How Can We Rebuild Trust in Public Health?

Speaker: 00:00:06

Hey folks. Ashish Jha, here from Providence, Rhode Island, coming to you on a beautiful, sunny day with a moment in health, a podcast where we talk about a data point, we discuss a study, and then we answer a question. And let's go ahead and get started. Let's talk about a data point. And this is not a great data point. This is a sad and disappointing data point, which is the number is 226 that's the data point. It's the number of kids who have died from influenza through May 3 this flu season. That makes it the worst flu season for kids in the last 15 years, and getting close to the terrible flu season when we had the h1, n1, pandemic back in 2009 2010 what we know about this is about half the kids this season have gotten a flu vaccine. That's way down from what it used to be about five years ago, about two thirds of kids got a flu vaccine. That number has been slowly but surely coming down. We think there have been well over 2000 kids who have been hospitalized, and about half of the kids who have been hospitalized did not have any underlying condition. So when you hear about how children don't get affected by flu, push back. 226 children have died of influenza this year alone, and that and the flu season is not yet even over second, we think for most of the data that it's mostly kids who have not been vaccinated, and about half of them are children who do not have underlying health conditions. This is wholly preventable, and what we need to do is get kids their flu vaccine. My kids get the flu vaccine every year, and I think it's it's critical that every adult, certainly older people and children, get the flu vaccine. So that's your data of the week.

Speaker: 00:02:02

All right, I want to move to talking about your study of the week. And the study of the week comes to us from two colleagues, one at Dartmouth and one at the University of Chicago, Angela Weiss at Dartmouth, Bruce Mayer at the University of Chicago. The study is a NBER that should not that's the National Bureau of Economic Research. It's an NBER working paper is called Saved by Medicaid, new evidence on health insurance and mortality from the universe of low income adults. All right, what does this study find? What they do is they look at Medicaid expansion, the Affordable Care Act. Obamacare expanded Medicaid across the country. Not every state expanded, and they all did it at different times, and basically what they find is that between 2010 when Obamacare was passed through 2022, about 3000 deaths per year have been averted because of Medicaid. Medicaid has expanded insurance substantially in the states that have expanded Medicaid and and there has been this big debate about how much of a difference does it actually make? Actually make? It turns out it actually makes a pretty big difference, about a 21% reduction in the mortality hazard from new enrollees. Well, you might imagine most of the beneficiaries are older people. And when I say older, I really mean middle aged people, because remember, people over 65 have Medicare. So we're talking about 40 to 59 year olds have been the major beneficiaries of Medicaid expansion, they actually find that a good number of younger people end up having their lives saved from Medicaid as well. This is the most comprehensive study looking at this question and two more data points that I think are really important. One is they do a little bit of a cost effectiveness analysis of like, Medicaid costs money. How much money is it costing US per year of life saved? They find that it pays the cost of Medicaid is about $180,000 for life you're saved. That's, you know, that's pretty comparable to a lot of other

Speaker: 00:03:53

treatments that we readily approve all the time. Last but not least, we know there's a large mortality gap, or health gap between the wealthiest Americans and the poorest Americans. And one of the questions we talked about this with Irene Papa Nicholas last week, and one of the questions that's been out there is how much of that is driven by health insurance? And these authors estimate that about five to 20% that's a big range, but let's say sort of in the 10, 15% of the mortality disparity between high and low income Americans can be explained by the fact that low income Americans don't have as good access to health insurance. So it's not everything, but health insurance makes a big difference in saving lives. It's very cost effective, and this paper comes right on the heels of a big debate happening in Washington about what to do with Medicaid. And I think if you're looking for evidence, and if you want evidence driven policy, this paper is yet one more and probably the best study to date, showing that Medicaid saves lives and it's highly cost effective. All right, so there you have it. Do. Data Point and study for the final part of this podcast, we're going to move on to answering a question, and for today's question, I have asked my colleague, Dr Jennifer Nuzzo, who is the director of the pandemic center and a professor of epidemiology here at the Brown School of Public Health, to answer my question. So let me welcome Jennifer

Speaker: 00:05:22

and the question for you, Professor Nuzzo, is pretty straightforward, what do we need to do to rebuild trust in public health? This

Jennifer Nuzzo: 00:05:31

is a great question. It's a central question. I think rebuilding trust starts with remembering the public in public health. First of all, I think we've come too far away from how public health has historically operated. We function best when we're seeing more like social workers helping people live better lives, healthier lives, more fulfilled lives, than law enforcement. And I think for many people these days, when they think of public health, I think more in terms of law enforcement, as someone who studied pandemics and thinks about public health preparedness. I'm really struck that about 20 years ago, when we were thinking really actively, what do we do for a future pandemic? It was always acknowledged that a response was going to be very, very local, and it was going to be a largely bottom up exercise. And so there was a lot of effort to engage the public in thinking about, hey, if there's a pandemic, what should we do? What works for you, what works for you, not just from a logistical and operational standpoint, but also tell me about your values, and how should we respond in a way to make sure that it's aligned with our values? And what we've learned in those processes is that the public has a lot of great ideas, lots of things that we can act upon. And also, when you ask people what you think we should do, you know, what should we do? And they weigh in. Sometimes they weigh in in ways that surprise you. That's not what the you know planners had in mind. And so you could ask people really detailed questions like, hey, there aren't enough ventilators. Who should we save? And the answers to those questions are often quite surprising. So what I really think we need to do is to think about public health is really a community driven exercise, and make sure that we start first with community engagement and find out for people you know, what are your circumstances? How can we help you in certain scenarios, given your circumstances,

Jennifer Nuzzo: 00:07:18

if we were to take action, what sort of actions would be acceptable to you. What might we not be thinking about, etc. And you know, I think we have a lot of rich experience and research to draw upon to do that, but I think we've sort of lost our way in that sense, as of late. So during the pandemic,

Ashish Jha: 00:07:37

one famous scientist said, but if you can save one life through coercive action, I don't think he said through coercive action, but I think he said if, if you can save one life through action, it's all worth it, because saving lives is the ultimate goal. I'm hearing something a little different than that, or a different way to think about that.

Jennifer Nuzzo: 00:07:58

Yeah, so saving lives is the goal. But I also know, actually, former Senator Sam Nunn once said, in an exercise that he participated in, he said, there is, you know, I'm gonna paraphrase, but something like, there is no government on the planet that is strong enough to compel and he was talking a sense of America, like 300 million Americans to take action that they don't think is in their best interest. And I think that's true. If people don't think it's in their best interest, they're not going to do it, and they're not going to stand for it. And so you either have to convince them that it's in their best interest, or you do something else. Another way to phrase it is Dr Tolbert nyanzwa, who was involved in Liberia's response to Ebola in 2014 he said, if the public health, if the public is not on your side, you don't have an intervention.

Ashish Jha: 00:08:43

Yeah, yeah. So community engagement, listening, understanding people's values and using much more persuasion than through demands and mandates. Yeah,

Jennifer Nuzzo: 00:08:57

I wouldn't call it persuasion. I would probably call it listening and sort of hearing where people are. I mean, people are extraordinarily smart. They can figure out a lot of things, and so hearing if something is not working for them, why? Trying to better understand that. In some instances, it's because they don't understand. But in other instances, it might be that what you haven't planned for them is actually not what they think is in their best interest. All

Ashish Jha: 00:09:20

right, so one last question is a follow up on all of this. Okay, so in when we're not in the middle of a crisis, like right now, we're not in the middle of a crisis, is there any role for mandates? Can you imagine, like schools mandating measles vaccines for kids or polio vaccines for kids? My school, my kids go to a public school that have vaccine mandates. I don't know. That feels coercive. Is that a problem? Yeah. So,

Jennifer Nuzzo: 00:09:40

I mean, I don't think that it's the case that mandates don't have a role. Certainly, mandates can be important as a normalizing function, but if you only have a mandate, and you don't have people's buy in to the measure, then you basically don't have a mandate, because people are going to find a way around it. So I think in the case of MMR, in the case of polio, historically, there's been. My support for those vaccinations, I think the fact that we're drifting away suggests we need to do more to help people understand why those vaccinations are important, safe and effective. But if you only have a mandate, and you don't have public acceptance of what you are mandating, then you might as well not even do anything. That's

Ashish Jha: 00:10:16

a great way describe it, and that's a great way to end it. Jennifer, thank you for coming by. This was really helpful, and I really appreciate your time. Thanks so much. Thank

Unknown: 00:10:23

you. Thanks for the conversation.

Ashish Jha: 00:10:30

All right. So there you have it. A moment in health where we talked about one data point, 226 the number of kids who have died of influenza this season through May 3, largely preventable through vaccinations. We got to get those vaccine numbers up. We talked about one study, a study in the NBR working paper, new evidence on health insurance and mortality from the universe of low income adults, demonstrating quite convincingly that Medicaid saves lives, is cost effective, and partly explains why poor people live shorter lives in the United States and wealthy people. And last but not least, we heard from Dr Jennifer Nuzzo about what we need to do to restore faith and trust in public health. And she really laid out what I thought was a brilliant approach, which is putting the public back in public health, community engagement, listening to people, understanding what it is that really motivates them and how they think about their lives, and reminder that mandates may have a role, but mandates without buy in are not much use of at all, and so we've got to do the hard work of engaging people, understanding where they are, and sharing what we know in a way that is constructive, respectful, that's how we move this process forward. All right, thanks so much for joining, and we'll be back again for a moment in health. You.