Opinion | A Public Health Lesson for Ron DeSantis, From Harvard

I’m Kara Swisher, and you’re listening to “Sway.” A couple of weeks ago, I finally got something I’ve been wanting to get for a long time: my coronavirus vaccine shot. I felt so relieved and victorious, but the elation quickly was dimmed by all the new questions I had. How will this vaccine change my day-to-day life? Can I visit my friends? Do I still have to wear my mask? Can I travel? Over a year into the pandemic, there are still so many unknowns. Have we learned enough to keep new variants at bay, or are we doomed to repeat our past mistakes? When is this going to end? To get some answers to all of these pressing Covid questions, I needed to talk to an epidemiologist. You know, someone whose job it is to actually study and try to prevent pandemics from happening, if only we listen to them? So I called one up: Michelle A. Williams, dean of the T.H. Chan School of Public Health at Harvard.

Welcome, Dean Williams.

Hi, Kara.

Thank you for coming. Let’s first talk about people thinking about public health constantly over the last year, and this is your area of expertise. And I know, in a certain way, most people haven’t experienced this before. I certainly haven’t, and I’m pretty old. But what’s it been like for you?

I love, first of all, that more people know what epidemiology is and like epidemiologists.

Were you, like, not popular before?

Oh, well, people would say, “Are you a skin doctor?” Everybody knows an epidemiologist now, you know?

Right, yeah. The dermatologists get all the attention.

Exactly. You know, this has been an incredible opportunity for people to understand how we’ve undervalued and not seen public health, that it’s everywhere and nowhere. It’s everywhere when Hurricane Katrina happens or a pandemic happens. It’s nowhere when we save lives and we prevent bad things from happening. And people tend to take that for granted. It’s like one and done. And we forget that public health is really the insurance for society. This pandemic shut down our economy. This pandemic brought us all to our knees. So what I take away from this pandemic is the collateral benefit is now everybody understands why public health is important. Everybody understands that when we underinvest in public health, we do so at our peril.

But does everybody understand? I mean, when you’re coming away — you’re a year in now, and cases are rising again. And some experts are warning about a fourth wave in the U.S. It feels like we should already have a handle on this. Talk about why we don’t, and talk about this fourth wave.

Oh, this fourth wave is going to be different than the three we’ve had before. This fourth wave is occurring at the same time we are really ramping up with our vaccines. You’ve got to give the Biden administration big credit for getting upwards of 4 million vaccinations a day is really impressive. And we’ve got to maintain that, and we’ve got to keep pushing because the hard part’s ahead of us. We’ve got to outrun the spread of these variants. We’ve been behind on surveillance and identification of the variants.

What is the worst case scenario variants that these vaccines don’t work on them, right? That people feel safe, they feel a sense of safety and go out more and do other things and feel that they’re not going to die of this. And then they get it.

Yeah, the worst case scenario is if we have broad scale community spread of the variant, and the vaccines are not effective against them. And we don’t have boosters in time. So it’s a chain, and that would be just devastating for us.

Because?

Because we would essentially be looking again at widescale spread reminiscent of last April.

The head of the C.D.C has been rather — she used the word doom. I think it scared a lot of people. Everyone felt like we were finally coming out of this. You know, it’s spring now. People are feeling better and feel like it’s behind them. How do you deal with the psychological effects of that?

It’s tough because you want people to understand relative risk. You want people to understand that it really isn’t so black and white. And what Dr. Walensky was trying to say is pump the brakes on your personal individual impression of going back to normal. It’s not just go back and do everything that you were used to doing pre-February 2020. Think about the fact that there are still spread in the community, that two-thirds of the country is still not vaccinated, that we are not testing sufficiently to understand when and where outbreaks are happening. And if you’re vaccinated, these are the things that you can do with other vaccinated people, but don’t throw open the doors and celebrate like we’ve got this completely under control, because we don’t.

There is also confusion with Rochelle Walensky was giving guidance as to whether or not people who are vaccinated can travel. Why do you think this message was so muddled — and I know this happens in public health all the time — and what is the message about that?

Yeah, so I think the message is those people who are vaccinated can travel, but limited to essential travel. And I think that was the piece that was missing.

Because it felt like “travel, but don’t travel.”

Yeah, it was like essential travel, and it came out muddled. And it was really sad because then the media was all over it. But I think what she was really communicating is measured re-engagement.

And what about wearing masks and social distancing?

Keep wearing masks. Keep doing social distance in public spaces. And again, why? The why is because the variants are circulating at levels that we are not yet fully understanding. And so err on the side of caution.

Because of the possibilities of the variants.

Because of the possibility of the variants.

Yeah, so that’s the argument, not that you’re trying to make it look like everyone should go along.

No, it’s not theater, as some might say.

Yeah, they love to use that term, theater. Some people are saying that, like, Florida Governor Ron DeSantis’s response to the pandemic, which was reopening early, keep the economy going, maybe wasn’t so bad after all, as far as unemployment rate is lower than states like New York and California. And the death rate is in line with the national average. What do you think of this argument?

I think it’s reckless. I’m just going to say there is this false dichotomy that health and wealth are two distinct opposing issues. And what I would say to DeSantis is the economic health and wellness of your state rests on your making strategic investments to enable and support all members of your state. As the virus was running its course, it was unduly unnecessarily burdening vulnerable populations. And this meant the elderly, this meant the essential workers, who, unlike those of us with a college education, couldn’t retreat to our home offices. The disparities played out just the way a typical public health person would anticipate.

Mm-hmm. As we mentioned earlier, the pandemic probably affected every single person in some way absolutely, but Covid did not affect equally. What were the disparities, and what did they look like?

So, remember what we saw early on in the pandemic. We saw double, triple rates of infection in Black and brown and Latinx populations.

And high much higher than their percentage of the population by several percentage points.

Absolutely. We also saw not only higher rates of infection, we saw higher rates of hospitalization and higher rates of death. We realized very early on that the public health interventions that we were suggesting — work at home, socially isolate — all of those are not necessarily opportunities that low-wage earners can take advantage of. We also saw a disproportionate access to testing. This wasn’t new. What we basically see in public health is health disparities as a consequence of decades, if not centuries, of policies and practices that have deprived Black and brown people of the opportunities to have health and wellness the way their white counterparts have.

But science doesn’t explain disparities across racial and ethnic lines, does it?

It does in direct and indirect ways. So there are high rates of diabetes, asthma, obesity. Those are conditions that existed disproportionately in Black and brown and Latinx populations pre-Covid. And you remember Freddie Gray, the young man in Baltimore? Well, Wes Moore, when he wrote his book, “Five Days,” in the opening of his book, he tells the story of Freddie Gray’s mother. Before he’s even born, Freddie Gray is at risk. And then he comes into the world in a poor Baltimore community in housing with lead paint all over the place. So you’ve got the intergenerational in utero insult on his development — attenuation — born into a physical environment that further attenuates his opportunities for normal growth and development. And then poor schools that further attenuate growth for normal development. And then aggressive, some would say inhumane, policing system attenuates his life. And you can see how wickedly complex and intergenerational some of these threats could be. These are folks living on the margin, and when a new risk comes along, they’re going to be inherently more vulnerable, biologically, socially, physically. So when Covid came around, these vulnerable populations, we could have predicted them. And because we could have predicted these things, we should have and we must be better prepared to attenuate these disparities.

Except that in the case of someone like Ron DeSantis, these to them are acceptable risks, correct?

Yeah. And I’m going to say this. I’m going to say, I believe in the goodness of people, and I believe that Ron DeSantis would do well if we could just get him in a public health class for three weeks.

[LAUGHS] Very confident.

And I have to believe that if one were able to realign his thinking about risks and bring compassion into his leadership through understanding the narrative and the data about how we can thrive while also caring for vulnerable populations and reducing disparities, we would be in a better place.

Uh-huh. It’s very optimistic and kind of you. How do you feel — do you think you could do that with Donald Trump, put him in a public health course for three weeks and it would work?

I’m a lifetime teacher. There are some people who are just not coachable.

OK, that’s — a lot of people think that. All right, right now, things are pretty hopeful in the U.S when it comes to vaccine rollout. Biden has asked that all adults be eligible by April 19. Most states are on track to meet that. But distribution is really fragmented with states making their own calls still. I’m curious what you think about the distribution system because it was sort of every man for themselves, every state for themselves.

Yeah, this is another one of those areas where I’m hopeful, but I’m cautiously optimistic. So one of the things that we had to do early on was make sure that we had the supply to meet the demand. And Biden’s administration has done that well enough. But what we also found ourselves locked in is another one of those false narratives that equity would happen at the cost of efficiency. And I’m going to push back on that false dichotomy because that need not be the case. As these spectacular vaccines came along, my colleagues in public health and I wrote this paper that basically said vaccine allocation should be done through a lens of equity and justice, and that because we saw such great disparities for the worse off minority populations, we have to have an allocation plan that manages to bring these vaccines into communities hardest hit. And the law vacillates around whether or not race-based prioritization is legal. So we said, let’s use Social Vulnerability Index that the C.D.C has used effectively in times of natural disasters because risks are segregated by place, and it was the hyper segregated communities, Black and brown poor communities that were hardest hit. So the Social Vulnerability Index would use variables like density of household, unemployment rates, high rates of chronic disease and would say these are the geographical areas within a community where we need to hit. And if put into place, one can then reach these vulnerable populations and maximize protection of the highest risk populations, while equitably pushing out the vaccine. And nationally, it’s been heartbreaking. It’s been heartbreaking to see vaccine distribution not get to those populations that need them the most. The one thing that’s actually helping, though, is increasing the supply and pushing that supply out, and making sure that we’re not just sending the vaccines to big box stores, because many of them are not in Black and brown communities. And then the other thing is we have to reckon with the fact that vaccine hesitancy has to be addressed.

Yeah, I want to get into that in a second. But when there’s limited supply, people are going to get, wait a second, why do I have to wait in line? How do you answer that?

There’s a collective argument here that the reason I waited patiently is because I have the luxury, I have the privilege of working at home. But the person stocking the shelves that are the essential worker, the V.I.P. and the supply chain of foods and goods that I need, are the people who need the vaccine the most. So I think for those people who say, why shouldn’t I cut the line, why shouldn’t I be there first, think about it as a collective chain, where, cut the line at your peril of further stagnating the recovery of our country. It’s the same thing with mask wearing, right? Why do I need to wear a mask? I’m fine. I’m healthy. But it’s not about you. It’s about the collective community. And somehow we’ve kind of lost the way to connect to that collective agency.

I do think it’s a myth that we had it. I’ll be honest with you. I think it’s actually been every man for themselves way too much in this country.

You might be right.

One of the things that was a problem is these algorithms because they’re not just determined by individual choices people make ethically. Public health experts said that the vaccine allocation algorithm used at the federal level caused a burden, and many state and local municipalities used their own formulas in the end. Did any of these algorithms do what they were supposed to do? And can you talk a little bit about making these decisions via computers?

First of all, all of these algorithms are going to be as good as the quality of the data.

Crap in, crap out is my expression.

Exactly, and I got to tell you, one of my biggest pet peeves about where we need to invest in public health has got to be, we’ve got to have better data and data infrastructure. There’s a lot of missing data. There’s a lot of imputation that was happening. And it was a lot of crap in, crap out. But it’s not just about the data and the algorithm. There was also a lack of operational preparedness. That was missing. We were fumbling way too many of the operational pieces. And what it told me is, part of the legacy of our underinvestment in public health has not just been in the infrastructure, but it’s been in the workforce. We were asking state and local health departments to implement on an algorithm and then bring that algorithm into communities with a vaccination program that had been underinvested in and supported for far too long.

All right, making vaccines available is one thing, but they’re only helpful when people take them. In general, vaccine hesitancy is decreasing across the U.S. — especially people of color, young people — but there is some resistance. Why are you seeing hesitancy at this moment? The Times for example, just wrote about evangelicals avoiding it. But talk about where distrust comes from because everyone’s got a different reason.

Yeah, distrust comes from many different places, and probably all those reasons have some basis for truth. Among the evangelicals, what I can tell is it’s largely misinformation that is promulgated by so-called religious leaders who are conflating their gripes and historical issues around women’s reproductive health, abortion, and vaccines.

So that there’s stem cells in this, et cetera.

Yes, right, and we all know that that’s completely ridiculous, and that is completely untrue. And that’s a deadly gambit. And so, we have to do something collectively as a society to break through and to bring truth and rebuild trust with this community. And I think it’s going to mean having a campaign that is attentive to meeting these evangelicals where they are and having those hard conversations and having influencers, people who they might be listening to, to really be clear.

There has also been a lift in the Black, Latino, and Native communities. Talk about their hesitancy of that group and getting them to change their minds. They’ve obviously had a history of bad behavior from the medical community. Can you talk a little bit about that?

For 401 years, Black bodies have been traumatized. People still remember the Tuskegee Syphilis project, right? People still remember the appendectomies that happened in Mississippi.

Mississippi appendectomies are forced sterilizations.

Exactly. And then that legacy and that failure to reckon with this legacy of trauma brought on Black people have contributed to hesitancy. However, that is not sufficient excuse for us not to reckon with these past harms that have been done and not confront this hesitancy. And one of the things we learned early was that Black and brown communities really respected the voices of their primary healthcare providers and of their community influencers. And they have a stronger sense of collective action. And so once community messages got out that the vaccine’s available and when vaccination rates increased, communities are protected, that is carrying sway. We still have a lot of work to do because it’s still about 20 percent hesitancy. It’s been going down, but we still have ways to go.

Parents are another group showing hesitancy about vaccines. Clinical trials have shown that the Pfizer vaccine is safe and effective for kids 12 to 15. But some parents are hesitant to vaccinate their kids. Are they right to worry?

No, they’re not. They shouldn’t be worried. But I’ll tell you the reason they’re worrying is because we just haven’t gotten the information out to them fast enough. There is a structural flaw in the way we do our science sometimes. And one of the things that really animates me and gets me a little angry is women and children are always at the back of the line, right? It’s like the back of the bus. It won’t be until 2023 that the first randomized controlled clinical trial of these vaccines are available for pregnant women. And the information that we have — and I believe it and I trust it — comes from secondary analysis of data, not the same rigor of this intentional deliberate beautiful design that started to come out with the Pfizer and then the Moderna vaccine. The same thing with children, and I understand it. There are pragmatic limitations for how much you can do right at the beginning. But that structural flaw in putting women and children later in the flow of evidence is important fertilization for this kind of hesitancy.

So we have conflicting advice from the World Health Organization and the C.D.C, to pregnant women initially with the World Health Organization recommending they do not take the vaccine, unless they were at high risk and the C.D.C recommending they should consult with their doctors. So in the case of young people and pregnant women, what is the advice now?

That the risk of contracting the infection and getting ill is higher than any slight perceived risk of the vaccine.

So there’s some skepticism swirling around the single shot Johnson & Johnson vaccine, which is showing 72 percent efficacy in trials. So let’s set the record straight. If offered the vaccine, whatever it is, should people be taking it?

Absolutely.

Any of them.

Any of them.

Pfizer, Moderna, Johnson & Johnson, which are the ones available in this country right now.

Absolutely, take them. And one of the beautiful things about the J&J vaccine is it’s a one-shot. You’re one and done.

So staying up to date on the most recent credible information is a real challenge. So how do you improve communication in general, and can you in an era of misinformation, which is reaching people through social media, messaging apps, word of mouth, everywhere. Some platforms have added labels to posts about Covid and vaccines, redirecting users to credible sources of information. How do you think they’ve done?

Policing that is — I mean, as a layperson in that space, it sounds like a really hard job. It’s a 24/7 job, where one has to be vigilant and to have to have a surveillance system that we don’t quite yet have for pulling down misinformation. And I think it’s an arms race of getting trusted sources, trusted platforms out there, and it has to meet people where they are. It has to speak to people. It can’t just be academic to academic. It’s got to be academic to consumer.

So the benefits of social media on health care do outweigh the costs of disinformation?

Oh, absolutely. Social media is a wonderful tool and like any tool that comes along to humanity, whether it’s the rock or the wheel or fire, can be used for ill or used for good.

Though you are battling, you know, Bill Gates, that he’s putting chips in people’s blood through the vaccine. Or — I’m like, you’re very creative, but it’s really not true.

It’s conspiracy theories that have to be pushed back. And again, if you have an educated audience and consumer, you would hope that you get a wry smile, and we move on from that conspiracy.

Yeah, no. I have to tell you, people really — I love your optimism, but I do not share it with you. [MUSIC PLAYING]

We’ll be back in a minute. If you like this interview and want to hear others, follow us on your favorite podcast app. You’ll be able to catch up on “Sway” episodes you may have missed, like my conversation with the BioNTech co-founders who created the Pfizer vaccine — which I took — and you’ll get new ones delivered directly to you. More with Michelle A. Williams after the break.

So let’s talk about the next steps. There’s been much debate about vaccine passports, which could be required in schools and workplaces to prove vaccination. Now we use these kind of things all the time, whether it’s a license. And for some reason, this one’s driving people crazy. Governor Ron DeSantis, our good friend, just banned them in Florida. What are your thoughts on these? Are they helpful or harmful?

I think they could be both. I think helpful because it would be important for us to understand the local and localized risks based on who’s vaccinated, who’s not vaccinated. Harmful because if access and hesitancy continue to be an issue, you can see how it would be used against individuals who are trying to get into school, trying to get employed. So it’s another tool that can be used for good or can be used for harm.

So are you for them or maybe not right now?

I’m a little on the fence, to tell you the truth. You know, when I try to go to Tanzania from Kenya, I have to show at the border crossing that I have my yellow fever vaccine.

Yeah, we do it all the time.

So they’re not unusual, right? But fast forward now to re-engagement in our economy, re-engagement in our society, reengagement with schools. And if they’re misused, we could be driving disparities.

And also playing into conspiracy theories that we’re trying to track everybody.

Yeah.

So, one of the last questions I want to ask you, you were one of the authors of a global health action agenda for the Biden administration, which outlined steps to recovery. Talk about them specifically, the recommendations.

Well, one specifically was the re-engagement with W.H.O. and the commitment of funds to the W.H.O. Covax, which is a global organization with finance facilities to purchase vaccines for low and middle income countries. Those were two immediate actions that the Biden administration has taken to really manage the Global Health Security Agenda. The other recommendations included reinvestment in the global health workforce. And that’s not yet acted on, but I think the infrastructure plan and the American Rescue Plan both include massive amounts of funds for workforce development in public health.

Did you receive any response from the Biden administration? Are you working with them in any way now?

Some of the co-authors of that, Larry Gostin, and I have had some briefings with the administration. And we are hopeful that these messages, these recommendations, landed.

What about the idea of politicians ignoring warnings from public health officials? And they’re continuing to do so, in some instances. How do you change that?

I’m going to go back to education. I think one of the things that I’d like to see is that every person who takes office should really have some training in public health to really understand the primacy of public health in the national security and the economic security of the constituencies that they serve. And it’s a remarkable thing that a governor will tell you that their job, first and foremost, is to protect the health of their communities, their state. But then they don’t lead with that mandate. And so what we have to do in public health is not allow ourselves to be pushed aside, not allow ourselves to be seen as the cost center, but actually, public health is the pillar for investment and strategic growth and development.

OK, so beyond recovery on a macro level, many individuals are still dealing with the physical effects of being infected and will be for some time. An estimated 10 percent to 30 percent of people infected with Covid become long haulers, continue to experience symptoms. I have a friend who’s still suffering. Do you worry we might be moving on too quickly to rush to put this all behind us?

Yes, I do. I think we’re going to have to deal with the long haulers and the lessons learned. There are some basic fundamental work that we’re going to have to get to in understanding the human immune system. Here’s the other thing, the mental health fallout is going to be even bigger than the clinical physical health issues because we are talking about levels of stress, anxiety and burnout. I mean, my two sisters are nurses. Your brother is a clinician. The level of burnout prior to Covid was already at alarming rates. I think the Washington Post and the Kaiser Family Foundation just came out with a survey. Fifty percent of healthcare providers are citing anxiety and burnout. This is alarming. And this is not just the professionals who’ve been at it for years and decades. We’re also talking about kids who are in training.

Kids in schools, too. So we were able to develop vaccines for Covid at a record-breaking speed. Do you think the technology experience will help us advance in this case in other areas? These mRNA technologies look like they could be moved into other areas. Does that give you cause for optimism?

Yes. First of all, these vaccines were decades in the making, built on basic science investments that were made decades before. I think there’s a bright future for really thinking about how to leverage this mRNA platform for a variety of therapeutics and vaccines going forward. People are already starting to work on universal SARS vaccines, and there will be opportunities to think about how can we use these mRNA platforms to develop treatments for chronic diseases as well and cancer therapeutics.

So, as we’ve focused on Covid, there have been collateral damage in other areas. If Covid didn’t exist, what is the public health crisis we should be most paying attention to?

Climate change. The impact of climate change on extreme weather, on displacing and putting people at risk are driving these zoonotic infections out of remote areas into places where people aggregate. The impact of forest fires, the high frequency of floods, and these air quality. I’m really deeply concerned about the impact climate change will have on population health, on our food supply, on how we live, on our extreme temperatures. And again, it’s the vulnerable populations.

All right, well, let me finish up with a question. You’re not just an epidemiologist, you’re the dean of a public health school. Has anything changed in your curriculum in response to the pandemic? Are more people applying to study public health?

I’ll tell you, our applications for our Master’s of Public Health and Epidemiology, 177% increase in applications.

Do you expect to see this trend continuing?

I hope so. I really think public health is an investment in health and economic and security agenda for society and the world. And if we can infuse our K through 12, college graduates and governors getting refresher courses, presidents getting refresher courses, will all be for the better. Because the primacy of public health is that it is the seed corn, it’s the bedrock of civic society economically, socially. And it’s not a tradeoff. We should never have anyone force us into health versus economy the way we were struggling with this a year ago.

That’s an excellent way to end it. Dr. Williams, I really appreciate this so much. There’s so much information in here, I think people will get a lot out of it.

Thank you, Kara.

I appreciate it. Bye.

Appreciate it. Bye-bye. [MUSIC PLAYING]

“Sway” is a production of New York Times Opinion. It’s produced by Nayeema Raza, Blakeney Schick, Heba Elorbany, Matt Kong, Daphne Chen, and Vishakha Darbha; edited by Nayeema Raza and Paula Szuchman; with original music by Isaac Jones; mixing by Erick Gomez; and fact-checking by Kate Sinclair and Michelle Harris. Special thanks to Shannon Busta and Liriel Higa. If you’re in a podcast app already, you know how to get your podcasts, so follow this one. If you’re listening on The Times website and want to get each new episode of “Sway” delivered to you, with a Harvard school of public health diploma, download any podcast app and search for Sway and follow the show. We release every Monday and Thursday. Thanks for listening.