It is a real honor to be here, I have just a huge amount of excitement coming and respect for UMBC. So I'm going to talk about putting the public back in public health. And I will confess that I work at a school where there are a lot of experts. Like you bump into someone in the hall and they, you know, there were all there they're doing is a particular type of water quality or a particular pathogen. And I'm like, you know, an inch deep and a mile wide. I get involved in all kinds of different things. Partly because my career was in the public sector where you know, the health commissioner of Baltimore, you can't be a specialist in something, or you work at the FDA, or for the state, so that just gives me an ability to take a step back and think more broadly, but it's also a weakness, because by the third follow up question, you'll see how little I know about any topic that I mentioned. So what is public health? This is my favorite definition from the Institute of Medicine in 1988: "What society does collectively to assure the conditions for people to be healthy." And you'll notice that there are three words in here that I particularly like: society, collectively, and people. So it is not clinical medicine. You know, one on one treatment. It's not talking to one person, just isolated, which might be counseling, which can be very important, but that's not really public health. Public health is what society does collectively, to assure the conditions for people to be healthy. And if you've been following the news or awake during the pandemic, you'll notice that there there's a lot of angst right now about this idea that we can do things collectively to assure the conditions in which we can be healthy, right. And so much opposition to different public health measures. Public health officials under attack. People marching around on their, on their lawns with guns or even shooting into their houses or driving them off the road. All those things are at least alleged to have happened during COVID. Hundreds of people fired. And then you have this idea of crisis of trust in public health. Do people believe in the vaccine anymore? Do they believe when you know, public health official says something? I was on a meeting earlier today among the Advisory Committee to the Director of CDC and there's a whole discussion of what can be done for better communication to enhance trust. How can CDC do this better? It's just on everybody's mind. So I just want to frame what I'm going to talk about in a little bit of a broad way to say like, okay, why are we in this situation. And I'm not going to talk about all these different things, but just to kind of situate what I will talk about in this broader discussion of a crisis for public health, a crisis for our ability to do things collectively. And I put the challenges into two big buckets. One is outside public health, which I said it's outside the house, and the other is within public health, there are problems within public health that we have to deal with. And there's a lot of debate right now going on, about these different factors. And I'll just say, outside of public health, what outside of public health is making it really hard for public health to do its job. Political interference, you know, we have governors who are just absolutely nasty to public health officials these days. You have misinformation, which is incredibly rampant, not just on Facebook or Instagram, but you have entire, like circles of WhatsApp, that are like closed circles of communication, which just comes in as information being exchanged. A lot of misinformation all over the world, some of it coming in here. This is just a recent poll, most Americans encounter health misinformation and most aren't sure whether it's true or false. Political polarization. You know, we've we've seen, like vaccines get kind of lined up by which political party you're in. It's sort of very predictive now in some areas of whether you've gotten vaccinated, and that's not a good thing for the field. So there's a lot going on outside in the world, where public health is affected. Sometimes I think of that as that's the dog and we're the tail. You know, we're getting wagged by political interference, by misinformation, by polarization. But there's also, you know, all that can be true, and we can also say, what can we do better? The part that we're the dog, and we have more agency. And there are three different general ideas that have come up, one of which is that public health is suffering from crisis in liberalism, and there's a book to that effect that just came out. Another is that there's been insufficient connection to communities. And the third is that there's been inadequate public engagement. And let me just say that, I don't think I fully agree with the liberalism critique. We're going to have a podcast where I interview the author of the book. You can decide whether you think his, his argument is stronger than mine. I would say he's very focused on social media kind of exchanges and how people can be quite, I don't know, pointed in their social media exchanges, that would be an understatement. And really not be open to hearing what evidence might be on different topics. I don't think though, that that was really a fundamental problem with the vast majority of the field of public health. But that is my view. I want to talk about these last two, which I really do think really fall under putting the public back in public health. One, insufficient connection to communities for the field of public health and the other inadequate public engagement. And my contention to you is that these are really important for public health. I don't know whether it'll be enough. I don't know whether those things that are, you know, where we're getting wagged, where it's the interference, or misinformation, or polarization, whether those are going to be so important, and our society is going to have all these problems that public health really can't do enough itself. So why is there a gap between public health and community? So let me start there, and then I'll talk about some of the solutions, I think. One of them is the legacy of past abuses. This was a headline I think of the Los Angeles Times "We want to study you for black Angelenos, Coronavirus triggers fear of another Tuskegee." So the history of medicine and of public health. This was actually a public health study,Tuskegee, run by the US Public Health Service, is a history of abuses and racism and that impact lingers. And it's one reason that that there's a gap and I'm not even saying that, you know, there are problems today, maybe not as blatant as Tuskegee, but I think that's the that is something that any public health official or public health researcher has to be aware of if you're thinking about how we work with communities. Another reason is inadequate resources for health departments. So between 2009 and 2020, health department's lost 40,000 workers. That means fewer positions for community health outreach, fewer resources for community partners, less time to sit down and really work with communities about issues that they care about. And that really puts a lot of stress. It's very hard if you have a barebones staff and you have to do certain things to be able to do the job of public health well. In the United States, there's a massive amount of variation in the public health system. In Maryland, every county has a health department. Is that true in the rest of the country, that every county has a health department? No. Sometimes there are town health departments. Sometimes there's only a state health department and no county health department. There's total variation. And some of these are reasonably well funded. Some of them are incredibly poorly funded. In some states, you have lots of tiny little health departments that really can't do that much. Sometimes the health departments have boards, sometimes they're appointed officials, it's just a total mismash. And you really saw that during COVID, that some areas were really able to to respond quickly and others have just enormous struggles in doing it. And so we have this very irregular map of public health. And one of the consequences of that is that there certainly are health departments that I think do a better job of community engagement, but there are many that do not. Another major challenge is that the core human resource structures in public health departments, and I'll say not just there, in academic institutions too, don't make it easy to hire community members. So if you were to say like, you know, why is there such a divide? Why can't we work together? Why can't we hire people from communities to do studies or to collaborate on different initiatives? One of the big reasons is there just, there's just not the HR infrastructure. They're not job descriptions, they're not promotion pathways, Also in the United States that people do a lot of community health work, but but in the informal sector. They don't actually have jobs. And so that that also creates a gap. And then you have research. Research project can be done and I'll talk about better ways and worse ways to do research projects. But even today, research projects can be real irritants in and again I'm understating the case here, in relationships between institutions and their communities. You can have a failure to collaborate in a proposal. No clarity in expectations. People can feel exploited, if, you know, the researcher comes in with a big grant and there's a lot of work for the community to do and then the researcher goes off and publishes the paper and gets the aclaim. And then the intervention can end abruptly when the grant does without, you know, the community really being better off. So these are all reasons why this has been a gap and a gap that I think really became clear in many places during the pandemic. Some of you may remember Dr. Leana Wen, now of CNN and the Washington Post. She was a Baltimore City Health Commissioner, in the wake of the unrest following Freddie Gray's murder in Baltimore, she was the health commissioner. And there were parts of the city that got shut down because of all the violence and she sent Health Department workers out. And she reported that when they knocked on people's doors, people asked, Are you here for a candidate? When they said no? And then they asked, Are you here for a study? You know, and you'd say, like what an indictment of public health and academic infrastructure. That's how people think that like, it's just people come and they need something, either free to vote for something or free to sign up to be a subject and something and that's when they show up. So I'm going to talk a little bit about what to do. And in all of these examples, I think I will say that there was a lot to do, and there's a lot that's being done. But I just wanted to start here by saying that the challenges that we have in public health, that lack of trust that got exacerbated during the pandemic, in my opinion, they relate to this underlying and long standing challenge between public health enterprise and communities that were that are supposed to be the the people who are getting better conditions of health. And among the different solutions to that are diversifying health professions in the Public health workforce. And this is a report from the black coalition against COVID. Where they talked about many different initiatives when the Biden administration came in particularly they funded efforts to support community organizations, not just public health departments, with community organizations to go and talk about the vaccine, and actually had a huge impact on closing the gaps in vaccination. Just a little bit of history here initially, when the COVID vaccine became available, there were like immediately, for example, racial gaps in access to vaccination in Maryland, there were huge racial gaps in access to vaccination. And people at one point, the then governor said something to the effect of, you know, we can make them go get vaccinated, I don't want to paraphrase. And so it's sort of like, you know, this has to do with the uptake, it has not to do with access. And that was not true, that it was very much to do with access, they actually, were supposed to be giving out vaccines in proportion to the population basically. And they were giving out a lot fewer vaccines to counties with predominantly black populations for use in their populations. And so eventually, I think they, they changed some policies, but there were huge gaps in vaccination right out of the gate. And people wonder whether they would ever close. And the Biden ministration came in just as the vaccination campaign was starting, and really invested in that, and it absolutely paid off in Baltimore. The Health Commissioner, Dr. Draza, I think did a phenomenal job. She was all over the media. She also hired 300 People from Baltimore neighborhoods, to go door to door to talk about vaccination as part of a community health score, I got to go out with them. It was really great. You know, I remember I learned from one of the community health workers, how to approach vaccination to somebody who is, you know, kind of resistant. And, you know, you might think your first reaction might be, Oh, you got to really explain, you know, let's talk about what the studies showed, let's show them the data or that this particular idea that you have is not based, in fact, but people would come and go, I'm not getting vaccinated. I heard this, I heard that that could be tracking me whatever they said, right? And this, this community health worker would look very kindly in them and say, if you were to get vaccinated, who would you get vaccinated for? And a lot of people said, Well, my mom and say, Oh, that changed the conversation immediately why your mom's like, well, she's not doing so well, I don't want to get sick. And before you know it, they're getting vaccinated, even without getting into like a rebuttal kind of situation. Second, is to actually partner with community organizations, to support community organizations, or bring them much closer to the field of public health. So rather than the health department trying to do everything by hiring people themselves, having like a set of organizations that they can work really closely with.