lessons you actually are hearing from community, leveraging innovative ways to use existing programs. What would you add to that?
Dr. Demetre Daskalakis:
So, I I'm going to add one piece on the community just because it's so important, which is in all of public health, whether you're responding to an acute or more chronic threat, there's an important frame of mind that you need, which is that your community is not the object of your work. They're the vehicle of it, right? This goes back to saying, and then I'll go into another topic, but just that that really the community was a principal teammate. And I think, as Dr. Jha said, you know the friction at the beginning. The louder someone criticizes you, the more important it is that they have a place at the table. And so that was like, that's not a lesson. And this is where I transitioned into my real point. It's not a lesson that's new. It is a lesson that that I think most acutely played out in the HIV story. And this is just not only looking at the lessons of the COVID pandemic, but also looking at the lessons of the HIV pandemic and saying meaningful community engagement doesn't just mean listening. It means also accountability, because what I think Nikki didn't say is when we heard from the community what we needed to do, the other thing that we did was show that this is what you told us and then come back and tell you what we did or what we couldn't do, or why we couldn't do it. And that really created trust to the point that you know literally it was one team. But I want to go into this idea of leveraging HIV and the leveraging of resources. So, I think there's a term that we use very often, especially in the HIV, STI, Tb, and viral hepatitis space. That's “syndemic”. Who's heard the term syndemic? Okay, so a syndemic is interacting epidemics, in this scenario infectious, that are made worse by social scenarios, social consequences. So mpox, the lesson is that we actually saw in real time a new infection- new to us, not to the rest of the world, but a new infection to us- enter a syndemic. So, it entered the syndemic of HIV and STIs. So, what we saw was, instead, before September, before the first publication there was a clear interaction between HIV and mpox, where there seemed to be potentially more cases among people living with HIV. In fact, 41% of the cases of mpox happened in people living with HIV- and with more severity. So, what do you do with that data? Do you sit and say, “Oh, look! There's an interaction,” or do you do what this team did in its all of government approach and – I’m looking at Robbie Goldstein and saying, “Thank you for this,” - and say, “How can we look at our system? That sort of addresses our community, people living with HIV or those who are at risk. And how can we leverage that to make it better?” So, early on when that data came out, the first thing that we did was say, “Hey, what we need to do is create flexibilities in Ryan White funding as well as in CDC’s STI & HIV prevention funding to address this emerging syndemic.” The next thing is we have the interacting infections. The next part is we have the social determinants. Soon thereafter it was clear that people with the worst outcomes of this infection were people who were mainly black and who were homeless. And so how do you then activate additional resources? And so - I think Nikki sort of foreshadowed this - what we did was when we saw the data and the data coming out, we didn't just say, “Oh, now we're going to report on the data.” But the day that the MMWR came out that said that homelessness was a signal. We activated HUD to come up with funding flexibilities. So, there's a so what? So - I think Dr. Jha sort of mentioned this already - that it's like about how do you take data to public health action and do it in a nimble way? And this is sort of where I think the lesson of why it's important to have a view outside of agency and on the White House level was so important because you don't have that same view from looking up into the big picture. But if you are sort of in this aerial view looking down, you're able to say, “We really need to have housing flexibilities because this is an issue.” And then we got mental health flexibilities as well. So, SAMHSA came to the table. We were able to sort of expand that. So, for drug user health - because we know that that that sometimes folks who aren't connected to HIV care also use substances and have mental health issues - what if we use that? And what's even more important, is like the people who had the worst outcomes were people living with HIV, who had T-cells that were less than 50. That's their T-cells, not their viral load. So, very late-stage disease and had never been on medicines and had never been vaccinated. So, though there were flexibilities built into Ryan White and CDC funding, those people didn't touch CDC and Ryan White funding. They touched SAMHSA for substance user health and they touched housing.
So, it's really sort of saying, if you have a syndemic problem, here's a lesson. If you have a syndemic problem, you need to model a syndemic response, right? So, it can't just be siloed infectious disease responding. It needs to be “How can we really look at what we're actually seeing in the data, and who this affects.” Community as principal partner, so that we can address it and all the domains the best we can. We still didn't do perfectly right. We still had people who died. Forty-six people died of mpox in the US. Almost all of them were living were living with HIV, many undiagnosed, T-cells less than 50. And so, it just also highlights the need. And this is my last thing, and I think Dr. Jha really framed this well, as did Nikki, which is that HIV, that the infectious disease infrastructure keeping that system warm means that you're ready to deal with something when it heats up. Right? If that system isn't warm, if I didn't have that HIV system, where would we have been, right? If we didn't activate that network, if we didn't activate the community that we had, if we didn't say, “Build this on the spine of something that's successful.” And so when you're looking at things like sort of giant funding cuts to HIV that people are discussing now, red alert because the lesson is that we're not going to have that infrastructure to be able to respond to the next thing. So those are my two.
NB: I love that. You know, you talked about syndemics, but also this idea of vulnerabilities that are common across the board that are going to put folks at risk. And it's interesting because that's the same lesson from COVID. And actually, if you step back is the same lesson from the Ebola virus disease, all outbreaks, which is that inequalities that exist at baseline are basically augmented. They're accentuated, they are worsened, and those are usually the folks that find themselves without access to the resources that need. So over to you, Adrianna, and the work that you've done is so much related to this. So, we'd love to hear that.
Adrianna Boulin:
Absolutely, and I love all that has been said leading up to this. And so, I will refer back to what I've heard. But approaches and interventions cannot truly be successful unless experiences like racism and stigma and other marginalized experiences are addressed. It’s super important, and something that we saw needed to be put at the forefront of our efforts and the term racial equity lens is used, and I appreciate that. And also it needs to be like laser focused, we need LASIK racial equity. We need to understand. That's a thing we need to understand. What stigma exists where it comes from how to work with it. It comes from family history. To address it, it requires education where things can be processed and broke down and time to do that is valuable, and that needs to be seen as valid, and having that as part of our process in addressing how to make services more accessible, and how to scale up care, such as vaccination is really, really important. Something else I want to mention, too, is also you mentioned partners as principal partners, and I appreciated that framing. It reminded me of connecting with one of our community partners saying, “Hey, we're thinking of doing this webinar. You might be a part of it.” And what I how I entered the of the conversation was, you know, “Here's what's going on with mpox. Have you heard of it? What do you think about it?” “Yeah, I heard of it! We're planning a webinar. We've reached out to the city of Boston,” and if I had entered that conversation like, “I know what you're going to do. And this how you're going to be involved,” it might have disempowered them, and we actually collaborated on the webinar that they themselves were planning as a partner instead of stepping in like, “we know everything.” And so, it's so important to make space for the table that already might be built, that you actually are asking to join, or the table that you're building for everyone to be a part of and there was one other thing that I wanted to mention, too, about accessibility and approachability. I think a lot of focus was put on accessibility and the importance of accessibility, and allowing folks to connect to the care and scale up what we need to do. But approachability is something different accessibility. A while ago, Demetre, when you described what syndemic was, that I could see, make made this presentation, and receiving it and understanding it so much more accessible for folks. And you talking about how you were partners, and when you were actually a part of the team makes individuals feel more approachable that you can approach, and they feel empowered. If individuals don't feel empowered, they're never going to see that they are a part of the team. We're all on the team. We all bring information to what we're doing, and it needs to be presented that way, because sometimes, whether we intend or not, we enter spaces as the expert. We are the experts in our field, but so is the community, and we are the community as well. And so, I could go on and on. But those were some major key lessons that came out of not just mpox. I saw that with COVID, and we're seeing, you know folks who are marginalized are even further marginalized if these things aren't addressed.
NB: Yeah, and to your point about accessibility and approachability, Céline, you have this dual view. You communicate with patients in the space of a doctor's office, and you communicate
with everybody, particularly with your role in CBS and elsewhere and throughout the COVID pandemic. What are your lessons from the last year or so of mpox.
Dr. Céline Gounder:
Yeah. So, there's an expression- I think this goes back to the management literature in maybe the 1960s or 70s- of wicked problems. Now, wicked problems are not just messy problems. The messy problems are intersectoral required all of government response and pandemics, for example. But a wicked problem is beyond that. Some of the characteristics of this are that we frame what is the problem that needs to be solved differently? All of us in this room might actually say, what is the problem with respect to HIV or COVID or mpox, we might be relatively on the same page. But that doesn't mean everyone beyond public health is going to agree on what is the problem. And the solutions are not necessarily right or wrong. Very often they're bad and less bad. And so how do you in that environment make decisions about how to prioritize and decide among solutions is relates to what Ashish was saying earlier. “Follow the science.” Well, “follow the science” does not help you solve around a wicked problem. It's a piece of it, but it's not all of it. And a key piece of it is really having functioning democratic institutions and social capital. And social capital, I think, was particularly important in the case of the LGBTQ community in HIV and in mpox and helping to solve both of those wicked problems. And I think, unfortunately, in the context of COVID, we did not have that same kind of social capital.
NB: It's a like, I said, mpox is a pandemic within a pandemic. But I want to open up a lens a little bit more. Nikki, you spent, you know, almost decade, I think - seven or something years, right - in CDC Director's office. And then after that, before you took the mpox position, you were with WHO and there, I'm guessing you dealt with a lot of the global aspects of this as you did with the mpox position here at the White House. Can you speak a little bit more about the strides that we've made in our global response to mpox? Because this disease the pandemic and has been affecting global communities for a really long time. Of course, before it became a pandemic we didn't have all the scientific advances. And now that we have that, what does that mean? Moving forward for the global response.
NR: Oh, I would have to say - so I was actually in Geneva when the White House team was stood up. So, I was very lucky, because I got to know the WHO team that was actually running mpox at the time. At the time it was called monkeypox, of course. And then I was plucked back here, by this guy, to join the White House response and leave my job at WHO early.
DD: You’re welcome.
NR: So, because I built those relationships, I got to see how they were sending up their response. And then I came here, and I got to see how we were standing up ours. And I have to tell you we were all standing up our global response really too slow. I think that is the one lesson that I would learn and actually change in the future is standing up the global response quicker. That was the one thing that I would've done a little differently. But I also watched how WHO was handling it. And in the beginning they were also a little bit like a fish out of water. They got their stuff together a little bit faster than we did, and I think it took us a few weeks, and they were trying to figure out how they could do risk communication with the entire world, which I can't even imagine how hard that is. And I think that was one of their biggest challenges is that they didn't know how to have appropriate risk communication to all the different countries. But one thing that was a huge benefit that came out of it was I came back here, and I kept very close relationships with all those folks. And in our mpox equity workshop, we learned very quickly that a Black trans woman refused to get the mpox vaccine because of the stigma felt because of the word monkeypox. And that kind of opened up the doors of you start paying attention and realizing, “wait a minute, this is a huge issue. I mean, this is inhibiting. This is a barrier to vaccinating.” And I was lucky enough to still have all those communications and contacts. And over a 3- or 4-month period daily, I would say I would, be WhatsApping with my friends at WHO, checking on their processes and their systems, and I think that they changed that name faster than anything because once they found out that it was actually inhibiting. we moved on as as quickly as they possibly could, which was pretty incredible and wonderful to watch and support.
NB: I'm going to ask you slightly different question, Demetre. Still, speaking about the stigma the, you know, the knowledge from our communities and that is your experience with HIV. You spoke about HIV and the responses. But what I want to specifically talk about is the experience of gay men ,who this pandemic disproportionately affected. And you were once quoted by NPR - and this is related to COVID, but I think you'd agree this probably applies to mpox as well - as saying gay men's relationship to public health has been tempered by fire because of HIV. It is a community that believes in science and public health stepping up to the plate. How did the gay community’s experience with HIV and their relationship with the public health infrastructure and the medical community effect how they responded to the mpox pandemic and how that played out?
DD: I’ll comment of the “tempered by fire” because I think there’s another Covid example that I think is really good and I was in the middle of that one too, although probably not as overtly known. So the relationship that gay, bisexual, other men who have sex with men have with public health, whether they know it from their own experience historically or through the sort of cultural experience through the lens of HIV, is one that really, as I said, was tempered by fire, because it wasn't good at the beginning with HIV, like it was about neglect it was about, you know, not really engaging with the community. Not being clear about giving guidance on how to stay safe because of the fear of actually sort of having conversations about taboo issues. There's taboo only to public help, but not to gay, bisexual, and other men who have sex with men. So, the sort of lesson from the HIV playbook was to say, “What did we do wrong with gay bisexual, or men who have sex with men in 1981 that we're not going to replay?” It's called trauma informed care, and one of the pieces of trauma informed care is, do not re-traumatize, right? You have to - cannot do – that. And so, when mpox started to percolate up, we had a lot of interaction like with folks from that from that community and we got lots of disparate messaging like “you need to get up and say this is a gay disease,” which we refuse to do because that's what happened in 1981. I always say, like think about for those of you who like lived through that time, or those of you who know the history. It only took one person to say “gay-related immunodeficiency” to create forty-one years of trauma. And so, we elected that the way that we were going to do it was the way that we talk about HIV, and that's based on our interaction with so many gay men, and the response that they expected, which is, “tell us how this transmits. Tell us what we can do to stay safe as best that you know. And then let us magnify this message louder. Right? So, I think Dr. Jha called me a trusted messenger to some - but not to all. So, like thinking about like, how can we get like transgender women, people of color, who are trusted messengers to sort of magnify this message. And so, the easy way to go is to say, “mpox is a gay disease,” and then you've done your message and created the trauma. The harder way to go is to say, “this is how mpox is transmitted and how you can keep yourself safe.” And now I have to do 800 engagements with the entire world so that they transmit the information in a way that's trustworthy in the network that matters. So that's really what the lesson is. And so that the example I was going to give common friend of ours is sort of the trust that's been built with public health that was born out of mistrust and anger, was the story of as we sit in Massachusetts, the [Covid] Delta outbreak in in Provincetown. Céline's going to help me. So literally, I was on, II was working vaccine task force. And our common, friend Michael Donnelly said, “Hey Demetre, a bunch of my friends who were in P-town, who are all who are vaccinated, are coming back with COVID.” And because Michael is who he is, he had it on a spreadsheet with all their information and said, “What do I do?” And so, we help figure out the way to connect to – Hi, Dawn [Fukuda, Mass. DPH Assistant Commissioner] - connect to Department of Health in Massachusetts. And literally he forwarded that spreadsheet. And what happened was people came out of the woodwork and said, “Me, too! Me, too. Me, too. Me, too!” And data was obtained, viral sequences were obtained, information came together. A great epi story was developed and that changed guidance. And so, this is the same the same population that felt that they had to hide from public health, historically were stepping up. And so this is the thing that you leverage the heck out of, right? You'd like sort of use that and we did to say, you know, this is a community driven response. So, if you're our principal partner, you got to step up and drive it. So, it's bi-directional. And so that, I think, is a lesson from gay, bisexual, and other men who have sex with men.
NB: I'm going to take a slightly different frame. Adrianna, you're the President of Boston Pride for the People, an organization that works on empowering the LGBTQIA+ community and working on it. I wanted to take that lens of how particular communities experience the same pandemic in different ways. As you know, there has been a large racial and ethnic disparity both in mpox incidents as well as vaccination. Fenway, and the work that Boston Pride for People have done has worked to try to erase some of those inequalities and inequities. What are some of the interventions that you found specifically for those disparities?
AB: The biggest thing has been partnering with those principal partners. I think about for Fenway Health, when we were thinking about, “okay, what do we do in our response?” So outside of like clinically and updating staff on the workflows, etc. Internally or externally, we developed social media infographics. We also had infographics that were provided that we were sharing with different stakeholders and we also planned webinars that we I mentioned before. We collaborated with other folks, and also was showing up where people already were. The whole like, “If you build it, they will come”? Well, not when people have places to be!
DD: Can I get that on a t-shirt?
AB: We just showed up where people were. So last year we were that Boston Black Pride, Boston Urban Pride. We were there this year at the Boston Pride for the People event. We collaborated with the Department of Public Health, the different health institutions that were doing health screenings. Fenway Health was at Boston Pride for the People, too. There were two or three organizations giving mpox and COVID-19 vaccinations, and people were there and lined up, and I had colleagues saying, “Girl, there were so many people coming to the table, and so many people asking questions, and everyone just felt comfortable.” And it was “Hey, I got one. I'm going to go get my friend.” And it just created this culture of feeling comfortable with approaching public health part of the response and feeling like they were doing their part by being vaccinated.
NB: Yeah, that's powerful. And I was going to say, a huge part of it is how Fenway Health has had a long of communicating with people across different subsections of communities that are vulnerable as well.
NB: You've had a different perspective, Céline. Both in the position as a public health researcher. You've also been, as I mentioned, at the forefront of public health communication. I'm hoping that you can tell me… You were in this pandemic response for COVID. You know, you were an advisor of White House. I think you've done, you know, work both as a clinician, but the communications part has been one of the hardest aspects, at least for COVID. What were some of the lessons from COVID that you applied for your communication for MPOX? What were the similarities and differences in how you found it for communicating that specifically at the national media level, because it's a very different approach trying to communicate to folks who may not see themselves at risk, compared to communities who are at risk where you're approaching and trying to. How do we make stakeholders with a larger community?
CG: It's really interesting. Early in the pandemic I was approached by a literary agent about writing a book. I said, “No, I have too much on my plate. I have something else going on.” But what she had tried to sell me on was this idea of “COVID's going to be the great equalizer. We're all in this. We're all at risk.” And this might have been March or April 2020, and even at that time I said, “No, no, you clearly have no idea about anything about public health. This is not how it's going to play out.” And I also said, “Yeah, I don't think we're like the right fit. You clearly don't get what I'm about.” I think that is very challenging. I think the focus on mpox for a moment. You know, stigma can really cut multiple ways. The trauma that Demetre alluded to. It also can cause us to think, overthink sometimes, or how we frame things. We're so concerned about the stigma that we're not clear in our message, that we filter ourselves. And I think that's on top of a very prudish culture when it comes to sex in the US. As an example, I spent 10 minutes on set before going on to talk about mpox. And we were debating, could I say “private parts” on national television. Okay? And what they really wanted me to talk about was, “Well, let's just focus on the towels in the locker rooms.” I mean, look, this is a sexually transmissible disease. Most of it was sexually transmitted. Yes, there are other mechanisms of transmission. But I think you do need to be clear about how it's transmitted so that people can protect themselves. And this is where it becomes challenging. Because, yes, you know, when you go on national television they really just want you to talk about what the middle of the road average person wants to hear about and that very much comes down to a soccer mom perspective. So, upper-middle-class, suburban, white mother. And that really does get in the way of effective public health communication, because very often those who are really at high risk are not that population. And so how do you bridge the two without creating excessive fear for people and be stigmatizing exactly is very challenging like right now, in this moment. We're going to have boosters coming out late September or early October. We'll see what the eligibility criteria are. Who are the people who most need it most? That's very clear, you know. By and large, who’s ending up in the hospital now? People over 75. It's people who have not been vaccinated, and, you know, are immunocompromised, and so on. And there's this desire to have this message for everybody, because then everybody's interested. But is that who most needs your message? And how do you balance it, I think, is very challenging.
NB: Yeah, I'm going to speak about a different type of stakeholders. I'm going to talk about our government stakeholders, Nikki, you've been in the federal government for a really long time. And I'm going to actually combine what I was going to ask you both together, because I think they apply. Most people in this room may not have a clear idea of how a pandemic response plays out at the White House level, and how the White House communicates and works with the interagency. How did you find what’s happened with the mpox response. And how do you think that that's going to be different with the new Office of Pandemic Preparedness and Response? You must have heard me say this. She is now the new chief of staff for the new White House, COVID White House, Office of Pandemic Preparedness and Response, and so great hopes that this office is going to bring change to that. But let's start with how it is now and how you see that changing?
NR: So currently when an outbreak happens, or there’s a pandemic, there's immediate action, and there are a number of agencies that want to stand up and get ready, and it can be hard to identify a leader, which is why many times there are people like Bob and Demetre coordinators or czars or like Dr. Jha over there. They're brought in to help clarify rules and responsibilities. I would say - and I think that that's probably one of the reasons why OPPR is standing up - there are many reasons, but one of the reasons is so that we do not have to keep on bringing in a specific coordinator. But instead, we can help identify the leads beforehand and things move significantly faster. I think there needs to be deep interagency coordination from the beginning. It's vital to a response. And all agencies, no matter the agency, have a role in deep subject matter in the emergency response into a pandemic as far as stakeholders go. I think people don't realize that they can reach out to the White House. And we want you to want you to reach out to the White House often and engage with us. It's not just about the intergovernmental agencies. It's about everybody. I think that many times people just think that they can't do it. There are things that they can bring that you just wouldn't even think. In the mpox response specifically, the HIV advocates were our most trusted messengers by far. When the epicurve dropped and vaccine administration plummeted - around the exact same time - they were the ones who we activated. And they told anyone and everyone need to get vaccinated – two doses. I mean, it was everywhere. We also activated CFARs, academic CFARs. And they did research that we identified gaps in. They were like our secret research society, if you will. But those are two groups that you wouldn't ever thought would end up becoming the strongest leaders in this response, and neither one of them are for work for any government. With OPPR, which I'm very excited about - day nine. Little bit of little bit of pressure. Our mission is pretty clear I'm working with Major General, Paul Friedrichs, who is an incredible man and a surgeon. We have kind of a mission. We have an aligned mission. We want to walk in, and we want to clearly state the roles and responsibilities. So that there's not really a question moving forward of is the lead where and how everyone can work together? We, before an outbreak, we want to have protocols in place. And, more importantly, we want interagency to actually have relationships with each other all of the interagency. Not just HHS. We want it across the entire interagency. We want people to actually have deep, trusted relationships when they're not in an emergency. There were a lot of relationships created during COVID, and even more in mpox and Ebola. And any outbreak that's ever happened that could potentially have ever come to America. Relationships have been built, but it's always been in a response. What if those agencies actually had relationships outside of a response? If those people were friends outside of a response? I know, it seems a little idealistic, but it can happen at our agency. It can happen. I can get anybody in a room and make them like each other. I can. It's a goal of mine always. It is one of our goals. It's going to take time, but it's one of the things we want to do. We also want to build back America's trust in public health. Another lofty goal, I know. The United States government needs to speak clearly, transparently, and with one voice. When it comes to an outbreak or a pandemic, people are scared so we need to have very clear communication as early on as we possibly can and it needs to be the same communication and it needs to be honest. So you know, they're a little bit of lofty goals. But I think we can do it.
NB: That's awesome. I'm going to switch gears a little bit. Demetre, you are at a research university and some of the early conversations that you and I had on mpox response were about remaining scientific or what we needed to do, what scientific questions needed to be answered for us to have an effective mpox response. Some of those were answered over the last year. What do you think are still the scientific unknowns that we need to still figure out for the mpox disease?
DD: I think that are a lot. I think there are a couple of unknowns. So, I’ll start with our favorite. [Inaudible. Mic cut out.] I urge the scientists to develop a test for syphilis. Then a clinician could take a swab of a person’s lesion and determine if it’s syphilis or if it’s mpox. We’re in the middle of a syphilis epidemic in the United States, with genital syphilis going off the chains right now. [Inaudible.] If we had multi-test diagnostics, we might have known about mpox earlier. [Inaudible.] With vaccines, we have good data on these vaccines, so we need to look at all of the science that hasn’t been resolved yet. [Inaudible.] We had a need to look at how well this vaccine works based on how you’re giving it, intradermally or subcutaneously. [Inaudible.] How to build confidence in our biological understanding [inaudible.] So I’ll say, I think with HIV [inaudible.] So a look back at the confidence [inaudible.] We know how to end HIV because we have the resources and people who are willing to use them. Same with vaccines. [Inaudible.] We’re actually using very rigorous methodology so that we can change our intervention and also the way that we deliver it. [Inaudible.] As you said, “If you build it, they will come,” doesn’t work.
NB: Because they have places to be!
DD: So bring it to the people.
NB: Maybe we can get you a-
DD: Can you hear me now?
NB: Can you guys hear in the room? Okay, hold on one second. I’ve got a better idea.
DD: Sorry about that. I thought I was loud enough to be heard on the internet, jeez.
NB: That is louder!
DD: That's sure is. And then so just saying again, we have to understand how to deliver our services. And we really need to understand by using rigorous methodology to identify what people actually need in service delivery. And what builds confidence in our interventions. Because we have story after story of biomedical interventions, including COVID vaccines, where we have it, we have access, and it's not getting into people's arms or in their bodies to make a difference. And so let's see, we did diagnostics, we did vaccines, we did we did behavioral. I think those are probably my biggest ones. Oh, and treatment is important. We have no idea if the current drug that we're using to treat mpox actually works. So we need to finish the job of recruiting the study so that we can actually identify that this actually works. And though we have a lot of anecdotal evidence mpox also is a disease that you get and usually goes away. And so you know, I think that we have a lot of anecdotes and not actual data. The STOP study is recruiting. They're trying to expand to other areas of the world so they can increase recruitment. But ultimately, we also need that answer because it's going to be valuable to us in the future, and also will be a bridge to normalizing the therapy so it's accessible and more routine ways.
NB: Let me switch to your point about behavioral research. Something else, Adrianna, that I wanted to switch back to you, particularly around your work and community engagement. So we've heard community engagement is a word that gets has been tossed around forever. Right? It means different things to different people. I think in in global health, there's an important part of that in terms of pandemic response, as it is here in Massachusetts. So far we've heard the use of trust messengers often talked about, talked about showing up where people are. We've talked about how you approach people matters. Are there other principles of community engagement? That it is a science? Right? It is. It is both an art and a science. So, what is the art and the science that we have not covered for community engagement you have identified in your work?
AB: Yeah, I'd like to offer a couple things to consider in your approach to community engagement. I mean yes, it’s humility, understanding who you are as an individual who you are in the context of we're engaging context in which you are engaged, the context of the other people. You're engaging with your power, the bias you may experience. We all experience it. The blinders we may or may not have really being honest with ourselves before interacting. Curiosity. I mentioned before kind of having a conversation with a community partner like, “Hey, this is what we're thinking about. What are you doing about it?” I'm glad I did that, and I didn't just pull up like, “This is what we're doing.” Cause it made space for that person to feel empowered to say, “Well, actually, Adrianna, we’re planning this event. We’re curious, what do you think about this?” This is important to us. Where do you all planning curiosity? Also, authenticity. People can feel when you're not being real. They can totally feel it. And I've been with peers and colleagues and friends, and we'll be together talking before a presentation or something and then, during the presentation, I'm like, “I don't know who that was!” There are things in the world that cause us to not feel like we can be authentic. So, it's not something I'm trying to shame. It's just an encouragement to find ways to be authentic and know that people will accept you in your authenticity. So, I say: awareness, humility, curiosity, authenticity, and kindness. We don't know what people what's going on in people's lives. Things are going on in our lives. What I feel like I can be sure in always is that I think kindness goes a long way. Those are the those are. That's what I would encourage folks to keep it on top of mind. And in addition to what we've mentioned.
NB: Oh boy, a little bit more kindness would be really great for the world. Celine, I wanted to actually just tell the audience, what I started with at the very beginning, one of the things – the many things - that you've dabbled in is you have a podcast called “American Diagnosis” that just won the Edward Morrow award. Can we just give her a hand. Just incredible, right? It’s one of two, right, as we talked about. But what I found interesting about this specific one is that you look at who gets to be healthy and who doesn't in America. And we've talked a lot about inequities in this conversation. What do COVID-19 and mpox pandemics say in how they played out in the United States about our health?
CG: I alluded this earlier once about the conversation I had with this book agent, literary agent. I think it was very predictable how COVID played out and how mpox has played out in terms of which populations have been most affected and I think part of our public health response is addressing what are those systemic issues that are driving those health disparities. We have not done that successfully, even in this moment. Think about the numbers and the proportion of the American population that every day is battling with food insecurity and housing insecurity. Sure, we've curbed the rate of inflation and by many different economic markers things are looking really good. But then why are people still having those fears? And so you ask people in the midst of a pandemic to do to take pro-social actions on behalf of other citizens when their number one emotions in that setting are fear and anger about their day-to-day life. And I think that is something that we need to do a much better job about proactively. Some of that is communication and communication is not just talking, it’s also action. And I think this is one area, the Biden administration did some very important things when they first came into office in terms of addressing some of those socioeconomic insecurities, but many of those have also come to an end with the end of the public health emergency. So that is a lot of what I cover in in that work as well as in other things.
NB: So why don't I stop asking all the questions and actually open up the Q & A. For those in the room, as well as those on Zoom. And before I do that, could I have all our speakers come up? So, Dr. Jha, could you join us again on stage? And I will take the moderator's privilege and just ask you the first question. I mean, I put you in the hot seat for a reason. We’ve talked about politicization of pandemics and the impact that's had. Can you talk a little bit about how politicization has affected both the COVID-19 pandemic as well as the mpox pandemic?
AJ: You guys can hear? Woah, yes, you can hear me. It works. Look, I’ll start off thinking about the fact that public health has always been political, and the fact that it is political, it sort of depends on what do you mean by political? What is politics? And politics in my mind is the way we negotiate different views and values in a democracy. The fact that it is political doesn't bother me at all. The fact that it has become increasingly partisan is a problem. And because public health has not always been so partisan, and has become more partisan now, what is interesting to me is watching the evolution of this response is. I still found in my - both in my time at the White House and I still find today - that there is a broad middle. Seventy to eighty percent of the population that fundamentally cares about promoting health, it’s not deeply partisan on these issues. I found that when I would go up to [Capitol] Hill and meet with Republican and Democratic members of Congress there was a lot of consensus, actually, behind closed doors about what we needed to do and to promote these things. The problem in my mind is that there is this very, very vocal political extremes on both sides. That has really kind of twisted the debate. So, what does that all mean? Well, what it means for me is we have got to continue treating public health as a nonpartisan or bipartisan thing. One of the things I worry a lot about, and some of my friends in public health have done. This is, they've really pushed the political the partisan angle, you know, talking about Trump counties, people dying at a higher rate than in Biden counties. I think that's a totally unhelpful way to look at the world. It is totally unhelpful because the moment you tie political identity to vaccines you have lost that fight,
because you're then asking people to go against their political identity, against their worldview, to do the right thing from a from a public health point of view. That is not helpful. And so my general request is we've all got to work on like kind of ignoring the extremes. Focus on the broad middle. Talk about issues in as much of a bipartisan way as possible to bring as many people along. I mean, that has always been the tradition of public health. You don't leave people behind. You don't say, well, you guys are conservative, or you're right wing, or you're left wing, and therefore we're not going to address you. I think the goal is to bring as many people along as possible, and to try to do this in a way that is as nonpartisan as possible, understanding that the politics is the process by which we get there.
CG: Just to follow up on something there. I was recently speaking with the president of the American Academy of Pediatrics, and he was saying that among their constituency they are now hearing that people come into the doctor's office and that parents will say, “Yeah, we don't do vaccines. We're Republicans.” Whereas in the past they would raise questions about safety, you know, “Are you giving too many vaccinations at once?” This is the first time they are so explicitly saying this is partisan.
AJ: That is bad, and there is nothing good about that, and there is no way out of that outside of like really working on delinking. This is why I did a ton of conservative media before I went to the White House. And you know, I was on Newsmax. Newsmax often makes FOX News look like MSNBC. And I would talk about these incredible vaccines that were developed under the leadership of President Trump, which they were. And I would remind people that a vast majority of people who voted for President Trump are vaccinated, which they are. And I think we've got to keep that mindset going. It is unhelpful, and I worry a lot about that, because to persuade that parent you've got it in some ways, almost - you're not going to just get them to stop being Republican. That's not the goal, right? You've got to get them. And, by the way, the kind of anti-vaccine bad information now, at this point in COVID, at least, flows from all sorts of places. It's not flowing from one side of the political aisle. I mean the number of people on the far left who are like, “These vaccines are useless.” Everybody should be like, it's just, it's nonsense. And we have really got to departisan-ize it, not depoliticize it, but departinsan-ize it.
NB: I think that's a great start to just questions that others may have in the room. We have circulating mics that we will get to you.
Audience: Veronica Wirtz, professor in Global Health at the School of Public Health. Really nice discussion. Thank you so much for the interesting reflections. Often we don't reflect, I agree with Nahid. One question to Ashish and one for Nikki. Ashish from your perspective. Now, lessons learned from a time at the White House. You're returning to Brown School of Public Health. We are training the future leaders and public health. I would love your reflections on what do we not teach, and we should teach now, from your experience. What are you saying I would like the future public health leaders not to arrive at the White House as I did, because I wasn't taught, and they should be taught to hear that and communicate from your perspective. Now, with the new opportunity of the Office of Pandemic Preparedness hopefully not been a banished in the future government as it was dissolved in a in a prior one. So I hope that this office will stay in place regardless of any elections in the future. What is now your vision for promoting equity in access to vaccines? We saw it with the COVID pandemic. Huge inequities, globally in terms of vaccine roll out. Similarly, although I think the data is not as clear to me. I looked at the literature in terms of inequities. I think there were articles out there saying huge inequities, but I think not so well documented as in the COVID. I would love to hear from you your perspective, for how we can promote much better equity from a US perspective. What role do we have? What responsibilities do we have as a government for tech transfer, patents, and so on. Thank you.
AJ: Two good questions. I'm glad you get that second one, Nikki. It's also much easier when I'm not in government to be able to talk about some of these things. So, on the question of what do I, or what do we, need to teach the next generation? There are a lot. I mean, one is, I think most people do not really understand the policy making process. They have these vague ideas of how policy happens. I think it's really important to teach the general public, but certainly our public health students, how to engage policymakers in a way that's constructive and useful. You can be an advocate. You can push certain policy things, but if you do it in certain ways, you're much more likely to get traction. I found in almost every consequential decision I made, I would reach out to dozens of scientists but the bottom line was there were some scientists who were just always unhelpful, and I stopped calling them. And that was because I had to make a decision for a 4 o'clock meeting. It's 11 AM and they would say, “You know, give me six weeks. We'll pull together a literature review.” I'm like, “I have an hour like, I just want what is your best understanding and your best guess.” And they say, “Well, the science is not so clear, so I can't give you an answer.” Well, I still have to make a decision. So, teaching people how to engage with policymakers with a different timeframe. One of the things I have thought a lot about goes back to the previous answer is, we all, every public health school says, “We're training leaders in public health. We're training leaders of public health.” We're going to work in blue states, purple states, red states. And we have to teach them how to work across very, very different political worldviews about the role of public health, the role of government, the role of individual responsibility, how that works. If we do not teach them that America is a deeply diverse country, not just racially and ethnically and economically, but also politically and socially we will have under trained them, and then they'll be like… And again, let's just be very explicit- we're mostly talking about public health schools that are, you know whether it's BU or Brown, we're in pretty blue states, in pretty blue communities. And if our goal is to turn out public health leaders who will do a good job in blue communities or liberal communities, that's fine. That's not what our job should be. And so we have to train people to work across a diverse group of political stakeholders. I don't think we do that at all. And we have got to do a much better job to basically be public health schools for America, not just for blue.
CG: We also train public health students for careers in public health schools.
AJ: That's also true. That's a that's a whole different story. And that that was clear even before I went to the White House. But yes, that's a great point.
NR: Alright, I'm up. So, I think we've already started actually incorporating from day one. It’s now day eight or nine. So everything that is coming up into our office, we are noticing, although people say that they want equity woven into every rollout plan and every communication. It isn't, and it needs to be. There needs to be a staple of the communication of every plan. It needs to be part of the implementation plan, so we're already trying to flag that so that that's kind of a new norm. I would say the way that you make it equitable is a blend of all the different outbreaks that I've been a part over the last few years. It is public-private partnerships. It is pharmacies. It is leveraging pride events. It is really, truly reaching everybody where they're at. It is going to homeless encampments. It’s going to where somebody is, whether that is leveraging CVS or Walgreens, or a pharmacy in the middle of nowhere, or a Dollar General, or a vaccine bus. So, you just need to think about it whenever you are implementing vaccines in any way. And during COVID we definitely focused on having high SDI areas have more access to pharmacies and we had the pharmacy hours opened later. I think that in the beginning of any outbreak you're always going to see that inequity, no matter what matter what you do, you're going to see it. And then you're always going to have to fight to try and improve.
AJ: Can I add one more quick thing to this, which is from the COVID. I know you were talking about also global vaccine access. Look, I think everybody agrees that in the first few months of the vaccine rollout there was… It was ridiculous. I mean, you did lots of vaccines in some places, no vaccines in others. There's been a lot of work and a lot of thinking about, how do we do something different? The administration, and I'll speak for the administration, but the administration at certain. When I was there we were very committed to, publicly and privately to distributed manufacturing. I think that is a key part of the solution. There are people who have different views on that. The Biden administration's views on this were very, very clear. At the end of the day, counting on the goodwill of others is not a strategy. Let's hope that happens. But that is not a strategy. Distributed manufacturing. By the way, everybody, I mean, we can all agree on that. It's really hard. There's a lot of important work to be done to get to distributed manufacturing. We worked with private companies to say, like, “Okay, you want to set up a manufacturing plan in Kenya? Fantastic! What are you going to do during peacetime when you don't have an outbreak? What are you manufacturing?” Because there's no such thing as having a plant sitting idle, and then you turn it on in a pandemic. It doesn't work that way. Who funds it, and how do we? So there is really important work happening there. I don't think we, my personal view now, I think, aligned with the administration. We do not achieve global equity and vaccines without distributed manufacturing. I just don't see any other strategy. So that has been certainly the view of the administration certainly been my view before I joined and after I've left. But it's going to be a lot of work if we're going to get there.
NB: Yeah, while we're looking for another question in the room, I want to also make sure that after this question in the room that we also check to see if there's anything on Zoom from our Zoom audience as well. But let me just add one thing, in addition to distributed manufacturing, one of the important things that I feel we've learned is you can't make the vaccine if you don't access to the raw materials. I think, looking up stream and ensuring that raw materials are available as we set up all these things is a critical, critical part of it.
Audience: Yeah. Hi, thanks Leo Liu. I'm an ID physician and a fellow Ebola responder. And now an editor at ProMED. So my question takes off something that she should say that I think Nikki also referred to, which is that the new pandemic response implementers. You have to make policy decisions based on incomplete science, often very incomplete science. So, what happens when the science comes out and says a major policy decision was wrong? We're going to have to walk back some of what we said. Can you cite an example? How do you manage? How do you gain trust with communities.
NB: Yeah, I don't know if our online audiences could hear that. But the question was as policies are made and science evolves, and then you have to change the recommendations, how do you maintain that trust back after it there?
DD: So I think probably this actually will refer back to a prior question, which is, what do people need to learn in schools of public health? And what do sort of clinicians or doctors need to learn if they're going to do public health work, then I'm going to answer the question, which is risk communication and risk communication is my answer to your question, which is that the humility involved is saying based on what we know today. This is what we're doing. But that could change tomorrow just needs to be really top of mind for how we communicate hard decisions through based in perfect science. The follow up to that is also have a path to show how you're going to make the science less ambiguous to the future. So intradermal dosing of a vaccine is I think, exactly the story here. And so I'm going to talk about one of our conversations which was when the FDA worked and identified - it was a study that that was based on correlates of immunity, that showed that intradermal dosing was about equivalent, though not exactly equivalent, but seemingly statistically equivalent to subcutaneous dosing and you know there was a- Look, the FDA's elite. They're the agency that sort of does all of the work with the emergency use, authorizations and all of the thought. And they felt confident, with their own scientific review that this was a good thing, and it was, “we need your help to support this decision, cause we're going to make it.” And so we, you know, I think at the White House stood back and said we will support you in this, and what we're going to help with is to communicate what we don’t know, and make sure that we do exactly what Dr. Jha said, which is to make sure that we create a swarm of humans in the science universe who we've spoken to, who are aware of what we know and don't know. And then we communicate that very clearly and then say, but as we go forward with this decision, we're going to make sure that their studies - and I’m looking at Dr. Goldstein here, thank you, Dr. Goldstein - to make sure that there are studies happening at CDC that would allow us to have data on vaccine effectiveness that are designed in such a way that we're going to be able to answer the question “Is subcutaneous and intradermal dosing about equivalent?” I commented before that we need to know more. But we actually do have a study that shows it's about equivalent. And so, really, starting by saying, we're making a decision. It is a calculated risk that's based on the best science that we have. We’ll improve the science, but if something is different, we will come right back to you and tell you that we need to pivot and change. So that, I think is sort of the core approach when you're making difficult decisions. One of my mentors in medicine, Marty Blazer, who is the chief of medicine in New York City at NYU School of Medicine. When I was the fellowship director for infectious disease at NYU, we were having this great mentorship meeting. And he goes, “Demetre, I need to tell you that the definition of what it is to be an expert. An expert is someone who makes decisions using imperfect data.” And so the correlate to that is a good expert is one that also shares the limits of the data that they used to make that decision.
NB: That was excellent. I'm going to see if there's any Zoom questions first, and then we'll come back to the room. Cassandra?
CEID staff: Yes, the first question on Zoom is: Demetre and Ashish talked about the use of data. Do you see a role for AI in pandemic preparedness? And if so, where?
AJ: Yeah, I mean, look of course, you know, I think of the evolution of AI, and what has happened is sort of when the internet became ubiquitous. It was like what’s your role for the internet in pandemic preparedness. The answer is “absolutely.” With the advent of the internet, information became a commodity. You could, you know now, at this point 80% of the world's got access, all the knowledge that has ever been created in human history. That didn't exist 30 years ago. So, what that means is that you change your approach to thinking about pandemics, or you think about almost any policy, to say, “No, knowledge is no longer power, knowledge is a commodity. Analysis becomes power.” AI shifts that further where analysis starts becoming more of a commodity. And then you have to start thinking about what's the role of humans? How do you use that? AI, I think for a lot of people, feels very scary. I feel like it is a reality. We have to figure out how to harness it in everything, from the way we're going to do predictive analytics to the way we're going to think, actually, the way we're going to build vaccines and treatments. And so, then the question is, “Well, what's the role of humans in all of this?” It's the relationships. It's the trust. It's the values. It's where do we put our priorities, that stuff. I think it's AI is not going to get us anywhere close for a while. So, do I think AI is going to be a part of how we do pandemic preparedness? Absolutely. Do I welcome it? I do. I think it'll make us better, but we have to be thoughtful about how to use it.
CG: The other problem, though, is we have a garbage in, garbage out problem. We have huge issues in public health with our data infrastructure. And so, AI applied to no data or bad data is not going to be very helpful. You really have to strengthen the data infrastructure for AI to be helpful.
NB: Okay, one more in person. Then I think what we might have to do, because we've already gone over, is actually stop it. And also, I can smell the food next door.
Audience: I guess I’m the one holding you back from food. So, I will be very quick. I'm Syra Madad. I'm with New York City Health & Hospitals, the Belfer Center, and CEID. So, my question is, well, first I'll say thank you for your service. We know it takes a village to respond to an outbreak. I want to go back to that fund, Nikki question. So, we know funding can make or break any type of response. And Nikki, you've mentioned that using existing infrastructure to find funding for mpox response. But we know that robbing Peter to pay for Paul is never a strategy. And usually the other, “Peter,” suffers in the middle of it. And Demetre you mentioned syphilis cases are on the rise. It's actually highest in the past seventy years that that's ever been. So, do we think that taking funding away from some of the STI campaign work and giving it to mpox made some of the other STIs suffer? And if that's not a strategy, because we know we can't wait on supplemental funding, what else can we do as we talk about outbreak response?
DD: I'll start, then maybe others will chime in, too. But I think that one of the things that was special about the way that we sort of generated the funding flexibilities in mpox was- I think the CDC letter is really great. If you want to look at it in terms, that is you may use this funding in the line of the work that you're already doing for mpox work. And so, I'll use an HIV example, and I think that there's some great - I'll use my home county of Fulton county, [Georgia] now. I think it's a good one. As a great example, they actually used their sort of the moments that we had excitement about mpox vaccine where everyone was coming in. They had great success, using their HIV resources to bring people in for mpox vaccines and then putting them on pre-exposure prophylaxis for HIV, and giving them an HIV test on the spot, and then linking the newly diagnosed folks to care. So, it's sort of the normalization of the intervention into the workflow that's also important for COVID. And eventually, what's happening with like the sort of the evolution event of this sort of pandemic and how we're dealing with it, which is that if there are no new resources, then advocates need to continue to advocate for new resources. It's really important. But thinking about ways that you can sort of weave it in where it's also doing other work. The amount of Narcan that has been distributed on the back of mpox work is amazing. And who knew an overdose is a part of the other part of that pandemic. And so when you sort of think, SAMHSA resources were used flexibly to bring folks to mpox. We were able to bring them to mpox, and then they got Fentanyl test strips and Narcan. So it didn't pull away in this scenario because of the overlap. I will, however, say it's really critically important to continue advocating for STI resources because we are in a crisis of syphilis, and though I don't think this pulled directly away from syphilis – it actually made some diagnoses to prevent some of it - I think it's important to remember that that area is always under resourced in the US. Maybe going back to the prudishness of the country on issues around sex and sexual health.
NB: Thank you so much. Yeah, any other thoughts on that? Alright. So, I'm going to try to play my role as an emcee as eloquently as I can. So first can we give a hand to our speakers? And now I want to do some stepwise instructions. First, let us say goodbye to our Zoom audience. Thank you.
DD: Wait before Zoom goes. Can everyone give Nahid a round of applause for being an amazing emcee?
NB: Oh, oh, thank you. Thank you.
