Latest / CareTalk: Healthcare. Unfiltered. / Innovations in Public Health with Dr. Megan Ranney

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Innovations in Public Health with Dr. Megan Ranney · CareTalk: Healthcare. Unfiltered.

• 0:00
  Dr.
• 0:00
  Megan Ranney is an emergency physician, researcher, and advocate for innovative public health approaches to prevent violence and related behavioral health problems and to reduce COVID related risks.
• 0:10
  This summer, she was appointed Dean of the Yale School of Public Health.
• 0:19
  Welcome to Care Talk, America's home for incisive debate about healthcare business and policy.
• 0:23
  I'm David Williams, president of Health Business Group.
• 0:26
  And I'm John Driscoll, the president of Walgreens Health.
• 0:29
  Dean Megan, congratulations and welcome.
• 0:31
  Thank you so much.
• 0:32
  It's a joy and a privilege to join both of you today.
• 0:35
  So in my, in our background research, it sounded like you've actually been interested in issues of social determinants since high school.
• 0:42
  Can you, can you kind of?
• 0:44
  Explain how you got such an early start in public health.
• 0:48
  Well, I mean, I think I'll think Thoreau and Louisa May Alcott for that.
• 0:52
  I grew up reading lots of books about the ways in which society and health intersect.
• 0:59
  Um, and if we go back to the founding of the American Republic, creating systems that enable health was part of the earliest days, um, of our country.
• 1:08
  I was motivated by that probably from honestly middle school onwards, although I didn't have The words to call it public health, uh, it took me another 10 or 15 years before I realized that this was my true calling.
• 1:21
  So did you have any mentors in that, in that area, or was it just from, uh, reading and sort of looking back on the, in the founding of the Republic?
• 1:28
  Because that's not the, I would just say that's not the conclusion that every, uh, you know, school, school kid, uh, draws from the American Revolution.
• 1:37
  I was lucky growing up in Buffalo, New York, there were a bunch of terrific, uh, volunteer organizations that welcomed teenagers into them.
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  We had something called Youth Engaged in Service, where we went and volunteered in nursing homes or for Habitat for Humanity.
• 1:52
  Um, and I would say that was actually my earliest introduction to the work behind public health, as well as to the fact that sometimes you need to create structural change rather than just putting Band Aids on an issue.
• 2:03
  I think at one point you made the comment that all medicine is political.
• 2:07
  How do you think about the interaction of politics and medicine?
• 2:10
  So I think that probably came from Rudolf Virchow, who was a founder of medicine and talked about how medicine and society or medicine and politics are inextricably linked.
• 2:20
  Um, you can't think about health if you don't think about the structure in which we live.
• 2:25
  Um, but I actually went into college planning to do...
• 2:28
  major in comparative literature.
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  I fell in love with a field called the history of science, which looks at how science and society interact.
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  The type of work that we do is influenced by the culture in which we live, and then the way that we, um, apply science can sometimes change culture.
• 2:47
  So, I was lucky enough to work with folks that thought about the intersection between Mental health, mental well being, cognitive function, and society.
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  There was a woman named Ann Harrington at Harvard as an undergraduate who took me under her wing.
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  And that path kind of started me thinking about the stuff that informs what I do today.
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  But I didn't think I was going to go into medicine at that point.
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  I actually applied to the Peace Corps after college.
• 3:12
  Went and spent two and a half years living in a country called Cote d'Ivoire in West Africa, um, ostensibly working on water and sanitation, but honestly doing a lot of work on HIV AIDS prevention and women's economic empowerment to help them avoid the circumstances that led to their getting infected.
• 3:28
  And that was the path that brought me back to medicine.
• 3:31
  If you had asked me as a junior or senior in college, I would not have told you that I was going to be heading into medicine, much less again, public health.
• 3:39
  That wasn't even really a word or a term that I knew.
• 3:42
  Um, at that point in the mid nineties and what got you excited from that?
• 3:45
  That's, that's, that's really hard work and very much almost where community organizing meets education meets, meets, I mean, and that, and at the time you were doing it, it w the, the, the science and the medicine and the, the, the.
• 3:59
  term of art, I think of Paul Farmer's work, were being developed in the field.
• 4:03
  Like, how did you, how did you then, what, how did you pull those pieces together and, and, and, and decide to become a doctor?
• 4:10
  So it was frustration, uh, with the way that things were.
• 4:14
  Um, when I was in Cote d'Ivoire in the late nineties, it was really at the height of the HIV epidemic there.
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  Um, Cote d'Ivoire or Ivory Coast had a major commercial highway, or a major highway system that served as kind of the commercial artery for much of West Africa.
• 4:30
  And so truckers would drive up and down the highway and spread HIV at the truck stops along the way.
• 4:37
  That's exactly right.
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  Um, and at that point, there was no access to antiretrovirals in West Africa, whereas here in the U.
• 4:44
  S., of course, we had them.
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  And although they were somewhat toxic and weren't perfect, um, I had family members who had been active in ACT UP, um, when I was a kid and, and a teenager.
• 4:56
  And so I knew the importance of that access to medications.
• 5:00
  And I got so frustrated that I couldn't get my friends access to those same meds that we had in the U.
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  S.
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  Um, that was actually what drove me to go to med school.
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  As I said, I don't want to just be able to kind of see this and describe it.
• 5:12
  Yes, I want to work on women's economic empowerment, um, so that they can leave an abusive relationship or so that girls can go to school without having to sleep with someone to get money to pay for their school books.
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  Um, but even more so, I wanted to be able to provide folks that hope on the other side.
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  You can't prevent a disease if there's no...
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  Hope about it being able to be treated.
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  If you can't talk about it out loud, um, you're never going to succeed in changing those underlying conditions.
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  And so I went back to med school very specifically so that I could learn kind of what I needed to know so I could go back to West Africa and provide access to meds.
• 5:48
  Of course, it's so often true, and I'm sure it's true for both of you as well, life took other directions, um, and so I didn't actually end up going back to Cote d'Ivoire.
• 5:57
  Um, although I continued to work with friends there for years.
• 6:00
  So why emergency medicine?
• 6:02
  Uh, emergency medicine, it, because it is the part of the American healthcare system that is first, the most available to everyone, regardless of who you are, where you come from, your ability to pay, your type of insurance, the language that you speak, anyone, anywhere can access, um, the emergency department.
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  Second, because it's a challenge.
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  Um, I remember as a med student being scared about CPR and resuscitations and emergency medicine was a way for me to conquer that fear and to know that I could handle anything at any time.
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  You get to diagnose mysteries.
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  You get to create connections with people who you've never met before.
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  Um, it's just a, a tremendous, um, kind of push of, of your skill set.
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  And then the third part is that it is, uh, the best place for teamwork.
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  Um, emergency medicine is the biggest team sport in medicine.
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  It's not hierarchical.
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  It's all about the community and taking care of each other.
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  And that was something that was.
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  Deeply attractive to me.
• 7:04
  I always like uh, speaking with emergency physicians because I know like on a podcast I can ask any question coming out of left field because if it could be anything, you know from yellow fever to uh, Pneumonia, you can handle the range of my questions.
• 7:14
  Maybe not of john's And also I think emergency physicians make excellent Entrepreneurs often because, you know, they could deal with anything.
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  They're not fearful of it.
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  They, you know, can overcome whatever concerns they have and deal with a broad variety of things pretty quickly without, uh, without getting bogged down.
• 7:30
  I think that's exactly right.
• 7:31
  We're used to making, um, decisions based off of limited data and then pivoting as we get more data in testing and then reevaluating.
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  It's part of our lifeblood.
• 7:42
  We're also used to MacGyvering, um, in, in limited, uh, resource situations.
• 7:48
  Um, and our shift work sometimes allows us to, to have a little more space and time to be entrepreneurial as well.
• 7:55
  One of the things I think we talked about last was, was your experience of working in the ER during COVID and kind of the lessons, uh, of what worked and what didn't work since you were sort of on the front lines at a very early stage.
• 8:08
  And I, I still don't think as a system or as a country we've necessarily internalized it.
• 8:12
  Maybe you could share some of the perspectives that you had, what you learned, what you saw and kind of what you'd like to see.
• 8:19
  different today so that we're better prepared in a world that's much more connected and much more prone to micro or macro events like the, the, the, the, the COVID related public health emergency.
• 8:31
  So this is where emergency medicine and public health are deeply intertwined.
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  We are both the safety nets of the United States and we see many public health problems first.
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  and most acutely in the emergency department.
• 8:45
  There's no buffer, right?
• 8:47
  We see folks before problems are differentiated.
• 8:50
  We don't necessarily have the whole team there, uh, present, but ready to support us at the time that someone shows up.
• 8:57
  And we saw that in spades in emergency medicine.
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  I will never forget.
• 9:02
  Um, I was working in the emergency department the night that our first COVID patient, um, came in and got admitted to the ICU in Rhode Island.
• 9:11
  Uh, he had, it's a public story, so I can share it.
• 9:13
  He had gotten sick on his kid's school trip to Italy, um, and ended up, uh, intubated and in the intensive care unit for quite a while.
• 9:20
  Um, and taking care of him was...
• 9:24
  Just, uh, traumatic for everyone, um, on the staff.
• 9:28
  It was seeing in real time all the ways that our health and public health system were broken.
• 9:34
  Getting a test was nearly impossible.
• 9:36
  We had to fax.
• 9:38
  and wait for faxes of results around kind of COVID testing.
• 9:42
  Um, we already were seeing, um, the harbinger of PPE shortages, but then when the patient got wheeled up to the ICU, one of the things that stuck with me most was that all of us as physicians and nurses had been in and out of the room as quickly as we could with maximal PPE at every moment.
• 10:01
  But our housekeeping staff had to go into the room after the patient was wheeled up to the ICU and spent.
• 10:08
  Over an hour in that room, cleaning every surface, disinfecting so that the next patient would have no chance of getting, would be protected and would not get sick.
• 10:18
  And that housekeeping staff put themselves in some ways at so much more risk based on what we knew at that moment about COVID than those who had been at the bedside.
• 10:28
  And it brought into stark, uh, reality for me the degree to which this disease was going to.
• 10:36
  Um, spread along and even exploit so many of those classic class boundaries and social structures, um, and, and the fact that those housekeeping staff had no power to go on TV or on social media and talk about their need for PPE, where I, as a doctor, did.
• 10:55
  And so I, I, I tell that story as really just being emblematic in the way that, of the way in which emergency medicine again served as the, the tip of the spear for COVID response, but also as, um, really an exemplar of all of the other problems across society.
• 11:11
  We saw it with issues with folks that were unhoused and got COVID and there was nowhere for them to go, um, with the prison populations, um, with vaccine resistance, um, and It, it continues, um, today, but there were also strengths because we saw people make do with little.
• 11:31
  We saw our teams come together to support each other.
• 11:34
  We saw movements like our Get Us PPE non profit, which really was created out of the frustration of a bunch of emergency physicians, uh, with not being able to get PPE in those early days.
• 11:46
  We ended up getting more than 20 million donated pieces of masks and gowns and gloves and distributed them to those in greatest need countrywide.
• 11:55
  Um, both the best and the worst, um, of the healthcare and public health system was really, uh, shown over the course of that crisis.
• 12:02
  So, you know, you talked about emergency department as being this, the tip of the spear in a sense, and, and one of those areas, of course, is, uh, firearms.
• 12:10
  Uh, you've been very active in firearm injury reduction.
• 12:12
  I thought we were going to start there because John started to say, like, he did a background check on you, but it turned out that was a high school background check.
• 12:18
  And I don't think we have any background checks about firearms anyway, that may be a different story.
• 12:22
  But, you know, what's the, what's the thought in terms of firearm injury reduction?
• 12:26
  What's your, what's your approach there?
• 12:27
  Absolutely.
• 12:28
  So John, you've heard me say this.
• 12:31
  Um, I, I think of firearm injury prevention as no different from any other type of public health intervention and prevention.
• 12:41
  And I think one of our greatest failures as a country is that we have failed to apply that public health approach to gun violence or to firearm injury.
• 12:49
  It is the public health model, which, to be clear, is four steps.
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  First, you measure the problem, then you identify risk and protective factors.
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  So, all things being equal, what puts someone at greater risk?
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  Or, all things being equal, what protects them from risk of injury or disease?
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  Then you create interventions.
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  The third step is you create interventions to either decrease risks or improve protection.
• 13:13
  And then finally, you scale up what works.
• 13:16
  You can do those four steps across individual level interventions, family or community level interventions, or even societal wide.
• 13:24
  And when you apply it, it works tremendously well.
• 13:27
  Uh, an example that I frequently cite is around car crashes, and former President Obama has recently started using this analogy as well.
• 13:35
  If you look to the history of car crashes in America, if you go back to the late 60s, early 70s, compared to today, the Car crash death rate adjusted for population has decreased by more than 70 percent.
• 13:50
  We have done that by applying the public health approach, not by a criminal justice approach.
• 13:55
  We looked at what was happening, where it was happening, what people, put people at risk, what protected them, and then we changed things accordingly.
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  We found out that drunk driving put people at risk.
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  So, yes, we passed laws.
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  We also launched educational campaigns.
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  We changed.
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  Community norms.
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  And of course, we have things like Uber now, which help further reduce the risk of drunk driving.
• 14:18
  We figured out that road and car design mattered, and we changed the way that roads are constructed.
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  And we put seatbelts in, three point seatbelts, and airbags in every car.
• 14:27
  We figured out that car seats make a difference for kids.
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  And so now, before you leave the hospital with a newborn baby, you have to show that you have a car seat, and if you have a car, you have to show that it's installed correctly.
• 14:38
  We've done a suite of interventions that address all these risk factors and that improve protection, and it's been that combination that has decreased car crash deaths.
• 14:47
  We have not banned cars, although, of course, there are certain cars that we don't let drive on the road, and there are certain people who we don't let drive.
• 14:54
  We've not taken that approach to gun violence.
• 14:57
  We've not applied a harm reduction philosophy, which we've used for every other major public health problem.
• 15:02
  We have, of course, failed to use policy appropriately, but we've also failed to create connections and community.
• 15:08
  Um, we have not changed norms in this country around safe firearm ownership.
• 15:14
  Um, and if anything, unfortunately, an increasing proportion of Americans think that they have to have a gun at the ready, at every moment, in order to stay safe, and it's become this self fulfilling cycle.
• 15:25
  So, to me, when I think about gun violence prevention, it's about that four step public health approach, and when we have applied it, We do have some great stories of small successes in individual communities or counties or states where we have shifted patterns of injury and death using that four step approach, um, doing things as different as putting in gardens and cities.
• 15:49
  To developing violence intervention wraparound programs for youth who are at highest risk of gun homicide to suicide prevention programs and safe programs to, um, increase safe storage among rural gun owners who are at higher risk of gun suicide, which, of course, is almost two thirds of gun deaths nationwide.
• 16:10
  We just haven't scaled those, and I think there are probably I know that there are more solutions out there that we haven't proven yet because of our country's.
• 16:19
  unwillingness to move beyond this, again, criminal justice perspective on, on gun violence.
• 16:25
  I like the car safety, uh, example, especially since, uh, my father was the principal author of the Child Restraint Study that you just mentioned from 1970 to 1973, around that time.
• 16:33
  Uh, that's a different story.
• 16:34
  I knew I liked you.
• 16:37
  But it would be, uh, it'd be great to be able to apply that.
• 16:40
  And, you know, there's a lot of views that changed, uh, during that time.
• 16:43
  If you think about, there used to be a lot of resistance to putting on a seatbelt.
• 16:46
  And somehow the idea that you were going to be safer if you're thrown from the car, you know, when there's a crash compared to actually having, uh, having the car, uh, seatbelt on.
• 16:54
  And there's a lot less resistance to those sort of, uh, rules now than there was.
• 16:58
  So there may be some, some lessons for that in firearms.
• 17:01
  I guess I, I guess I'd like to test the, the, the, the.
• 17:06
  The public health perspective, what is, as the Dean of the School of Public Health at Yale now, you have to opine on everything.
• 17:13
  There's this horrible incident in Lewiston that we're just starting to get our arms around, but it's quite clear that you had a mentally unstable.
• 17:22
  Guy who with, who is, who is highly trained, had access to, you know, incredibly powerful, high capacity weapons.
• 17:33
  Um, and yet the, yet the system failed.
• 17:37
  As you look at the current system with a, or a country that's suffering.
• 17:42
  Uh, some of the highest rates of anxiety and depression and, and mental illnesses that we've measured in, in modern times.
• 17:49
  And that is, that is committed to protecting the folks, second amendment rights, even in blue states.
• 17:58
  That are, that are particularly that are rural, what can we do to start to address using that public health lens, this issue of, of, of, uh, people who are mentally unstable, potentially at risk and, and balancing that with, uh, the constitutional obligation to the second amendment.
• 18:17
  How would you think about taking a public health lens to that, that problem?
• 18:21
  Absolutely.
• 18:22
  It's a great question.
• 18:22
  And I think, you know, we still know so little about the horrors that happened in Maine.
• 18:27
  Um, and unfortunately, we're never going to know the story from a proactive standpoint.
• 18:32
  It's going to be a post hoc forensic autopsy of this man, um, to, for us to figure out what happened.
• 18:40
  There's a few different parts.
• 18:41
  So when I think about risk and protective factors and applying that public health approach, there are so many steps along the way where this could have been avoided.
• 18:50
  Even if we don't, you know, maybe there was stuff back in childhood, who knows?
• 18:55
  Maybe there was diagnosis of mental illness for this man and getting him into treatment earlier that would have made a difference.
• 19:01
  And God knows we have insufficient numbers of mental health practitioners in the United States.
• 19:06
  Everyone that calls out mental illness is the cause of gun violence.
• 19:10
  We don't have more mentally ill people than any other country.
• 19:13
  And there have been studies showing that even if we increased the percentage of behavioral health providers by 10 percent, It would only decrease the number of gun suicides by about 1.
• 19:23
  2 percent.
• 19:24
  Difficult to say, I know.
• 19:26
  Difficult to say the effect that it would have on other problems, but treatment certainly could be helpful.
• 19:31
  Even more so, it's having someone be linked into a community, and that's a healthy community, not an online social media community of conspiracy theorists, which foment hate and often drive the ideas that lead to these mass shootings.
• 19:45
  We have ample studies showing that being part of an in person community group provides resilient.
• 19:51
  mental well being, and decreases risk of violence in general.
• 19:55
  So those are all upstream factors.
• 19:57
  There's also stuff around that man's access to a firearm.
• 20:00
  From what I understand, again with that caveat that we're still at a very early stage, there were such clear warning signs.
• 20:06
  And we know that the vast majority of mass shooters actually do have warning signs before the shooting that no one knows about or knows how to act on.
• 20:15
  In this case, people identified it, but did not act appropriately.
• 20:19
  Unfortunately, Maine had a yellow flag law as opposed to a red flag law, and that is part of the public health approach.
• 20:25
  Policy does matter.
• 20:27
  The yellow flag law would have required him to be evaluated by a medical professional, someone like me, who would have declared that he was unfit to own a gun that would have gone before a judge and resulted in seizure.
• 20:37
  Most of us as doctors are not trained to do that kind of evaluation.
• 20:42
  Most ERs or clinics don't have that kind of person on staff.
• 20:46
  It is an insufficient law and the red flag laws have been shown over and over again to work.
• 20:51
  So had Maine had a red flag law, it is possible that this could have been avoided.
• 20:56
  There's also questions about whether the yellow flag law should have been activated.
• 21:00
  Did people know that it existed?
• 21:02
  And then, you know, you can go down the line to his ability to purchase, um, uh, a, uh, a long rifle that was semi automatic and to take together multiple magazines.
• 21:14
  In today's day of 3D printing, that is possible.
• 21:18
  Again, should there be additional, um, policy strictures and, and to, to make it more difficult for anyone who has not gone through certain assessments of stability to access, um, that type of firearm?
• 21:30
  Something up for debate, but a place in which we apply the public health approach frequently.
• 21:35
  So it's a combination of that individual level trying to decrease risk, trying to mitigate risk of harm, and then sometimes policies matter deeply, but you can't only rely on policies.
• 21:45
  It's also a normative and cultural change, um, that makes a difference.
• 21:50
  So unfortunately, lots of holes in that Swiss cheese that allowed that horror.
• 21:54
  I think the fact that, the fact that you've got, I think the other thing I would double click on is often the underlying systems with everyone working hard.
• 22:01
  Do not connect and are not updated and modernized in a way that your, your, your airline check in facilities are.
• 22:11
  And I think if we, if we start even just supporting the modernization of the basic infrastructure.
• 22:17
  That people agree on would be a step forward, but the fact that you've got some ideas on how we can improve it is, is, is honestly, uh, makes me feel slightly better about the fact that we are continuing to generate good ideas to improve, not, not to radically change where we are, but to improve it and, and, and perhaps save a lot more lives.
• 22:36
  And John, just to say about the data that is true, not just for violence prevention, but for every part of public health, if I go back to COVID, we didn't have data on anything.
• 22:46
  Demographics, nothing.
• 22:48
  We were putting together kind of citizen science.
• 22:50
  It was the Atlantic that put together one of the best sources of hospitalization.
• 22:54
  It was my non profit that had the best source of data on PPE.
• 22:58
  Same thing is true for violence.
• 23:00
  We literally can't get two state agencies to talk together or to share data sets, much less to get a hospital to share their data set with a state.
• 23:09
  Um, the CDC has been pushing for its data modernization initiative for quite a while.
• 23:15
  People say, well, why does that matter to public health?
• 23:18
  It is the lifeblood of public health, just like it is for every other industry.
• 23:22
  They're asking for a pittance of money in terms of the overall federal budget to try to update.
• 23:28
  Public health data infrastructure.
• 23:29
  Um, it's a national security issue.
• 23:31
  Just to be clear.
• 23:32
  Having a dashboard on the Health of America at a time of bioterrorism, of pandemic threat of, of, of, of, you know, uh, viruses jumping species.
• 23:43
  It is literally a public, uh, a national safety issue as well as a public health issue.
• 23:48
  I'm really hoping we can, we can solve that, but perhaps not by the end of this podcast.
• 23:53
  David, I think we have to wrap.
• 23:54
  Let's pick, let's pick an easier one.
• 23:56
  And, um, how about opioids?
• 23:59
  Solve that one?
• 24:00
  Talk about data challenges, holy cow.
• 24:03
  Do you know how long it took us as physicians to be able to see someone's history of opioid prescribing?
• 24:09
  It was years.
• 24:10
  Oh, it was, it was only, I mean, it was only a couple of years ago that we were actually able to see the opioid prescriptions that someone had previously received from other doctors, particularly if they'd received them in other states.
• 24:23
  Wow, so the 30 pills you got from the first doctor, you could go to a different doctor and get another 30 pills?
• 24:29
  With no tracking, no reporting system.
• 24:32
  It's really over the last year.
• 24:33
  decade that we've developed, um, these prescription drug monitoring databases, um, and then integrated them into electronic medical records.
• 24:41
  There were lots of patient safety and security concerns, but back to that same data issue.
• 24:46
  So when people, yes, there were horrible, horrible physicians who were pill mills, um, but also you couldn't necessarily see if someone had just walked down the street and gotten a prescription.
• 24:56
  Plus, we were told as doctors that opioids weren't addictive.
• 25:00
  Um, we were sold a.
• 25:03
  Um, by, by a couple of large companies.
• 25:06
  Uh, and now it's further complicated by the spread of, um, synthetic fentanyl analogs, which is not through medicine, um, but through, uh, really kind of the criminal markets that make it so dangerous.
• 25:19
  I mean, I've taken care of patients that thought that they were smoking a joint or using cocaine and not that either of those are.
• 25:26
  Great ideas on a daily basis, um, but, uh, you shouldn't die from, um, one of those in a second, which is what happens with those synthetic, um, fentanyl analogs, so.
• 25:37
  We've gotten ourselves into a deep hole of addiction.
• 25:39
  We have this, um, very dangerous supply out there.
• 25:44
  Um, we need to reduce harm for those who are currently using substances, but we also have to work on preventing more folks, um, from, from taking up, uh, opioids as a way to dull their pain and escape the, the trauma, um, of the current world that we're living through.
• 26:00
  Well, we always save the easy question for last, so I'll say that's it for another episode of Care Talk.
• 26:05
  Our guest today has been Dr.
• 26:06
  Megan Ranney, Dean of the Yale School of Public Health.
• 26:09
  I'm David Williams, President of Health Business Group.
• 26:12
  And I'm John Driscoll, the President of Walgreens Health.
• 26:14
  If you liked what you heard or you didn't, we'd love you to subscribe on your favorite service.
• 26:18
  Thank you, Megan, for joining us.