A global health expert on U.S. public health in an interconnected world

Full transcript below:

Dave: Welcome everybody to another episode in our podcast series on the "Extended Public Health Enterprise" here in the United States. We're very excited to have a distinguished guest today to help illuminate an aspect of the public health enterprise that we haven't talked as much about up until now, which is our link to the global health landscape. I'm joined as before by my co-host Nicola Dawkins-Lyn. Nicola, I'll leave it up to you to introduce our guest.

Nicola: Thanks very much, Dave. We're very excited to have with us today, Dr. Jeff Koplan. Some of you may know Dr. Koplan from 1998 to 2002 when he served as the Director for The Centers for Disease Control and Prevention. Since then, he's been at Emory University with us here in Atlanta, where he has served since 2006 as the director of Emory's Global Health Institute. Dr. Koplan will be able to help us, as Dave was saying, take a look at public health beyond the U.S. borders.

Dave: Welcome, Jeff. Can you tell us a little bit about what you've been doing as part of your role there at Emory over the last decade and a half and how you've been experiencing 2020 from your vantage point?

Dr. Koplan: Sure. I went from CDC to Emory in 2002 for what I thought would be a few weeks of acclamations before I found what I really needed and wanted to do. And I've still been at Emory for over 18 years now. Maybe I'm still looking. During that period of time, I continued with my underlying interest, obviously in both public health and global health, but I also was able to enjoy a return to clinical medicine. Being in a large healthcare delivery system with several attached hospitals, I had been away from doing public health work and global health work in countries around the world.

It was nice to be able to keep those, but also to have the interesting dynamic of the U.S. healthcare “non-system” playing out before me and being in hospitals with doctors who wear white coats and carry stethoscopes. All that was exciting and kind of a return to previous academic pleasure.

So since that time, I've worked on some large projects, one of which was an organization that we shorthanded as the global CDC. It's called the International Association of National Public Health Institutes. It's institutions like the CDC in the United States, like public health in England and France. My thought for many years before had been that it would be good to get these groups together and share information and knowledge to the benefit of both themselves and other countries in the world.

So I've spent a fair amount of time on that, and I enjoyed it. We just had our annual meeting, like everyone else, in front of our computer screens on Zoom. We started this program with about a dozen different directors of global health institutes rather than national public health institutes. And at this meeting, we had 118 different countries represented. It's interesting to hear how countries with much less resources than we have in the United States have been coping with the COVID-19 pandemic and doing remarkably well.

We have also been involved in some other large projects, including child health and causes of child death. We’ve also been doing lots of work with students in coming up with creative, novel programs for student instruction to enhance their own careers. In pulling together the different components of the university and demonstrating the interconnectivity of global health—whether you're in law school or business school or medical school or nursing school—our program can be challenging but always satisfying.

Caring for individuals and communities

Dave: In prior episodes of this podcast series, we've dealt with the fragmentation of the U.S. approach to public health in terms of governance and systems and processes and staffing. Now we have a chance to talk to you about the comparison of the U.S. approach to public health with those of your colleagues from other countries. And the International Association of Public Health Institutes is the kind of defining institution to help illustrate that. To start with, in comparison with other countries, how would you articulate the U.S. approach to health outcomes with those of other countries? How would you define the similarities and differences?

Dr. Koplan: The underlying commonality is a concern for improving health on a population-wide basis. We go to our insurance. You take your child to the pediatrician, or you go to see a specialist, and you’re the major point of interest and concern for that health care provider at that moment. You may leave in half an hour, and someone else takes your place, but nevertheless, it's largely focused on the individual. Some cases may be a family where an illness is affecting more than one individual, but the underlying issue is a targeted person or small group of people.

With public health, the patient is the community. If you're the chief public health official and state in North Carolina, then you're worried about the health of everyone in North Carolina. That premise is true in most other countries, which are poor, or wherever you have some structure that at some point includes those of a city or region, a county, or a state. From that point on, you see a very different manifestation of what that public health action is based on geography, culture, history, politics, and the economics of fiscal flexibility. In the United States, the system closest to the action is, in most places, a county or town health department. In some cases, it might be a city health department. Moving on to the next higher level, the primary public health agency is the CDC. There's the National Institutes of Health, which largely does research of a basic or clinical kind, but nevertheless, it takes an active role in improving public health by the background information they provide, and in some instances by specific programs that they're responsible for. So we go from field to city to county and up to state/federal. Other countries have things like that, but they may not be connected. For example, you can have a country where there are some local public health activities, but they aren't necessarily under the immediate supervision of the state and, similarly, the federal level. That's true in the United States as well.

CDC investigators cannot invite themselves into an outbreak or to a problem. They have to get an invitation from the state health department. The state health director then sends a note saying, "We invite you to join us in trying to solve and cope with this problem." The relationship between those pieces is different in some countries. There's more research focus in some countries, so it varies; in some cases, minor variations, and in other cases, quite major ones.

Dave: Do you notice fundamental differences in effectiveness based on these different models in different challenges? Is one model more effective at delivering population health outcomes in terms of chronic disease? Is another better at managing infectious diseases?

Dr. Koplan: I think that places vary, and they'll vary over time. The director of a state or city health department brings a particular focus and concern. With that, you get differences in risk. Some states have higher rates of obesity or diabetes, for example. It may depend on how they allocate resources, the interest of the players and parties involved, or differences in geography, culture, and ethnicity. You can't walk into a county health department in the United States without seeing some variation in what they do, how they do it, and what their outcomes are.

U.S. health and global health

Nicola: It's certainly hard right now to have a conversation about public health and not think about the significant influence the pandemic is having on all of our lives. The pandemic has really revealed so much and reminded us of so many things, and among those is just how central the global health environment is to U.S. public health. What are the most important ways global health issues affect the United States?

Dr. Koplan: It's, unfortunately, a terrible time for all of us, but it provides a good example of how an organism can affect our daily lives, our economy, our businesses, and how we think about ourselves. It also illustrates the unbelievable interconnectivity of the world. So it's not just a typhoid outbreak in a city or an insect-borne viral infection in the southern part of a country. Everyone is at risk, some more than others.

In early days of public health, in Atlanta, our neighbors would have been Tennessee, North Carolina, South Carolina, Alabama, and Florida. Our neighbors now are places like Burkina Faso, Sri Lanka, and Bangkok. It's everybody. And that's a good thing in a lot of ways. It makes life interesting, and it permits us to see problems in one place where we could be helpful. Or they see problems with us that they solve.

This virus seeks out places where it may not have been before, and it's been very successful at it. And the needed actions at this point are ones that are technically simple: more space between other people when you walk, staying out of closed indoor places, wearing paper or cloth masks. There’s a range of things we can do to help control it, and that has been documented to help control it. Then the crisis becomes one of basically working with the population.

Nicola: As you think about the increasing recognition of global influence on public health in the United States, what important skills do you think the public health workforce needs to have to operate in this environment?

Dr. Koplan: You need a team that works well together. Think of an orchestra playing Beethoven. If you're the second violin, you don't leap up in the middle and give a rendition of “The Devil Went Down to Georgia.” You've got to have a game plan—in this analogy, a composition. You need to have everyone know their part, and people have to be receptive to their role, and the nature of that role needs to be conveyed to them such that they want to do it and recognize the need for it.

In this instance, we're involved in all these pandemic mitigation activities. It's not, “Do it because I'm telling you to do it,” it's, “Do it because it's good for you.” It’s good for the people who live around you. And it's good for people who you don't know and can't identify.

But we're all in this together. This is a time to pull together, and that has to be conveyed clearly. When it’s not, one of your major tools is removed from your hands. The outcome, unfortunately, is not just inconvenient or unpleasant. It’s tragic and final.

Dave: The divisions in American society we've observed have driven some of those behaviors or the lack of receptivity you've just referred to. Have you seen other nations with analogous political divisions that have impacted their public health performance?

Dr. Koplan: It's striking that the number of countries with a real shortage of funding and that struggle on a regular basis have done so well in this particular outbreak. And that involves encouraging the population to take advantage of these behaviors, or else there is a price to pay of some kind, whether a fine or reprimand.

One of my colleagues is the former director of the Dutch National Public Health Institute. It's really a first-rate institution for a relatively small country, and they provide similar services to those of a much larger country, like the United States. And he said they had a strong push back from people adopting this mitigation behavior—not everyone, but a large enough fraction of the population. So that was surprising to hear.

One sees a number of places, though, like Finland and Norway, doing quite well. They're doing much better than us. We’re a much larger population, but also we have many more assets than these places. I think the jury's out on how this is all going to go, but the advent of the vaccine is an amazing accomplishment. That isn't the behavioral end, though, and I think the behavior part still has to be there.

And we have to prepare populations for being receptive to vaccine use. Until you vaccinate much larger numbers, some of the problems we have in terms of businesses opening, travel, and comfort will still be there. All these factors will require successful vaccination, but they’ll also require—for the foreseeable future, and maybe for much longer than we think—some of these behaviors related to keeping transmission as low as possible.

Where public health meets climate change

Nicola: Another area we increasingly understand to have a global impact is the area of climate change. How should the public health impacts of climate change be addressed?

Dr. Koplan: First of all, there needs to be a broad consensus that climate change is real. It's significant when it occurs. There are plenty of manifestations of it now, and it has a broad societal impact—a major component of which is health. You can interpolate what climate change just in terms of temperature and weather, not even counting for huge disasters, the multiple hurricanes and typhoons that cause damage to people and their property.

Some people say, “So the water temperature is three degrees higher, what difference does that make?” You'll soon get a long list of the differences that makes and how it affects our lives. So never mind that. I mean that all those are real and major.

There's no shortage of other major influences on our health. Most of the day, we don’t have to think too much about mosquitoes. And yet, mosquitoes, in particular, historically assist in the movement of viruses or other organisms from one person to another. Up through World War II, the southeastern United States was, in essence, a tropical locale because the mosquitoes there could transmit yellow fever, or dengue fever, or chikungunya. And there were mosquitoes which transmitted malaria. So, as you go from place to place, the influences of climate change and what it can do (whether it's the introduction of unwanted biting insects or other things) will impact different places in different ways. But the overall sum of them is not in our best health or economic interest.

Dave: Do state or local jurisdictions that exist along borders have to take health conditions across the border into account? Does that impinge on their public health mission?

Dr. Koplan: Yes. An example would be dengue fever, which is spread by having a bite from a particular type of mosquito, Aedes aegypti. Dengue fever is a most unpleasant disease; it seems to go away and come back again. And there's been an outbreak of it going on and off for a couple of decades now. In parts of Florida and parts along the whole southeastern coast, some of our neighbors across the border are more likely to not have a program of insect control. And because of that, there’s much more transmission of the disease, person-to-person, on the other side.

On the whole, as with most diseases, there tends to be a desire to categorize the disease as coming from somewhere else and then blaming that country for the disease. I won't say never, but virtually we never blame it on our own locale. So if some new virus were to spring up outside my house in Atlanta, I wouldn't rush to go name it the Atlanta virus. People seem to derive some level of comfort from naming it after somebody else and after someone else. And that impulse is hundreds and hundreds of years.

So we are not the model of perfect health around the world. We are not innocent in all this. But rather than innocent and guilty, we’re all in this together. If you can do a better job in Nigeria over this problem, it helps us—and we should aim to do the same if it helps you. This isn't starry-eyed do-gooderism; it’s hardcore pragmatic.

Sending the right message

Dave: You know messaging is so important in motivating our fellow citizens to take the right actions over time to keep us all healthy. What are some of the examples of really creative public health messaging you've seen in other countries that maybe we could steal from?

Dr. Koplan: We're trying to find health messages. And usually wanna convey that there's a danger or value when you're doing something. And we would like you to minimize the things that are risky to your health. In the last 30 years, social media has provided input into what those messages should be and in disseminating them.

The CDC has a wonderful website where you can get lots of information. Whatever university is near you probably has important things on its website. Unfortunately, there are also things that are pure fantasy, or things presented themselves in a manner that leaves the population to downplay the things they need to do. So the stakes can be high.

So first of all, be sure what message is correct. The message should make sense or come from a reliable source. And if you get something that comes from more than one reliable source, then you're on the right track. And if you still aren't quite sure, you can check with your doctor's office or call up your local health department.

Do things change such that the message has to change over time? Yes. When it's a new disease, you don't have all the answers on day one. You may have to make major changes in what you're saying, and it's not because we're stupid. It’s just the nature of the investigation. That's where it pays to stay up-to-date, tuned, etc.

How to deliver that message? Clearly have it repeated in different ways. Don't have different messages coming out from the government where one group is advocating one thing and another group is advocating another, and then a major political figure is saying it all doesn't really matter.

Consistency is an important part of the message. Accuracy and verification need to be part of it, as well. And if you can make it mildly entertaining, such that you can watch it without scaring someone out of their wits, all the better.

Dave: But worse to live by. I think we're gonna leave it there. Thank you, everyone, for listening to this episode of our podcast series on the "Extended Public Health Enterprise." Thanks to Nicola. Again, thanks to our guest, Dr. Jeff Koplan. We'll see you all next time.