Public Health: Lack of Trust, Loss of Workers

The following is a transcript of an Instagram Live event where Jeremy Faust, MD, editor-in-chief of MedPage Today, and Megan Ranney, MD, MPH, incoming dean of the Yale School of Public Health in New Haven, Connecticut, discuss professional issues in public health, including how the sector has changed after the COVID-19 pandemic (note that errors in the transcript are possible).

Faust: We’re talking about public health today: the field, the good, the bad, where we’re headed, where we’ve been. Who better to join us than my good friend Megan Ranney?

Dr. Ranney is a practicing emergency physician currently serving as the Warren Alpert Endowed Professor in the Department of Emergency Medicine at Rhode Island Hospital and Alpert Medical School at Brown University. But she’s also departing that role, where she was also academic dean at the School of Public Health, to become the dean of the School of Public Health at Yale University as that school bridges out from its past as part of the Medical School at Yale and now becomes its own separate entity. It’s sort of a reboot.

You have a background in gun safety research and have been a rational voice to not just me, but to millions of Americans. So, Dr. Ranney, thanks for joining us today.

Ranney: It’s a total pleasure, Jeremy. It’s an honor to be here.

Faust: I’m always very formal with my guest — Dr. This and That — we’ll go back and forth a little bit. I’m very conscious about making sure that I use the word doctor equally to everyone who has that title. You and I are such good friends, it’ll be a little weird not to go back and forth. So Megan, thanks for coming on the show.

Let’s talk about where we’ve been. It’s 2023. Public health wasn’t really on people’s radars in 2020, would you say so? What do you think the through line of that has been? What do you think the average American thinks when they think of public health?

Ranney: You’re exactly right. Prior to COVID, when I told people that I had a deputy dean position at the School of Public Health, or that I was a public health professional, they kind of said, what’s that? Nevermind if I talk about epidemiology or biostatistics. It’s like I was speaking a foreign language.

Now, I think there are few Americans, few people worldwide, who don’t at least know of the concept of public health. But I think there’s still a lot of confusion about what we do and the scope of our work, the impact of it, and the ways in which we work with communities, with educators, with for-profit and not-for-profit businesses. I think folks’ view of what public health is is a little skewed by thinking it’s all about COVID.

Faust: Yeah. This is a question that I have, maybe not for the audience, but you teach in both medical school and a school of public health, which are very, very different disciplines. One’s really about patient care and one’s about understanding the system in which healthcare is delivered and all the challenges that a society may face.

Do you think that people who don’t practice medicine who are in a school of public health or have a career in the health professions are kind of missing something by not seeing what we see, which is that this is what it’s like on paper, but in real life it’s a different story?

Ranney: I would say the same in the opposite direction, that many healthcare providers are missing the view of people who practice public health every day.

I think of the two disciplines as being kind of an overlapping Venn diagram. So, two circles that share a lot, and which can both be enhanced by talking to each other and by having some shared training, but they’re not completely overlapping. Not all things in healthcare are public health, and not all things in public health are healthcare.

In fact, you and I would both say there’s a lot that we do in the healthcare system that unfortunately is not informed by those basic principles of public health.

Faust: That’s fair. My soapbox on this is that — I don’t have an MPH, that’s a master’s in public health — but I also feel like medical students who are applying to residency and want to be competitive often take a research year, which is very prestigious, and then you can go down into a field that’s competitive.

Stopping to get a master’s in public health, people do it, but it’s not necessarily held in the same kind of prestige … I kind of wish that was different, because I think it’s a skillset that is far more applicable and long-lasting than 9 or 10 months in a lab where maybe the project worked or didn’t work.

Ranney: I completely agree with that, and I think that the MPH deserves to be elevated overall.

We had a good discussion yesterday with some folks at a Department of Health training the public health workforce and about how we really need to use that MPH to not just teach people the basics of sensitivity and specificity and how to program and how to understand basic environmental determinants of long-term health, but also to use it as a chance to teach people how to be leaders within the field of public health.

And I do think it’s an essential skill set for physicians to understand the ways in which society, the environment, climate, the design of streets, the design of houses, economic systems, how all of that impacts health, and understand, on the other hand, how to use data, what good data sources look like, what they don’t, and how do you analyze them.

One of my colleagues here at Brown works with some folks at Yale and they teach a class on napkin math. So, how do you start from an incomplete data set and do your best to get reliable and reproducible answers? Those are essential skill sets for healthcare providers, or at least for healthcare leaders, to have.

But I agree. We do have a ways to go in terms of elevating the perceptions of the rigor and the leadership value of that Master’s. It’s something I look forward to taking on in my new role at Yale.

Faust: What are some of the things that someone getting an MPH would learn?

Ranney: You learn about basic statistics, biostatistics, epidemiology. You learn how to track disease risk factors, preventive factors, how to create data sets, how to analyze those data sets. You learn about the basics of the healthcare system, both globally and nationally, how it’s funded, how it’s structured.

You learn about environmental health; everything from toxins — in that disaster in East Palestine with the train overturning, there were public health professionals that were part of that response team that were thinking about the long-term effects.

Then you learn about communication, leadership, policy — all the things that go into creating a functioning public health system, which of course is about more than a governmental public health system. It’s about setting up the structure to keep society healthy, both physically and socially and emotionally.

Faust: I think that, from the perspective of an emergency epidemiology perspective, which is the perspective that I bring, we’ve never been in a better place than we are now in terms of who knows what. The workforce is amazing.

I suspect that the same is true with the MPH with who’s coming in and what kind of work is being done. I mention that because the title of this conversation is a little doom and gloom — loss of trust, lack of trust — things are bad. But do you sense a difference in students that are coming out of public health schools in this country today?

Ranney: We’ve certainly seen a huge rise in the number of applications to schools of public health over the past couple of years as people have been so personally affected through the COVID pandemic, through mental health problems, through gun violence, through the effects of structural racism.

So yes, in some ways. But I will also say that I hear a lot from my colleagues in public health a little bit of the doom and gloom that is the title of this conversation, which are the same things that we have paid attention to in the healthcare workforce over the past 3 years. The burnout, the effect of misinformation, the effect of workplace violence, the stressors of declining funding — those are present for public health as well.

So although I see a lot of bright potential, I also think it would behoove us to pay attention to those warning signs, because we actually know that we’re losing a lot of people — particularly young people — from the public health workforce.

It’s the same thing that we’re facing, Jeremy, in emergency medicine, right? We had 500 residency slots that didn’t fill this year. We’re seeing that somewhere around 50{7b6cc35713332e03d34197859d8d439e4802eb556451407ffda280a51e3c41ac} of people who are in governmental public health in their first 5 years of that job have left due to the same confluence of factors that we’re facing in healthcare.

And let’s be clear, healthcare in the healthcare system cannot work if we don’t have a strong public health system to partner with.

Faust: This idea of a mass exodus of public health workers — nearly half of all public health workers in state and local agencies left their position over the last half a decade, which is from a Health Affairs report. I think that some of it might have been early retirement and some of it might have been burnout.

What’s your sense of that? From the people that you know who left, do you have a sense of why?

Ranney: There’s certainly an early retirement portion. The same thing as we’ve seen with the nursing workforce in healthcare, where we’ve had a lot of people that were getting towards the end of their tenure who’ve said, “You know what? Now’s a good time to leave.”

There are a lot of people who have had childcare challenges. There was the ridiculous work hour expectations, the lack of a break for the last 3 years, that has just made people burnt out and crispy. Just as those of us in emergency medicine or intensive care had to work more than before during COVID waves. Similarly, many of our public health colleagues were called to do more over the last 3 years and really have reached the end of their ropes.

There’s also an element of that misinformation and workplace violence. I’ve talked to reporters about, I know you’ve had these too, stories about people who I’ve taken care of who were vehemently opposed to the idea that they actually had COVID as they were sitting there with an oxygen saturation of 70{7b6cc35713332e03d34197859d8d439e4802eb556451407ffda280a51e3c41ac}. And I’m like, “No, no, you can’t leave the hospital, I swear.”

Public health workers have experienced that too. I’ve had colleagues who have left because they were tired of experiencing personal attacks on themselves, fearing for themselves, fearing for their family, and if anything, I think particularly some of our governmental public health workers have been more exposed to that.

Lastly, there’s been a disturbing trend in many states of reducing the scope of practice of public health professionals. Just as with healthcare, people that go into public health do it because they care. They do it because they want to create a healthier society. Then they’re working in a state that says that they can’t do their job anymore, that’s putting laws in place that reduce their ability to track the incidence of disease, to track risk factors, to provide interventions for substance use disorder or HIV or COVID.

That gets really dispiriting after a while when you know the thing to do, you know how to do it, and you’re literally not allowed to. It has created this sense of moral injury for many.

Faust: One of my readers asked a question adjacent to this, which was: what can someone who’s not in the field do to say to the CDC or their local public health agencies, “Hey, we want you to track COVID and infectious diseases. Don’t shut down your website that tells us what’s going on in the wastewater or a case count or hospitalizations or mortality.”

You and I can write emails to people we know and various apparatuses in the healthcare structure, but what can my readers do who aren’t doing this every day?

Ranney: I think that they can actually be in touch with their elected officials.

Ultimately, a lot of that ability to track and publish that data on a public-facing website depends on permission to access data and then to share it. So you need both those permissions for data access, which are being withdrawn as we speak as the public health emergency comes to an end. So reminding your legislators how important that is. There’s also the funding involved in having the workforce to allow that to happen. This is a place where legislative advocacy really can make a difference.

I’ll say, Jeremy, you and I have had a lot of conversations over the past few years and before about citizen science as well. I do think that this is also a place where, for better or for worse, sometimes citizens who have an interest and a skillset can partner to help create alternative data sets. We saw it for PPE [personal protective equipment], we’ve certainly seen it for firearm injury tracking — the gun violence archive, which is privately funded, serves as really my best source of injury data. We saw it for COVID in those early days, the COVID tracking project, which was created by The Atlantic, served as this amazing source of data.

So I would say to your readers: do not underestimate your own power to create local change.

Faust: To add to that, the idea of long COVID really came from patients ringing the bell, saying, “Hey, we’re bringing something to the attention of the medical field.” I think that that’s another example of how you don’t have to be in the field to influence it. I think that’s been a good story.

Let’s talk a little bit about trust in people like you and me, doctors, healthcare professionals, people in this space. One of my readers asked a question that’s adjacent to this: Trust is something that is hard to win and easy to lose. We go on TV or we write things and it can go well or not well. So for both of us, let’s do this. What’s something that you got right early on or during the pandemic, and what’s something that you didn’t get right and you take it back and say, “Oops, that was not right.”

Ranney: It’s a great question. I think that I called out earlier than many — not most, but earlier than many — the fact that COVID was likely airborne, which we now know to be true and that surface disinfection was less important. That, honestly, mask wearing made a difference, which despite a Cochrane Review that was deeply flawed, we actually know from the data around COVID that masks, particularly well-fitting masks, did make a difference at the height of those Omicron, Delta, and earlier waves.

I’m proud of calling that out relatively early and continuing to share my voice in that realm.

One thing that I did get wrong is that the early data on the vaccines strongly suggested that they stopped transmission. That they didn’t just reduce severe disease and hospitalization, but that they also stopped infection and transmission. We had been so lucky to not have mutations at that point, and I did not anticipate the degree to which that was going to change.

I will say that the data changed, but I think that probably many of us, myself included, overemphasized that and created a false sense that these vaccines are magic, when really they’re just regular old vaccines just like the flu vaccine, which is tremendous particularly for high-risk populations, but doesn’t fully stop infection or transmission.

How about you?

Faust: Alright, very fair. Things I got right? I have to think about it, I feel like I haven’t gotten much right.

Ranney: That’s not true! I think you and I wrote a nice piece together once or twice.

Faust: I’ll start with the thing I think I kind of got wrong early, which is that the early data sets coming out of China and elsewhere really showed that this was a disease of the elderly, and that’s who we had to worry about. In fact, there were so few deaths of young people that I wasn’t sure if there would really be a bump in what we call “all-cause mortality” in people who were not in a geriatric population. So I thought, “Well, we might see a few deaths, but that would probably be a statistical anomaly in younger people. We really have to worry about the older folks.”

In fact, I set out to study that question thinking that we might not find anything in the younger groups. And you know what? We did find something. We found out that younger adults, people in the 25-to-44 age group, actually had a massive increase in their mortality. Even though it was just going from a little bit to a little bit more, which doesn’t seem like as much, right?

So one in a thousand people usually die, and then it becomes one in 900 or something like that. That doesn’t seem like much, but that’s a huge, huge difference of life you’re losing. Decades of life. It is a big relative difference, even though actually, the raw number of deaths certainly was highest in that older, sicker population.

I was wrong about that, and I’m actually happy that I was the one to go find that out and correct. So your priors, we call it “bias,” can ask a research question. I thought it was one of those situations where I thought, “Let me be the person to ask this, because if I don’t find what I’m looking for, that’s okay.” And we went with it. So that was a turnaround.

I think another thing that I probably got right pretty early on was not necessarily that it was airborne, I actually was late on that, but I was thinking it was airborne enough [to be] precautionary. I wasn’t sure how airborne it was, and I’m still confused about how this virus transmits, because you’ll have a roommate on a cruise ship not get it from somebody, and then half of a choir in Washington got it.

We have to learn about the airborne-ness of this virus. It’s in the air, it’s airborne, but it’s not so clear that it’s constant.

But I think that I was safe on that. Like, okay, it’s airborne enough. Even if it isn’t, which it is, putting a mask on keeps people like me from touching their face all the time, which I’m sure is how I was getting sick. I mean, I haven’t had a healthier stretch of my life than 2020 because the hand hygiene was up, the hand hygiene was great, the masking kept all the junk out of my face, my allergies were better that year, it was great.

Ranney: Yes. I’m also going to call out my state, Rhode Island; we put kids back in school in September of 2020, and I think I gave a lot of leeway to folks that were not putting kids back in school, both nationally and globally. Bangladesh, for example, did not put kids back in school for another 2 years after that.

I think that it’s a space where we could have advocated more strongly. We didn’t have complete knowledge; we were worried appropriately about teachers and their health in the pre-vaccine era. Luckily, some of our colleagues came up with nice studies showing that masking, ventilation, et cetera, did make a difference. It’s a space where I think that the public health community and the physician community could have sounded the alarm.

Many of us talked about the potential negative downstream effects of the COVID pandemic. Yes, we were healthier in some ways, but less healthy in others — gun violence and mental health amongst them. Both are problems that existed before COVID, but certainly got exacerbated.

I was a local advocate for getting kids back to school, but I think that we could have been stronger nationally and internationally.

Faust: I’ll add to this point. It’s super-important because this was an area where public health officials and experts got a lot of heat. The approach that I took was that the idea is not to open schools, but to keep them open. You can keep schools open by taking a more aggressive approach on things like routine rapid testing.

So there was this weird disconnect where the people who wanted to open the schools the most were willing to do the least to achieve that. I think people like us were fighting an uphill battle to say, “No, both things are true. You can take this thing really seriously and do a lot of testing and do some masking and ventilation, and that’s what’s going to keep the kids in school.” As opposed to some groups who were saying, “Oh my God, it’s too unsafe. Kids have got to go home.” They didn’t think about the possible consequences of that.

So I think that even within our own field, there was this debate about how to do it, and I think we were right about it. The idea that you aggressively track it, you aggressively address it, with the aim of keeping those doors open.

Ranney: I think there’s also a reality in looking back, and this is another place where I think we could have been clearer, is that the information was bound to change.

This was an emerging pandemic. We had literally nothing. We got nothing out of China, right? We had nothing when we started trying to fight it. And I think being clear about how the scientific method works, how we ask questions, the fact that we converge on truth, and that we were going to have to make choices with incomplete information, that we would do our best to make those choices accurately, but that it is inevitable in a pandemic that things change.

I mean, heck, Jeremy, you and I could probably sit here and go back and forth about things that we’ve done in emergency medicine over the course of our career that have changed substantially. We were all in that emergency state. I don’t think there was any intentional not sharing of the fact that we were doing the best we could with the data that we had.

But I do think that that’s an important part of the conversation going forwards, about making sure that everybody understands the basics of the scientific method, and that we continue to be clear that we’re making our best possible recommendations, and these are the reasons why.

Having a little bit of humility, particularly in these emergency situations about how stuff may change down the road, but we’re doing the best we can with what we’ve got.

Faust: One of my readers reminded me of something that I forgot about you, even though we’re good friends, which is that you are a history of science major, so you might have a longer view on this. Do you think that the prestige of science has been worse in the past?

Ranney: Oh yeah, this is not a historical anomaly. I do think that the history of science — I adore it. I could talk about it all day. But we look back at the plague, and you go back further to the Greeks and Romans. You look at Galileo and Copernicus, you look at the history of hand washing and belief in germ theory. You look at the history of vaccines and over and over throughout recorded history, the way in which we interpret science has been deeply influenced by the society in which we live.

There’s been really good evidence that gets dismissed because of societal biases, and there have been mistakes made.

There have been periods of deep distrust in medicine. I mean, that’s what the Flexner Report came out of in the early 1900s, trying to professionalize medical schools. It caused a lot of harm to particularly medical schools that were training Black physicians and women physicians, that Flexner Report, but it was created out of a fear that medicine was turning into snake oil salesmen.

So there have been many points throughout history where science and medicine and public health have been deeply distrusted.

I see this as cyclical, but it’s also a space for us to lean into and to do better around creating trust. I do want to highlight, though, that we can be doom and gloom, but actually trust in public health and in public health institutions is not all that bad. People trust public health and healthcare practitioners way more than they trust a lot of other institutions in America.

I think we’ve seen across the board decline in trust of government, of higher education — you know, name an institution and it’s less trusted than it was. The NIH and the CDC are trusted equivalently to the American Cancer Society. No one would say that they are political; it’s just I think that we’re living in a world in which folks don’t trust each other right now.

I don’t want to get too down on what we’ve done, because we’ve really had some tremendous successes and saved a lot of lives.

Faust: There’s this poll out of the Harvard T.H. Chan School saying that 26{7b6cc35713332e03d34197859d8d439e4802eb556451407ffda280a51e3c41ac} of people trust their state and local public health officials. We had PR for this event and in our mentions people said, “Oh, how could we trust you guys?”

But I’ll tell you, the other day, when there was an emergency on the plane that I was on and they said, “Is there a doctor on board?” and I rang in, nobody said, “Don’t trust that person. They’re a doctor.” Everyone on the plane was very glad that a doctor was on board and that I could help the person and help figure out not to land the plane, but we’re going to help this person anyway.

When push comes to shove, I think people do have trust, but we know this, depending on how a question is asked and in what situation, people answer differently.

I’ll just throw another thing in about the history of science and how much we’ve learned. You look back at landmark studies from decades ago, things that really informed our practice, and they were decent, but a lot of these even in The New England Journal of Medicine or JAMA or The Lancet — the best journals in the world — would never get published today. They’re not nearly rigorous enough.

So I think we’ve made a lot of progress. And I think that anytime we overturn anything that we thought was true and now isn’t, I’m always packaging it as: that is the process. We want to own those things, because that’s what science is about. Science is not about an established body of knowledge; it’s about an evolving body of knowledge. I think that when we have that message out front, people actually do understand that.

Ranney: I agree.

Faust: My last question for you is really about the fact that you said something about politics, which is interesting because on one hand, this should cut across all political divides. I think you have really been excellent in your work on always trying to reach both sides of the political spectrum and not being political, but at the same time, there’s a saying that health and science are political. How do you thread that needle so that work gets done, because it takes politics, without alienating half of the country?

Ranney: I think it really is a both/and. Of course, health and politics are deeply intertwined because health and societal structures are deeply intertwined. There’s no way to fully separate them out.

We do know that states with certain policies and laws in place have lower mortality rates — whether it’s maternal mortality, child mortality, elderly mortality, lower rates of chronic disease, lower rates of obesity — than states without those legislative decisions. So there’s a very real impact of legislation and of politics on health.

At the same time, you can respect that people’s decision-making may not be informed entirely by health and/or they may be prioritizing different aspects of health. To me, part of being a great physician or a great public health professional is balancing those realities and meeting people where they are, prioritizing the things that they prioritize.

Again, this is a space where I think some states did better than others during the worst of the COVID pandemic.

I will frequently say that there is going to be 10{7b6cc35713332e03d34197859d8d439e4802eb556451407ffda280a51e3c41ac} or 15{7b6cc35713332e03d34197859d8d439e4802eb556451407ffda280a51e3c41ac} of society who is never going to get on board with something that creates greater health. But the vast majority of us, if you ask us, we care about our own health, about our kids’ health, about our parents’ health, about our community’s health, but we’re going to put it in the context of we also need to pay our rent, right? We need to make sure there’s food on the table. We need to make sure that we’re safe when we walk outdoors.

It’s making people realize that that’s part of health and working to advance those things that are deep priorities of every community and are not unique to a political party. It’s finding ways to create bridges across supposed political divides.

I will also say, of course, that politicians need to create drama and controversy, because that’s how they get attention in fundraising. Not all politicians, but many. That’s not my job in public health or in medicine. I’m not about trying to create drama. I’m about trying to work with communities where they’re at to meet the needs that they identify.