President's Podcast: A conversation with Demetre Daskalakis, MD, MPH

Carlos del Rio: [00:00:09] I am Carlos Del Rio, president of IDSA. Welcome to the Let's Talk ID podcast. Joining me today is my friend and colleague, Dr. Demetre Daskalakis, the Acting Director of the National Center for Immunization and Respiratory Diseases at the CDC. I asked him to talk to me about his broad and successful career in infectious disease. Welcome, Demetre.

Demetre Daskalakis: [00:00:28] Thank you, Dr. Del Rio. Nice to see you. Thanks for having me.

Carlos del Rio: [00:00:31] It's a pleasure to have you. You know, you're down the street, yet we don't see each other. But this is we speak a lot on the phone, so this is great.

Demetre Daskalakis: [00:00:38] We'll see each other at IDWeek.

Carlos del Rio: [00:00:41] So,  Demetre, you left the New York Department of Health where you had done a lot of really innovative stuff to try to improve HIV care and came to CDC as Director of the Division of HIV Aids Prevention in December of 2020. And those of us in HIV were very excited to see you take that job. But since then, you've had an amazing run in the federal government. You were called to head the monkeypox response at the White House. You now are the acting director of the National Center for Immunization and Respiratory Diseases. You have a lot to do with Covid and influenza. How did your training as an infectious disease physician prepare you for this

Demetre Daskalakis: [00:01:14] My training as an infectious disease physician, in fact, is the reason I've been able to do all of that. So first, the clinical care and the clinical service that you do in infectious diseases is often dealing with many diverse types of medical providers and trying to tell them how to do better in a space that everyone thinks that they know everything about, but they don't necessarily know everything about it. So telling a surgeon what right antibiotics to pick, doing a consult with someone in general medicine and being strategic in letting them know how to do infectious disease care better. This is not different than the skill of working in a large governmental public health department where your job is to make sure that you can communicate science in a way that people who may think that they know a lot about it but may not have all of the details on the ground to be able to make good decisions. So, in effect, every one of those infectious disease consults where you had to change the direction of what people were doing with care of a single patient ends up being informative for how to really have the interactions in public health of how to teach policymakers how to do better in the space. This has just been several years of the longest infectious disease consult of my life [laughs] is what I think this is. So no matter what the category is, it's always the same. I feel like that, you know, the way that you think scientifically and infectious diseases is really important in public health, but also like how you learn to interact with colleagues and how you learn to be a consultant is so critical in the work that I've done every day in public health.

Carlos del Rio: [00:02:55] So tell me a little bit more. Let's dive into the mpox response and the work you did at the White House. What did you learn about how the government works working inside the White House?

Demetre Daskalakis: [00:03:03] That experience was so valuable to me because when I landed at CDC for the Division of HIV Prevention, I remember one of the criticisms was, well, you know, he doesn't have a lot of federal experience. Well, that's different now. So I feel like the experience of sort of being in an agency, having a lot of different work within the agency and then leaving the agency as a deployed official into the White House and seeing how decisions are made in that sphere and how it is possible to coordinate government to create one mission. Working with Bob Fenton from FEMA, really, really closely with him and working with my colleague Nikki Romanick, who is now working in the Office of Pandemic Preparedness and Response and getting to work with Paul Friedrichs for a bit. That all has been so valuable because what you really learn is that government is about the positions, but it's also about being able to pick up the phone and talk to people. That I think was probably the most valuable lesson, which is that if you dream it, you should do it. So if you're like, I really need to let these people know what's going on, call them. The convening power of the White House, what you see happens just by bringing people together, just reminds you how important those interactions are in the way that we do work in government, not only in public health, but beyond.

Carlos del Rio: [00:04:20] You know, going back to your saying that this is like an ID consult again, it's what we do as an ID consoles. We just don't write, only write recommendations. We call our colleagues. We communicate with people, right? We get on the phone and talk to people and try to solve the problem.

Demetre Daskalakis: [00:04:33] It's the same skill set. The work in public health, at least from where I sit, is just a consistent, very challenging and recurrent infectious disease consult with different bugs and different problems all the time, but always the same strategy, which is like bringing the science and make sure that you convene the people and talk. And so it's exactly what you said, Carlos. It's picking up the phone and just saying, hey, you know, like, how can we do this better? And then you end up becoming a very successful consultant when it's that versus here's I'm dropping the consult in the chart and not explaining it and you don't know how to use Imipenem. [laughs] That doesn't work.

Carlos del Rio: [00:05:09] The other thing I think you hinted, and I want to emphasize, is that there's a lot of really talented people with a lot of desire to do well working in the federal government.

Demetre Daskalakis: [00:05:18] One of the things that's really fun about being at the White House level is that when you're in an agency, sometimes you only stay in the agency and then there's opportunities here and there to cross. I mean, like, I got to see people from like HUD, from SAMHSA, all over the federal government, from the Department of Commerce, like everywhere. And what you learn is that that people really, if you give them the tools that they need, they really want to do the right thing and they want to work collaboratively. And it's really remarkable at that level to see how you can move a big machine. It's possible to move a big machine because all of the people who are working in that machine really want to move it. It's amazing. So I agree with you.

Carlos del Rio: [00:05:56] So tell us a little bit, about in that role in the White House, how did IDSA and your physician colleagues help you?

Demetre Daskalakis: [00:06:03] Do you have a year? [laughs] So we have a very special bond among us, infectious disease physicians, as well as other medical providers that do infectious disease. Whether we work sort of in the research universe or we work in clinical care, those interactions are so valuable because infectious disease doctors and other medical providers have a really amazing blend of very specific scientific and clinical knowledge and also a place as trusted messengers in the system, you know, reaching out to folks that HIPAA as an example when we were seeing that so much of the pathology and the worst outcomes were among people living with HIV, having the HIPPA folks rise up and be like, This is our thing. We need to pursue it. And just giving them the tools that they need really demonstrates how important that is. And so it's not just the HIPPA folks, but we convened folks from IDSA over and over and over compulsively because it was also about getting feedback about what was going wrong or what could go better with the response, giving the tools that they needed to do their job better. But also hearing on the ground, you know, it's really hard to get Tecovirimat, What can you do about it? Well, we did something about it. And so having that experience at the frontline ends up being so important. There were not infectious disease folks at the frontline, but those folks often called our infectious disease colleagues for an assist. It's like going further upstream toward the knowledge base and the trusted messengers that providers use. It was priceless. In short.

Carlos del Rio: [00:07:39] Well, that's great to know. And again, I couldn't agree with you more. I think IDSA and the ID community, really we were all tired from Covid and we rose up and started roll up our sleeves and started working again when mpox hit and whether it was vaccinating, giving tpoxx, doing whatever was necessary to control this and work to try to crush this epidemic. And I think it was really a fantastic response. So now you finish at the White House, you come back to CDC, and now they're asking you to be the director of Immunization and Respiratory Disease branch, as an acting director. How does your previous experience inform this work?

Demetre Daskalakis: [00:08:13] What you learn in doing this is the core skill sets to sort of responding to all infectious diseases tend to be very similar. There's very similar pillars across every response. It's how do you communicate with the community as your base and then how do you use diagnostics, treatments and prevention strategies together along with good situational awareness to come together to create a response that's unified and sort of builds a structure of the response that delivers. That's the same in HIV. That's my experience that I had running a big measles outbreak in New York City. That was what it felt like at the beginning of Covid when I was the incident manager in New York for ten months. And the skill set, I've got to say, really comes from the core of what it's like taking care with someone who has an infectious disease issue. Specifically for me, it was sort of focusing on HIV, either from the treatment or prevention perspective and how you can then translate that into population health, because it's always it has the same basis. It's like, how do I treat the whole person? How do I deal with the stigma component? How do I use my diagnostics in the best way? How can I use my treatments in the best way? What other prevention strategies can I offer and how can I make sure that I'm monitoring this person correctly? So then multiply that by a million and that's an infectious disease response to any outbreak or any chronic or acute issue that we have. So it's it's that playbook is the same over and over again. And as the people in FEMA would say, it's an all hazards playbook for infectious diseases, you need the community and you need the science and you need the political will to bolster the response. And it's your job running those large events, whether they're acute or chronic, to make sure that you keep all of those three components moving.

Carlos del Rio: [00:10:01] Well, that's a wonderful response. So we're delighted to have you this year as our Joseph Smadel lecturer at IDWeek. You know, this is one of the four named lecturers, it's a really big honor that you richly deserve. Can you give us a preview of what you're going to be talking to us about?

Demetre Daskalakis: [00:10:16] Well, so for fear of sounding like Sally Field at the Oscars, revealing my age, you like me, you really like me. So I'm really excited. I mean, the first thing is when the folks that taught you and the folks that are your colleagues say, come and give a big name lecture at IDWeek. It's just like I'm beaming with excitement that I get to do it. And I'll tell you, Carlos, I've just given you a preview of my talk in the entire conversation that we had, which is I'm going to use mpox as an example of how our response needs to really be built on equity, built on a pandemic strategy that looks beyond a single pathogen and then uses all of the components that we know work infectious disease to actually achieve the end of controlling an outbreak or an epidemic. The preview is it's going to be about mpox, but it may end with respiratory viruses.

Carlos del Rio: [00:11:05] Very good. Fantastic. And I love that you threw the word equity in there, because I think in all this infectious disease outbreaks that we've been involved, you and I have been involved, whether it's HIV, whether it's mpox, whether it's Covid and you name it, and go on and on. Health equity has always been I remember one time asking early in my career, when I go to a different countries, how do I find populations impacted by HIV? And Jonathan Mann said to me, Find the most vulnerable population in a country, in a city, and look at them, and that's where you find the virus.

Demetre Daskalakis: [00:11:38] So this continues your question for me about the preview for my talk. I feel like Jonathan Mann's perspective to you captures the essence, which is that all of infectious diseases and so many other medical conditions follow the same fault lines that so many other inequities follow. It is not the exception to the rule that when we have some new or chronic infectious disease challenge, that the folks who could least afford to be affected by that challenge or the folks who have the worst outcomes, that axiom that he gave you is one that everyone who does infectious diseases should remember, which is that if it's going to go to someone, it's going to go to the person who can't afford to do it. And starting from a place, assuming that that's what's going to happen as opposed to being surprised that it did. Because what makes infectious disease clinicians special.

Carlos del Rio: [00:12:25] That I think is also the reason why many of us in infectious disease are very passionate not only about health equity, but we're passionate about advocacy, right? Because we realize you have to advocate not only for funding for the disease, but you have to advocate for the populations. You have to improve the lives of people in order to prevent infectious disease. In HIV, we know it's about housing. It's about transportation, It's about food security. It's about so many things that decrease your risk of HIV.

Demetre Daskalakis: [00:12:50] Yeah, I mean, and Carlos, it was about housing. It was about linkage to care. It was about mental health. For Mpox, it was the same. Infectious disease folks, these things are burned in our minds. Like we could switch this and talk about tuberculosis and it's the same story. So I feel like it's just so consistent. We can talk about viral hepatitis and who has worse outcomes from viral hepatitis. It's always so similar that when you have interacting conditions that interact with social determinants that magnify the intensity of those conditions, you have worse outcomes in the populations who are most vulnerable to the negative social determinants. It is an axiom of syndemic work, which is again the topic of my talk. So I think I think that that's right. The advocacy piece of this is so important because an antiviral or an antimicrobial can only do so much if the circumstances that the person lives in makes it such that they're not able to sort of look after the rest of their health or potentially allows them to actually partake in those technological interventions that we know work?

Carlos del Rio: [00:13:52] Well, I'm really looking forward to your talk and I hope everybody listening to this will tune in and we'll be there at IDWeek and attend your lecture, because I'm sure it's going to be a fantastic.

Demetre Daskalakis: [00:14:01] I can't wait. I'm so excited and I'm so grateful that I get to be in person with you in Boston.

Carlos del Rio: [00:14:05] I can't forget really, that you came to CDC to work on HIV. That is your passion, that is my passion. Can you tell us what you think? Where are we in the HIV epidemic in the US? What do we need to do? Why are we not making the progress we need to make?

Demetre Daskalakis: [00:14:19] I will first bow to my colleagues now in the Division of HIV Prevention because they're the owners of that material now, since I'm over in the immunization and respiratory disease part of CDC, the same things that challenge us in terms of the work that we did in Mpox are the same things that are really blocking us in doing the work for HIV, which is that, you know, there's first of all, there's like the social determinants and the stigma components that make it really hard for folks to access these technologies, which are increasingly just shockingly efficacious between pre-exposure prophylaxis that works, antiretrovirals that keep people healthy and happy, injectables, all of that's there. And, you know, I think we're limited by systems that sometimes make it hard for us to actually deliver the service that's needed. There is a resource to response ratio in HIV. The more resourced that HIV is, the better it does. I mean, my experience in New York City with a small investment relatively in New York City for and for ending the HIV epidemic work in that one city, we drove the numbers of HIV down. And so it's like the ongoing advocacy to make sure that programs in HIV are funded. Really important sort of work to continue to make sure that Ryan White has the resources that they need work to make sure that we are funded to end the HIV epidemic.

Demetre Daskalakis: [00:15:40] I think it's going to be hard to reach goals with funding that has been flat and not to the level necessary to achieve the goal. There's two things that really need to be funded in the world, in my opinion, in infectious diseases. And so I'm going to first do the HIV one and then the second one is the one that I'm working on now, which I think is equally, if not potentially more important sometimes. the first one is a national PREP program. I think a lot of people are talking about it. It's been in the President's budget. It's going to be rough to get it through where it has to go. But it's like I think a really important thing to continue to advocate for. But with my new hat, I'm going to say we have vaccines for children and it saved trillions of dollars and millions of lives and we have nothing equivalent for adults. So really focusing on vaccines for adults and that request that's gone up in the President's budget a couple of years, really trying to make that a reality. I think those two things will change. The game and the PREP program will help end the HIV epidemic, and vaccines will create a preparedness level that we've never had in the United States as we learn better and better how to roll out countermeasures that prevent infection. How's that?

Carlos del Rio: [00:16:47] Oh, that's I think you're absolutely right. I mean, I've always said, you know, before we had Covid, I always said, look, we needed to take one of the year's flu vaccines and roll out a program as if there was an outbreak because we don't have an immunization program for adults and we have to have something in place. It's kind of surprising how well we did with Covid given the fact that we didn't really have a program.

Demetre Daskalakis: [00:17:08] Well, imagine how much easier it would have been had we had a program because all of that stuff had to get stood up on top of other things. So, I mean, I can tell you, even in my little micro universe, how much easier would it have been had I had vaccines for adults for mppox. Just like the prep resources are sort of building infrastructure, the vaccines for adults create this fully rounded, full lifespan view of like how we can use vaccines. That work isn't just about access. It's not just about delivering vaccines, but it also lets us actually invest in vaccine confidence and in getting people to feel like, you know, these are really important interventions for their daily health. But with the next Covid, which is inevitable, having the VFA having vaccines for adults means that we are plug and play as opposed to hustle and create.

Carlos del Rio: [00:18:00] As opposed to create, right? Yeah. And as my colleague and friend Walt Orenstein says, you know, vaccines don't save lives, vaccination saves lives. You have to vaccinate people. You're absolutely right. So count on us and IDSA to to work with you and and to advocate for this. I think having a national immunization program for adults should be one of our goals as a nation. So any closing remarks that you have?

Demetre Daskalakis: [00:18:21] I mean, other than gratitude and just to remind everyone that we have flu shots, we have Covid vaccines that are recommended for everyone over six months old. We have new RSV immunizations for folks who are over 60 as well as for pregnant persons and newborns. Use them. They will prevent disease and help us attenuate what could be a pretty busy season. So other than that, I'm just so grateful to spend time with you, Carlos. Grateful to have the conversation and also so excited to join you for this lecture in Boston. So thanks for having me.

Carlos del Rio: [00:18:50] Well, thank you. And again, I want to remind everybody that infectious diseases is an amazing, exciting job. It continues to be and that this time this year, for the first time, we are putting out together with CDC a joint IDSA IES fellowship which allow you to get the skills in infectious disease that Dimitri got in his fellowship, and I got in my fellowship, and then combine it with subsequent to getting the public health skills at CDC. And I think again, strengthening the relationship between IDSA and CDC is one of the things that has come out of this pandemic and will continue to do going forward. So thank you very much for being with us today, Demetre, and I look forward to seeing you at IDWeek 2023.

Demetre Daskalakis: [00:19:28] Thank you, sir. Nice seeing you too.