The intersection of infectious diseases and public health: strengthening career paths

Mati Hlatshwayo Davis: [00:00:07] Hello, everyone. My name is Dr. Mati Hlatshwayo Davis and you're listening to Let's Talk ID. I am so excited for today's topic because it's something that I'm incredibly passionate about. We will be discussing the intersection of infectious diseases and public health. I have three incredible guests to dive into this with, so I'm going to go ahead and introduce them. First, we have Dr. Nahid Bhadelia. She is an associate professor of infectious diseases at the BU School of Medicine and the founding director of the BU Center for Emerging Infectious Diseases Policy and Research. Welcome, Nahid.

Nahid Bhadelia: [00:00:45] Thanks, Mati.

Mati Hlatshwayo Davis: [00:00:46] Next, I'd like to introduce Dr. Eric Chow. He's the chief of Communicable Disease, Epidemiology and Immunizations at Public Health, Seattle and King County. He's also a clinical assistant professor of medicine in the Division of Allergy and Infectious Diseases and at the Department of Epidemiology at the University of Washington. Welcome, Eric.

Eric Chow: [00:01:07] Pleasure to be here. Thank you so much.

Mati Hlatshwayo Davis: [00:01:08] Last but certainly not least, a mentor and friend, Dr. Virginia Caine. She is the director and chief medical officer at the Marion County Public Health Department. She's also an associate professor of medicine at the Division of Infectious Diseases at the Indiana School of Medicine. Welcome, Ginny.

Virginia Caine: [00:01:25] Hey, thank you.

Mati Hlatshwayo Davis: [00:01:26] So let's dive in. It has been a incredibly unique but also really rough period for public health, I would say, over the last couple of years for obvious reasons. COVID, in my mind, was integral in the public health response, in the response to COVID in general, but also has been seeing a record level of disinvestment at the same time globally, nationally, at a local level. So it's a really interesting juxtaposition. So I want to start by us framing the importance of public health and infectious diseases. What would you say is the role of public health in infectious diseases, given the gamut of what we do in our field? I'll start with you, Nahid.

Nahid Bhadelia: [00:02:16] Thanks so much, Mati. I have never been able to separate the two in my practice, in my understanding of how infectious diseases works. ID is a rare field of medicine in which you're not just dealing with one living being, but also the pathogen and that pathogen, the epidemiology of it, is spread, is so ingrained in the mosaic of how we function as a community, as a society, what we value and what we don't value, what we invest in, what we don't invest in. Public health when it comes to infectious diseases is what kind of decides what happens within the clinical space between the physician and the patient when it comes to infectious diseases. And so it's not really predictive of the problems that our patients will face, but it's also so ingrained in how we practice it in terms of our balance. Right? Think about AMR. I mean, the decisions that we have to make about what's best for the patient, what's equitable in terms of thinking about what the impact on the entire public health system. To me, the two cannot be separated, partly because of that reason.

Mati Hlatshwayo Davis: [00:03:18] I love the way that you frame that, because I've always thought of it as the implementation arm. But the way that you framed it also kind of describes it as this bridge between sort of the research and the clinical and the implementation arm, Right? And I've just never heard it put that way. Jenny, would you add anything from your perspective?

Virginia Caine: [00:03:37] I think the thing is that when we look at public health, it's trying to improve the health of the entire population. You know, a lot of times if you're just a clinician, you're concentrating on those individual patients, but not the population and health. There are so many factors that play a role in that. But just think about one of the major aspects of public health is tracking disease outbreaks. And if you go back in history, just go back in history. Our biggest impact, H1N1. We saw Zika virus. We saw Ebola virus. And so now we are seeing this COVID-19 pandemic in all of this, these reemergence of infections, whether it's tuberculosis or drug resistant TB, that are popping up now. There are new fungal infections, Candida onerous, but it's just not affecting that person in the hospital setting or the E.R. It's impacting populations like our homeless. And never was that more clear that we saw this big gap in disadvantaged socially racial and ethnic populations occurring.

Mati Hlatshwayo Davis: [00:04:48] That's right. Eric?

Eric Chow: [00:04:48] Yeah, well, I see the two disciplines as part of a continuum, but also part of a network that's intricately interconnected. While not all of public health is infectious disease, many urgent or emergent public health threats are frequently due to infectious pathogens, and thus the field of infectious disease plays an important role in shaping our public health action. Well, on the flip side, what we learn in public health also contributes to the clinical practice of infectious disease and how we advise a patient who is seen in clinics or hospitals about, you know, how to prevent infections is frequently using population level data and epidemiologic principles based on an individual's risk. And I'm thinking, you know, this is, of course, not limited to these factors, but, you know, burden of disease in their communities, sociodemographic and behavioral risk factors as associated with infection and complications and also the availability of medical countermeasures and their effectiveness oftentimes influence what we say at the patient level that's really drawn from the experiences and the work done at the public health level.

Mati Hlatshwayo Davis: [00:05:47] I couldn't agree more and I love that all of you, without saying it explicitly, just really underscore the leadership that is embedded within public health as this sort of implementation. You said it's so beautiful, Eric, being on a spectrum, but also very intricately interconnected in every fiber of what we do. And I believe that it has placed our field in this uniquely positioned place to lead in these times of great prioritization in our nation and at a global perspective. But to take really complex issues and make them accessible. We spend millions, billions of dollars in research that is much needed. And yet this continued gap between impact and what we want to see at the human level still exists. And I believe that's the space that public health occupies. So I don't think anyone would argue its importance. So some of you started to talk about this. It's hard not to talk about the role of public health in infectious diseases without reflecting on what happened during the COVID-19 pandemic. So at this stage that we're in, reflecting back on the past three years, what was the role that public health played within the COVID-19 pandemic and what were its strengths and weaknesses as you all see it? Eric, I'll come to you first.

Eric Chow: [00:07:05] Public health continues to play a key role in the pandemic, but this was particularly critical before we had effective medical countermeasures such as vaccines and antivirals and before we had the detailed knowledge of the viral properties and transmission dynamics of SARS-CoV-2 that we know today. I remember those initial moments when we were on the ground and learning about new cases of COVID-19. You know, back in February of 2020, I was an EIS officer in the influenza division, and I was actually part of that initial group that was deployed along with other CDC folks to support public health, Seattle, King County, the team that I work with now in their investigation of the long term care facility outbreak. As in many situations in public health, we were operating from a position of uncertainty and limited information, while also generating data in real time that could help inform public health messaging and guidance. We had to be open minded and nimble enough to be able to overturn any underlying assumptions and be open to new knowledge about the virus. As an example, contact tracing and our investigation of the outbreak led to some really critical findings early on that shaped our guidance that we continue to use today. This includes symptom screening that initially we were using to be able to determine who's capable of transmitting infection, and early on the focus was on symptoms such as fever and cough. But in reality, we know that the illness course can actually begin with a variety of symptoms. And in fact, early findings from our investigation uncovered that asymptomatic and pre-symptomatic infections and transmission could occur. This ultimately shaped guidance around source control, including masking, which has been a key mitigation measure throughout the pandemic.

Mati Hlatshwayo Davis: [00:08:40] And Ginny, it's easy for me to come to you next because Eric set us up with these really tangible examples of the role that public health had to play, must play, always plays immediately, when there's that gap between actual data driven guidance, right? Because we're still collecting it. It's so early in its course. So for you, as the director of a major public health department and a chief medical officer, what are your reflections about the role public health had to play during COVID-19?

Virginia Caine: [00:09:08] So actually, I was the incident commander for the entire operations under my mayor, Mayor Hogsett, and just an incredible leader for me and always believed in the evidence. And so that required me to meet on a weekly basis with all of our hospital systems, meeting weekly with our school systems, meeting frequently with our businesses. And then you have to deal with the public. And when you look at the diversity of the different racial and ethnic populations and we had a lot of individuals who were illiterate, they couldn't even read their own language. I'm patting myself on the back. I've got third grade literature education out there and they can't even read. And so you have to come in all of those and you have to listen. That's an important thing for us to listen about. What are the tools and the best vehicles of communication to reach all of those groups. But we try to be all on the same page and not everybody doing their different thing. And it's not coordinated and it's not integrated well. At the same time, working with our state health officials, as well as our federal officials, to get a united message out there.

Mati Hlatshwayo Davis: [00:10:28] And so it's an area that most physicians, as they train, are not comfortable with, like people are not accustomed to having to work with a political entity, a mayor's office, and then to be able to take these incredibly difficult pieces of information in the absence of evidence, to Eric's earlier point, and be able to, in real time, educate the public. To me, you cannot argue the importance and the prioritization and just the necessity of public health. And so I purposefully came to you knowing what you were involved in during the pandemic and sort of the global lens you have. What are your thoughts about what you've heard Ginny and Eric speak to, and then your own experiences about the importance of public health during the pandemic?

Nahid Bhadelia: [00:11:08] I think you arranged this on purpose, Mati, because what a great transition because clearly my position is very complementary to what Ginny and Eric were doing. Most of my work was to of course, be a physician like everybody else on this call during the pandemic, but also to advise my hospital and the health system as well as our state. I did this thing for a couple of years where I was a medical contributor for NBC, which helped me really get a front row seat about the difficulties of communicating about this, the critical role of public health. And then most recently, I served as a senior policy adviser with the White House COVID response team for the global COVID response and was able to apply a lot of the things that we were seeing on the national level was seen repeated multiple times in different ways globally as well. Let me go back and tell you the number one lesson that I sort of thought about in terms of public health. Two years ago or something at the very beginning of this pandemic, I tweeted something along the lines of why it is so difficult to be in the field of public health to communicate about COVID-19.

Nahid Bhadelia: [00:12:07] The reason it is so difficult is as opposed to maybe diseases like Ebola virus disease that are generally quite severe for most people, I mean for some people they're lucky it's not that bad. COVID had this strange setup where for some people it was quite mild and for others it really took everything from them. How do you communicate that risk to society where every individual is very individualistic. Public health in this setting, in the COVID-19 pandemic setting, served as that network that shared how your individual actions are affecting other people's health outcomes. It was this big trust exercise and we could have done better, but we did pretty well in terms of starting to build that agreement until we got to a point where a lot of the response was politicized. And what keeps me up at night is H5N1, and the idea that there might be another respiratory pandemic down the road and maybe unfortunately, even sooner than we think it's going to be. And the worry that I have is that that trust has been eroded and it keeps me awake at night to try to figure out how we rebuild it in time for potentially a new threat.

Mati Hlatshwayo Davis: [00:13:16] That was so good. It was so good because me and you shared one thing in common where I also did some medical contributing, specifically trying to be the representation I didn't see. You're so forgiving about all of the criticism we received in this space about the lack of great communicators, but I really do think that we didn't have enough people who do the work that is represented with the four individuals right here, right now is that we had a lot of people who don't do this work, who don't intimately do the work of public health day to day to day, who did have the highest platforms. And that can be a difficult place to communicate. Because from Ginny's perspective, from Nahid's perspective, from Eric's perspective, I know that you guys day to day have to deal with educating people with the foundation of understanding that COVID and everything we deal with in infectious diseases are just not monolithic. Right? That was one of the really, really difficult parts of the communication at the beginning, is that I don't know that we trusted the public enough to understand a more complex idea in the way that you just so beautifully put it, Nahid, and that was communicated effectively. I think you're right. I think we did better than our critics will say. And I think a lot of what is now criticized is under the sort of politicized umbrella. But I think that's why the work of public health is so important, is because not everyone - there's people who are amazing at the bench, people who are incredible clinical researchers, but not everybody is a health communicator at their core. Right. And understands how to reach real people every day with really complex issues. I, like you, have sleepless nights, too, because the politicization of this makes it so difficult for us to engage this population again if we have another respiratory virus at a close level.

Nahid Bhadelia: [00:15:04] I'm with you. We could have done better. Don't take me wrong, I completely think that we could have done better. What I mean to say is that it was a very difficult task to begin with. Do you know why? Because there's objective proof that it's going to be difficult. I mean, I think there was like a report in October 2022 from Network for Public Health Law that said over half US states have released enacted laws, I think over 160 laws that limit public health authority and activity, which we know is going to be hard, because the laws are already in place to make it.

Mati Hlatshwayo Davis: [00:15:34] Yeah, and I think it's going to come up in some future conversation that we're going to have here about what the future of public health is and must be, and what we need to see from our society to have that happen. But I want to give an opportunity for each of you to kind of talk about your experiences. Some of you did to a certain extent. I would love for this podcast to serve as an opportunity to really encourage trainees and young faculty members who are maybe finding their ways to understand the diversity of public health, excellence and opportunities there are to have really exciting careers within infectious diseases in what are historically nontraditional pathways, right? And I think the three of you have done so in such exciting ways. Eric, I'm going to come to you first because you do a lot of public health work, but you also are in the leadership of this really exciting new, it's not a new fellowship, but I think the way that it's being rebranded and being made more accessible, at such an opportune time. So I would love to hear about your current work and especially the EIS fellowship.

Eric Chow: [00:16:37] I'll start off by saying that the Epidemic Intelligence Service or EIS, is the CDC's premier training program in applied epidemiology. It's for physicians, PhD scientists and people from other clinical and non-clinical training backgrounds. What's exciting about this training program is that under the mentorship of seasoned public health leaders, these officers are at the front lines of public health. Boots on the ground, investigating outbreaks, speaking with media, building those communication skills that you had talked about earlier, and expanding our public health knowledge across both communicable and non-communicable diseases. The specific program typically is about a two year training program where people will apply and then later match to a position within a team at CDC or within a local or state health department. Now, just as background as context, I was an EIS officer in the class of 2018 and how we classify our class years is the start of our program. So I was between 2018 to 2020 and I matched to CDC headquarters in Atlanta in the influenza division where I was based over the next two years. And let me just say, EIS was quite possibly the best time of my training career. And I recall Dr. Eric Pevzner, who's the chief of the program, telling us the first day of orientation that many people will remark that they can't believe that they're being paid to do the work that they do in EIS. And I have to say, I thought that every single day of my two years of training. To provide this critical update about the ID/EIS Joint Fellowship program, this is a unique new training program that blends the strengths of academic, clinical training in ID with the public health opportunities and mentorship offered through the EIS training program.

Eric Chow: [00:18:14] This is the start of the pilot year with 11 adult ID programs across the country who will be participating. And each of these programs are not only clinically strong ID training sites, but also have a history of training public health leaders. Interested applicants would apply to both programs at the same time. Application and acceptance into both programs will allow you to essentially have the next four years of training planned for you. And this is an incredible advantage of this pathway because you don't have to worry about what you're going to be doing next at the end of your ID training. You can focus your research and training activities during fellowship on your future public health interests. For the field of public health, this pathway would bring a new generation of medical epidemiologists with strong clinical training in infectious diseases to the field of public health. In ID fellowship, you'll gain the clinical skills and some subject matter expertise, but in EIS, that clinical training will be further honed and shaped for public health work by equipping individuals with additional skills for communication and data analysis that can be used across different public health activities.

Mati Hlatshwayo Davis: [00:19:17] I mean, it's incredible. I don't know about you, Ginny, but we're both directors of large public health departments, and I had to figure it out for myself. There was no formal pathway. There wasn't a lot of mentorship. And that can be a really lonely place for a fellow in ID and specifically for you and I, Ginny, in our intersectionality as black women also being the representation of the very communities that need to be served, it's really exciting for me to see IDSA and infectious diseases in general take such a directed approach at supporting fellows to make sure that these pathways exist, because the elephant in the room is that public health doesn't pay. Let's be serious. I always joke that I get paid the medium bucks to do really important works, right? And sometimes you're being really, really generous with the medium bucks. And so I think providing at least a very supported, accessible pathway for fellows is going to be incredible. What do you think, Ginny, hearing this, especially since one of the reasons I have Ginny on this call is to me, Ginny is one of the, one of the, what do the young people call it, OGs? But also the people that pave the way for black women in infectious diseases. So you've seen a lot and I think you had to build a career with much less than I had. And look at you now. You are the only person I could look to when I was crafting this who had a pathway that I wanted, that I could see, I could follow. But I know you did this in the absence of a lot of of tools. So what are your thoughts about this fellowship and what it could mean for the intersection between infectious diseases and public health?

Virginia Caine: [00:20:49] Well, I just think this fellowship opportunity is just awesome. It's an incredible opportunity for folks to see that intersection between public health and infectious diseases. I started out as a research hound, believe it or not, at John Hopkins, and got recruited to Indiana University to try to get a similar NIH grant. But at the same time, I was director of our STD program, which was a health department program. So they get me to answer any of their communicable disease questions, infectious diseases on the side. So that's how I got invested in public health. And then I actually got blackmailed into getting into public health. That may not be a great way to say this,

Mati Hlatshwayo Davis: [00:21:31] [laughs]

Virginia Caine: [00:21:31] But my research project was going on in the health department and they didn't have a director. And so they said, Well, if you don't take this job, we're guaranteeing you that your research projects are going to end. And that's okay. I'll take it. Just make it temporary, no problem. And wow, this was during the HIV epidemic. I got into that position as director of public health and looked at the different opportunities I can make in the community and work with the community. It was just so addicting. Once you get into this field, you do not realize the incredible impact you have, the different people that you meet, the different disciplines. It's just, oh, it's just amazing. And I did have a tremendous amount of people helping me on my way. My mentor, Dr. Hunter King Holmes. You know, he's Mr. STD. What can I say? He followed my career all the way through public health and has continued to follow it. So we've got to have good mentors that will continue to push our people.

Mati Hlatshwayo Davis: [00:22:38] That's right. And you are the exact example of what a career can look like at the end of an ID/EIS joint fellowship. It's just remarkable what you've done and the trail that you've blazed for people like me to do the same impact work. So I want to thank you and honor you. Nahid, I'll come to you. Do you want to talk a little bit about what it is you do and how trainees can think about forging a career in public health in a similar way.

Nahid Bhadelia: [00:23:05] To your earlier point about feeling like there aren't enough mentors right in the space that you're in, I feel like this is such an important point. Many ID careers, or types of phenotypes of ID careers as there are, ID fellows are out there. I mean, I think that this is the incredible part of public health and ID is that truly there is a lot of space for a lot of folks to be able to make a career in what they're interested in. And so my focus has always been in emerging infectious diseases, particularly to Eric's point, diseases that we don't know that much about and we have to make clinical decisions, public health and health systems decisions in terms of how we act to control them beforehand, to prepare for them. So I, for a decade or so, ran a special pathogens unit patient care unit that was designed to take care of patients with highly communicable diseases at Boston Medical Center. And that backed up our biosafety level four laboratory. So if you ask me how I got into that, I've always been interested in outbreak response. I've always been interested and actually got into EIS fellowship and didn't end up doing it. I know there are CDC folks listening to this are going to be like, Yep, she accepted. And then she withdrew. I took my current position 12 years ago. I would have been very happy in the EIS as well, but I'm actually very happy with the position I ended up taking.

Nahid Bhadelia: [00:24:16] The way that I got it is my focus had been in my fellowship with H1N1. It was 2019 and a huge part of my research was the impact of that particular pandemic on health care workers and health care worker policies within our health system. It had me hooked. I'd worked in global health in the past, had sort of been disenchanted because I felt always about like, what is my added benefit when I go to many other countries abroad? There are so many incredibly talented folks, and so what do I bring as a potentially an American in global health? My own answer to that was that it had to be that I brought something that was specific expertise that complemented already existed and that can only be used to continue to strengthen the communities that I was part of. In that expansive time, the majority of what I did was pandemic preparedness and response, particularly around Filovirus response, as part of the West African Ebola virus disease response in Sierra Leone over a couple of years, and then in the aftermath of that, we had a Fogerty grant in Liberia helping train the next generation of Liberian principal investigators. As of this year in our program, four out of the five trainees that we took into the program are in PhD programs or have just been accepted.

Mati Hlatshwayo Davis: [00:25:24] Love that.

Nahid Bhadelia: [00:25:25] The other thing that I've been part of is in Uganda was the clinical lead for viral hemorrhagic clinical Fevers unit that was run by Joint Program Executive Office of Biological Threats, which is run by DOD, which is a six bed unit that again was a partnership with Health Ministry of Uganda to help create better standard of care for patients who have viral hemorrhagic fevers.The thing that I discovered was that a lot of times with emerging pathogens, we think that their mortality is so high because they happen in countries that potentially don't have the resources to respond. And so our understanding of those diseases is very much based on the level of care that we're able to provide to those patients. And so that's been sort of the pathway. And then the latest thing, which I mentioned earlier, was about a year and something ago I was tapped by Ashish Jha, who's the White House COVID coordinator, as you know, to be a senior policy adviser for global COVID response.

Nahid Bhadelia: [00:26:17] So here I am, a physician, a public health person who now has the chance to do public health policy. And the scale of it. You know, if I were to tell you how trainees can be involved, let me start by saying two things. If you're interested in public health policy, I want to make you aware of two opportunities. If you're a medical student or a resident and you don't have a lot of time, you want to have a short amount of potential involvement and try to get to learn how our federal government works, particularly at the White House level. You can apply to be a White House intern. They're paid positions now and they're incredibly helpful in seeing how agencies communicate with each other, how our government functions, because governance in itself is actually a capability, a capacity that you have to learn, as I'm sure others on this call will say.

Nahid Bhadelia: [00:26:59] The second is, if you have longer ticket, if you have about a year to give, you can actually do the White House Fellows program. Incredibly helpful. I mean I think that it allows you to, and this is if you're a fellow, you've just finished your residency, I think even if you're a potentially early attending who's thinking about switching to policy, this is a great way to get into public health policy at the federal level, which gets you really close up because you really get to see how programs are built, how accountability is held within the federal government and priorities are set and what the barriers are. And then, of course, I would be remiss not to mention that if you're interested, the center that I run, the Boston University Center for Emerging Infectious Diseases Policy and Research, the core mission, our core mission is to build resilience against new pandemic threats. Our core mission is to try to link technical knowledge to policy questions about the very same emerging infectious diseases that we've been talking about, and we offer summer internship opportunities as well.

Mati Hlatshwayo Davis: [00:27:58] It's just so exciting to hear the three of you map out what would be perceived otherwise is widely divergent pathways towards a career in public health that are incredibly complementary but have taken you to global opportunities. But to change the very communities from which you were born in the case of Ginny Caine. Right, Ginny?

Virginia Caine: [00:28:19] One of the things that led me is that I got involved with the National Medical Association, that's the oldest and black physician group across the country, and they have such a network of folks in the academic arena, but we're also so interwoven with our private practitioners. So when you were talking about the messaging, you know, what do we do? But we have a program too. We have what we call the COB Intimate Institute, where we get research fellows and we put them with a mentor or faculty person. But as the chair of our infectious disease section, and we had our COVID-19 task force, we were the ones that got the pharmaceutical companies to have that accountability of saying, how many African Americans? How many Latinos do you have in your clinical trials for these vaccines? You got to tell us. And have you looked at your HIV patients? Have you looked at your sickle cell patients? What does that mean? But these are incredible opportunities that they could be involved with. We talk with the FDA, who's on your advisory committees in terms of making these decisions, and we allow you to come and present your research or if you're interested and want some training. There are so many ways in interconnections through public health with all of the different partners. Hey, Eric, save me a slot. I got some friends who are interested in those positions now.

Mati Hlatshwayo Davis: [00:29:47] And this is what I love about this powerhouse team is you're hearing it here first. You can join the ID/EIS joint fellowship program. You can reach out to Dr. Caine around the Cobb Institute and embedded within the NMA, and our very own Dr. Bhadelia's Center for Emerging Infectious Diseases Policy and Research does sponsor students in this way. And so it can seem incredibly isolating, but we have to do a better job of making sure that all the way from medical students and even before just pathway programs to folks who are interested in both infectious diseases and public health have these opportunities. So it's a natural question to go into. I listened to you three, it's clear to me that there's so many opportunities and diversity of excellence within public health right here within infectious diseases. Are we doing enough in academia to promote public health pathways and to collaborate, even if you're not interested within public health

Virginia Caine: [00:30:45] No, we're not doing enough. We have wonderful infectious disease clinicians. They do a fabulous job in the hospital setting. But hey, do you know that if you got a homeless person who was infected with COVID-19 and they're seen in the ER, do you discharge them back to the shelter? Hell no. Because then you've infected all the people in the shelter, all of a sudden you got a major COVID-19 outbreak. But with the average clinician, the infectious disease person, know not to send them out to the shelter or even think about the fact that they're going to leave. Where do they go? We have to have a better grasp and understanding of what goes on out in the community, not just what resides in our individual institution. And this is where the training comes between public health and infectious diseases. Now, at Indiana University, our infectious disease fellowship involves a rotation through the public health department. They don't have a choice, but I guarantee you they love us.

Mati Hlatshwayo Davis: [00:31:48] [laughs]

Virginia Caine: [00:31:48] And they enjoyed that rotation. And I think we have to do more of that. They see our case conferences. They understand what we're dealing with, our refugee program. I got all these Haitians, people coming from the Congo. How do they differ? How do we help them? What do we do for our homeless population? So you've got to understand all those aspects and be trained and educated related to that. And so more focus from our academic partners need to set up and do these type of collaborations and partnerships. Never more so than when we saw with the COVID-19 pandemic that we've got to have our medical epidemiologists and our clinicians. Give us the expertise, what's happening with all these dialysis units and we got COVID-19 breaking out with them. We got all this COVID-19 breaking out in these long term care facilities. What are we doing about this? Who's got that expertise to help us out related to this? We need you, ID folks. We need you.

Mati Hlatshwayo Davis: [00:32:51] Oh, you are preaching now. Listen, Eric, you did this. You came from academia. You represent what should be a really obvious way that this collaboration and this mix should exist. Why don't we see more of it? What are the barriers here? And do you think we're doing enough in academia to promote this?

Eric Chow: [00:33:10] I think we can always do better. I think we can always do more. I think for me, thinking back about the opportunities that I had that enabled me to embark on this public health career path was really coming down to role models and mentors. ID mentors such as Dr. David Mattson, Dr. Leonard Mermel, Dr. Nicole Alexander-Scott, all important infectious disease clinicians, but with a passion for public health, sought me out as a mentee and paved the way for opportunities, met my enthusiasm with active mentorship that really fostered this curiosity that I was then given permission to kind of explore throughout all stages. And never was there a point during my time that they ever said no, that this was a ridiculous pathway, that everyone goes through the traditional kind of research pathway to be able to get to public health. Instead, they sought out new networks and contacts for me that then. Allowed me to further explore this burgeoning interest in the field. Of course, as soon as I got to the point where I connected with eyes, there was no longer any lingering doubt in my mind that public health was part of my future. So having role models and having that type of mentorship is so critical to trainees, particularly when they're trying to explore what career path might look best for them.

Mati Hlatshwayo Davis: [00:34:29] I love that. And you cannot separate active mentorship from sponsorship, though. It's a conversation we don't have enough of. You can have great mentors, but if they're not positioned to put you in a place to succeed, either through real and active funding opportunities, grants, or just having that position of power to make sure that you're getting equitable advancement, promotion, protected time to be able to do that work, we lose a lot of fellows because, if we're going to call a spade a spade, what either through perception or reality is happening in our academic centers is that people who come through traditional pathways, basic science, traditional clinical research, they have cleaner and more visible pathways that are better supported. And so we have to create visible, tangible, supported opportunities for folks in public health, especially if they're from minoritized communities, because we don't get enough of those trainees to begin with, and they're the very representation that they seek.

Mati Hlatshwayo Davis: [00:35:25] Nahid, I want to come to you. Given the global, national and local disinvestment in public health, we've made a case for the importance and prioritization of public health. We've made a case for why academia needs to be involved and the need for leadership. But 2021, 38,000 public health workers left the workforce. We know that these are less salaried positions, and we know that this extends all the way to the global level. So, I mean, it's a terrible question because I'm asking you to fix this dilemma that we've had, and that's been increasing over the last five years, but what do you think must be done to support public health as a priority moving forward at the global level to ensure some of these changes we've talked about can happen?

Nahid Bhadelia: [00:36:06] Before COVID, on the global scene, we were so obsessed with assessing capacities of countries to be able to do this, and that's still important. That is still necessary, but it is not all there is. Well, we realized with things like the global health security agenda or the joint external evaluations, to look at how we detect surveillance, detect and respond to threats is that you've got to have the capacities, but then you have to have the capability to actually mobilize those capacities. And that's to do with governance and that's to do with engagement. Part of what that comes with is ready, necessary resources to be able to bring those capacities to bear, and that requires sustained financing. I know that comes as no surprise to you because we just talked about how public health workers are underpaid. The entire public health system is underfunded. Again, no surprise. And a couple of things that I'm watching on the global side, or the global scene, one is the World Bank's pandemic fund, which just had its first cycle of funds which were released to countries, low and middle income countries, that are looking to build that capacity, which will hopefully provide some of that sustained financing to build public health workforce, better surveillance. The other thing that I'm looking at is how negotiations go around the pandemic treaty, because that's going to help decide where equitable resources are put into play if there's a threat next time.

Nahid Bhadelia: [00:37:24] So those are the two important things that I'm paying attention to on the global side. And the last thing that I will say is we've all learned how important trust is in this in the national setting. It could not be more important in the global setting as well. There are faculty at my center that did some research looking, for example, at how impact of religious leaders and conversations affected women of reproductive age, willingness to get COVID-19 vaccines. Right? People are getting their public health news everywhere. We need to have a better way of how we support those. That means that there's space in this public health world for every type of public health worker, not just the EIS and the ID doctors and things like that. We need better communicators. We need to pay them. We need, you know, we need to bring in a bigger group under the umbrella to meet these very varied needs of public health, both in the global setting, as well as the domestic setting. I think IDSA should continue to advocate for better investments, continued financial investments in public health. They should advocate, as you mentioned, how we fill these roles. I think it was like 2200 state epidemiologists and local epidemiologist positions were still open in 2021.

Mati Hlatshwayo Davis: [00:38:30] It's astounding. So one of the creative areas I've taken is as a local health director for a city health department, I'm sitting on an external national committee for an emerging school of public health at an academic center. Why does that matter? It's because I get to sit with the people who are building this school from the ground up and are talking about the billions of dollars that they have in funding to talk about a vested program where they pay faculty members, right? They take the burden off of the local health departments and they pay faculty to be embedded within the local health department that they then have a constant stream of graduate students that are embedded. Because one of the things that drives people like Ginny and I crazy is when people ask us to house interns who are there for 6 to 8 weeks. By the time you've trained them in anything, they're on their way out. So we need one year, two year commitments, long term commitments to building workforce capacity. That's the kind of innovation we need until we can bridge the gap in funding, that comes down to political prioritization.

Mati Hlatshwayo Davis: [00:39:33] So why do people like me and Ginny sort of leave our academic pathways that we were passionate about our whole lives? It's because of need. And the last thing I will say to you is when you see a US Supreme Court make the type of decisions they did within the last week, that directly impacts the message that you're sending, Nahid Because when you're saying we have to diversify the workforce, when you're saying it can't just be doctors and epidemiologists like some of the folks on this call, you're speaking about representation. We know that the gap between trust and mistrust within public health is filled, and there's data that supports representation really making a difference here. And so we've got to do and continue to commit to diversity, equity and inclusion measures even after the Supreme Court has made it even harder for us to do. And I just appreciate your message. What an incredible conversation. I want to thank you all for your passion, for your transparency and for your leadership. Thank you so much.