Lessons learned: Michigan's Coronavirus Task Force on Racial Disparities

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0:00:32.1 Dr. Celeste Watkins Hayes: Welcome to the COVID 19 reflections series hosted by the Center for Racial Justice at the Gerald R. Ford school of Public Policy Poverty Solutions and the National Center for Institutional Diversity. All at the University of Michigan. I am Dr. Celeste Watkins Hayes, Director of the Center for Racial Justice and the Associate Dean for academic affairs here at the Ford school of Public Policy. I'm also a Professor of sociology. The first two events in our series were led by my colleagues, Dr. Mara Ostfeld and Dr. Luke Shaefer from poverty solutions. The first event included a phenomenal panel of scholars and activists focused on the local impact of COVID 19 on communities of color in Michigan and Dr. Shaefer moderated an amazing conversation with Dr. Cameron Webb of the, on the national response to COVID 19 racial disparities. I invite you to check both of those out on YouTube and on our website.

0:01:31.1 DH: I am so happy to be joined today by Dr. Joneigh Khaldun. Dr. Khaldun is a nationally recognized healthcare executive health policy and public health expert who currently serves as the Vice President and Chief Equity Officer for CVS health. In this role, she advances strategy programs and policy to achieve health equity across all CVS health lines of business. Prior to this, she served as Chief Medical Executive for the state of Michigan and Chief Deputy Director for health in the Michigan department of health and human services, where she oversaw public health, Medicaid, behavioral health, and aging services. She was the lead strategist guiding Michigan governor Gretchen Whitmer's COVID 19 response. And in 2021 was appointed by President Biden to the COVID 19 health equity task force. Today, Dr. Khaldun and I will be reflecting on the two year anniversary commemoration moment pausing for of the COVID 19 pandemic and specifically talk through the lessons learned related to Michigan's response to COVID 19 health disparities. Welcome Dr. Khaldun it's wonderful to have you with us.

0:02:45.0 Dr. Joneigh Khaldun: Yes, yes. Thank you. Thank you for having me.

0:02:47.7 DH: Yes. So we wanted to do this series as we thought about two years or now over two years of this pandemic and just to pause and reflect on the lessons learned, but I wonder if you can first take us back, take us back to that time in early 2020, where we became aware of COVID 19 and tell us about how you got involved in the fight.

0:03:15.8 DK: Absolutely. So I first say that, we have, and many people don't know this there's a great apparatus of public health professionals across the state in local and in the state health department who really their daily job is just this responding to public health threats, responding to infectious diseases, outbreaks, environmental health threats. And so I have an amazing team at the state. Many of whom are still there who were really looking at this very early on. So I remember actually being on vacation in late 2019 and over the holiday break. And I remember seeing international news about this virus in China. So to remember that, and I remember saying to my husband, you know what, this is gonna be a thing. When I get back, I'm gonna have to talk to my team and kind of see what's going on here, because what I know is that oftentimes for these types of infectious diseases, particularly respiratory they tend to get ahead of us as far as being able to identify them, and track them.

0:04:23.0 DK: We know that it's a global society, right? So they often don't stay within borders. So essentially fast forward, maybe a week or two we're in January of 2020 now. So actually at that time, I was engaging with my team with the CDC, we were making sure we had the latest information on the virus. Again, at this point we weren't even sure if close contacts were being impacted, how it really spread, but we certainly were making sure we had our teams together. I actually remember talking about, I think we're gonna need more capacity as far as staffing, to be able to deal with what it ended up becoming. And so essentially really just got our team together, made sure I was preparing our health and human services director, our governor's office briefing them. And then unfortunately it became what it did which is of course the pandemic that we all know now, but there was a lot of behind the scenes work before the actual first cases were announced in the country or in the state.

0:05:28.1 DH: And that's so important because it's such a great example of how policy and public health are operating. And the wheels are turning before the general public really has a strong awareness and you're you're right. People remember those early news stories in 2019 and, and perhaps thought about it as this far away distant issue, but it's key for policy officials and public health officials to move it into the present in terms of "alright, what's gonna be involved in our day to day planning, right? How are we gonna think about putting the mechanisms in, in place?" So then can you walk us through, as the cases started rising and we had our first cases in the United States, and we saw the movement, the first cases in Michigan, can you talk to us about what that was like and what some of the initial responses reactions were from a public health perspective and from a policy perspective, as you were trying to figure out exactly what we were dealing with.

0:06:33.7 DK: Absolutely. So I think what's important about these types of crises and public health responses in general is that often we don't have complete information. We don't know everything about the virus, how it spreads who's been impacted. And so that information, again that's kind of how science works unfortunately we don't always know what we research, we investigate. And then as we know information, we share it. We tell people what to do and then we continue on. So I would say that I know I remember the very early days, excuse me, the very early days. And don't quote me on this. It was maybe late January or February. I'm forgetting the exact timing, but certainly before we had cases identified in Michigan. I remember speaking to my team and they had been in, and there were many CDC calls. And I remember someone telling me that we were only going to be able to test people who had recently traveled to a subset of countries or I remember in the early days people were saying, "Oh, it's just these countries." Right? So only people who had recently traveled and only people who were severely ill were going to be able to obtain a test. I know that sounds crazy now in 2022, that's really what it was...

0:07:48.0 DH: In that Point the horses out of the barn and people are asymptomatic at that point. Right? 

0:07:53.3 DK: Exactly. We were only going to be able to test people who were severely ill. What I know as an ER doctor, right? As a physician, as a scientist, as a public health leader is that often respiratory illnesses are not always severe. If you only test a subset of people you're going to miss a lot and you're, therefore, again, it's not just tests to, for the sake of testing, you test you know who has it, and you can isolate them and they don't spread it to others. So if you're not able to identify the illness early, you're not going to be able to prevent the spread. And so I remember having that conversation and saying, are you sure, like that's what the CDC said. And I don't mean to disparage the CDC at all. I just think as a country, we weren't prepared as much as we would've liked. And I don't think that anyone would disagree with that. And so essentially that's what we did. We had limited testing. We had to work very closely with our hospitals identifying, making sure people who they thought might need a test, met this very rigid criteria.

0:08:49.5 DK: Then they got a swab. They sent it to my, my lab at the state. We would then send it to the CDC. And then this is very early on and wait for the result of that test to come back to us. And that's what the CDC was doing for essentially every state. So I share that because I think that alone is partly how we got a little behind as a country in being able to quickly identify and stop the spread. However, again, my kudos to our lab public health professionals in the state. We did build up a state lab capacity pretty quickly. We trained other labs across the state. We partnered with others. And so we were able to expand our testing capacity. But again in the early days it was about testing, trying to isolate and then making sure people had the information they needed to protect themselves. And one other point I'll make is about data. And so in the early days, I believe people probably didn't understand just how underfunded and inadequate the public health data infrastructure really is. Many health departments, most health departments quite frankly data sharing is with fax machines, fax machines.

0:10:03.6 DH: Wow.

0:10:03.9 DK: There is no system. There had not been a system where someone goes to X hospital, they have a certain symptom. The test is there. It automatically goes to the health department. I click on it. [chuckle] And then all of a sudden, I know who they are, where they've been. And so that system does not exist, right? The data infrastructure, the communication, it was literally on paper. And so again, that's a national challenge where we don't have the data infrastructure, so you can't understand and respond in the way that we really needed to be able to do, to be able to hold this pandemic back.

0:10:41.1 DH: How do we help the public understand the importance of resourcing data infrastructure? It's not the most exciting thing, but it turns out that data ended up being critical for the identification of racial disparities, in the response, and then the subsequent ability for us to be responsive and to help save lives. So how do we think about making that connection between data and ability to save lives? 

0:11:15.5 DK: Absolutely. I mean I'd like to say you measure what you treasure if you don't measure it, you're not going to be able to do anything about it. And so I absolutely think that... And people in public health, public health leaders know this, we've known [chuckle] There's been a lack of infrastructure support for public health for decades. What tends to happen is that when crises occur so H1N1 flu, Ebola you know, things happened and then funding is made available. And then the funding goes away, the funding goes away, the staffing goes away and that's kind of just the life of being in governmental public health.

0:11:56.9 DK: And so absolutely the data infrastructure building out the IT systems to be able to collect the data interoperability right between hospitals, doctors offices, the local health department, the state health department, the CDC, and all of their lab capabilities right. We should not be in 2022 or in 2020, we should have not have been on fax machines right. There should have been a system in place. Literally in the beginning the way we were able to identify demographic information about cases was if someone actually wrote it on the lab requisition form that was shipped [chuckle] literally shipped physically to the state lab in Lansing, right. That is a failure of the public health system as a country. Again, Michigan is not unique in that.

0:12:52.8 DK: That is a national challenge that I think many people have recognized there have been efforts to expand funding for public health. And I know governmental public health officials have been grateful for that, but we just were ill prepared, not prepared as a country to be able to address just the basics of where the virus was, let alone how it was really impacting communities at the local level.

0:13:18.0 DH: So cases are rising in 2020, and we're working through this kind of early operation in terms of testing that we know is not going to be adequate and the cases are rising and we start to see who's being most affected and who's being disproportionately affected because of the nature of COVID 19 being a respiratory virus and all of the dynamics around close contact, their social dynamics, their sociological dynamics. So of course we see how it maps on to social life and who has access to what? So can you walk us through the conversation, the awareness about this is an infectious disease that can affect anybody and yet we're seeing disproportionate impacts? 

0:14:09.4 DK: Absolutely. So that that's really critical when you talk about health disparities and health equity. And so, you know, I would say that for my team, my epidemiology team who were just phenomenal, absolutely phenomenal. We had a just a general understanding and I will say this is something that I've always championed in my various roles. So whether it's the opioid crisis and deaths, maternal deaths, I always encouraged our team to when you're looking at data sets, make sure you're looking at, by race and ethnicity, which is really really important. And so COVID cases, we started building up our capacity to be able to track them appropriately. The team really built out a... Continue to build out a great dashboard. We had a website, right? Just building, building, and I asked, you know, excuse me. Let's look at these cases, let's look at these cases by race and ethnicity. Can we do that? You know, the challenge was, again, going back to the data infrastructure, people weren't putting in on the lab requisition form that was being mailed, right? Or they weren't asking it, clinicians weren't asking it, when people were getting a test or again, we had the contact tracing.

0:15:26.8 DK: We haven't talked about that, but the contact tracing where you called someone or the case investigation, some of that information we had to get when we actually identify, so got the positive result. And then we called the person back to understand more about that person, right? The person who was the case and where they had been. So we could identify their close contacts and then call them to make sure they were isolated before quarantined appropriately, etcetera. And so essentially the team said, Yep, you know, Dr. Khaldun, we're gonna look at this. And so they really did. We really worked on collecting that race and ethnicity data and being able to analyze it and share it. Michigan was actually one of the first states to be able to do that, which I'm really proud of. But I also wanna talk about the disparity and I wanna make sure people understand this is not about genetics, right? And disparities that we have seen in COVID 19 Blacks and Hispanics, particularly early on about three times as likely to be hospitalized almost twice as likely to die from COVID 19.

0:16:31.8 DK: Those are not because of genetic differences. You know, there's nothing about a gene that dictates how much melanin you have in your skin. [laughter] That says that you should die from respiratory virus, that's just, does not exist. However, what we need to talk about is unfortunately, the structures in society, right? So racism, classism, etcetera, that mean that there are disproportionate numbers of people, of color, black and brown individuals who are more likely to live in poverty, who are more likely to not have access to high quality education or high paying jobs. Jobs that allow them to work from home, jobs that allow them to buy and have their own cars so that they can again, get into COVID 19 isolate and not take public transportation, right? Access to healthcare. Right? And so not having access to healthcare, not being able to live in communities where you can have access to safe places to exercise chronic diseases that come from that. Right? So you have a situation where as a country, some individuals because of the structures of society, less likely to have resources. And so, again, COVID 19 and respiratory illness.

0:17:45.1 DK: If you are more likely to live in less stable housing or crowded housing, that's how the virus is going to spread, right? If you're not able to stay at home, right? And isolate, if you're a frontline worker, you're going to be at risk for getting the virus. So more likely to be exposed, not because of genetics, but because of your social situation, chronic diseases, we've learned that chronic diseases made you at higher risk for getting sicker from COVID 19, right? That's why we had that hospitalization rate, not because of genetics. It was because the underlying, the higher likelihood of having chronic disease. And of course, if you're more likely to get severely ill, you're also more likely to die. And so I think we have to really understand that landscape when we start talking about the disparities, because it was not about anything that people were doing wrong, right? Blaming those communities. It was really about the structures that were never set up for historically marginalized communities to be able to be protected from a public health crisis, such as COVID 19.

0:18:46.7 DH: So, so many of those issues that you talk about are the things that I think about as a sociologist, and when you're able to... When you're making those linkages between the sociological and economic dynamics and their implications for health. How do you begin to target that through policy? How do you begin to respond to the disparities through policy in terms of, do you think broad, in terms of, we've gotta address the broader structural systems, do you think at the institutional level, in terms of people's access to different kinds of helpful institutions? Do you think at the micro-level in terms of what individual behaviors can we try to promote? How do you begin to attack what is such a large and significant issue? 

0:19:39.7 DK: Right, so those structural barriers that I spoke about, you can't fix those overnight, they took centuries to get to where they are, and so you can't snap your fingers and fix them, but you can at least understand that they probably exist, so that data piece was really, really important, early identification of data, and then you have to understand what those risks are and why people are... Who have been historically marginalized and have not had the resources to support themselves or their communities, you have to understand what those barriers may be, and then you have to respond. And so, for in the middle of a pandemic, it has to be immediate response, and so, of course, we looked at the data, we identified there was a disparity and then we acted and kudos to many people at the state and local level for acting. One of those actions was creating the Michigan Task Force on racial disparities who, Lieutenant Governor Garlin Gilchrist who's my friend, was the a chair.

0:20:36.2 DK: So that was one response, but what that really was, was one, the Governor saying that racism is a public health crisis, which it is, and that's how we got to the disparities in the first place, the task force was really about, we can't do this alone and government, you can't sit in your office and look at data and then decide you're gonna watch programs because you think you know everything, right? So really the task force was about pulling together the amazing expertise across the state, people with lived experience, people from and in the communities who were disproportionately impacted by the pandemic, so bringing those just brilliant, many people together to really advice on what are issues on the ground, what should we be doing, and also using, I shouldn't say these, that doesn't sound right, but really, I think leveraging our resilience and in these communities, and so actually many of them on the taskforce were spokespeople, spokespeople for the community, just getting basic information out, this is what COVID-19 is, this is how you should protect yourself, wash your hands, wear a mask, get your vaccine, so really making sure it was not just me, Dr. Khaldun, or the governor sharing that message, but really the communities that were disproportionately impacted.

0:21:55.8 DK: And then it's also about, in fact I'd say, understanding what people were living through in the moment, so we did a lot around supporting people in their home, so providing food, providing isolation. So if someone didn't have a safe place to isolate, being able to provide that type of housing, stable housing, food delivery for people who were in their homes, free masks, we sent out millions of free masks across the state, particularly focusing in underserved communities, and the message that we put a lot of, when we initially identified those disparities, we pivoted our message and our communications team did a great job of this, and we really focused our messaging in southeast Detroit Metropolitan Area, again, early on, where we were getting the most cases, and thus focused our communications efforts as well, and then I'd also say Medicaid, so this was not just about the public health team, but our Medicaid did great work in looking at their policies, being able to get 90 days of medication as opposed to 30 when you're trying to get medications.

0:23:03.1 DK: Virtual, making virtual visits, being able to be paid for through Medicaid, which was not something that was possible before the pandemic, so again a lot of, it's about data, understanding what people are going through, leveraging the communities and then acting with resources, money, communications, and then policy changes where you can.

0:23:29.2 DH: Absolutely, and it's so helpful to hear you lay all of that out because it helps people understand the larger apparatus that it is a public health response, and to understand all of the different players and systems and how they have to work together in order to be able to create a kind of outcome. There were nevertheless barriers I know through that process, when, in terms of continuing challenges around access to testing when vaccines were rolled out, getting people to get access to the vaccines and trust the vaccines, I wonder if you could talk about some of the challenges that began to emerge as the pandemic unfolded.

0:24:16.7 DK: Absolutely, I think in any public health crisis, communication is so critical, and for something that's a global crisis, aligned messaging and coordinated messaging is so critical using the right messages, making sure your message is accurate, credible, early and frequent. And so that's something that we certainly at the state really prioritize and I know people saw my face many times on TV and press conferences and other media outlets, but it wasn't just me, it was also to be used again, local community members as well. But I would say one of the challenges early on is that we did not have a consistent or appropriately science-based approach to communicating the pandemic at the White House level, early in the pandemic. There were just things that were shared at the level of the federal government that were sometimes untrue from the White House, that were simply untrue and not scientific, and unfortunately, I think that contributed to this pandemic becoming quite political.

0:25:39.8 DK: And it really impeded our ability as a public health community to be able to respond as much as we could. And that just [0:25:45.7] ____ fuel on all of the issues that, that I talked about earlier, where we already know that there are historically marginalized communities of lack of access, etcetera but it just made it even more difficult to gain that trust and to be able to respond. So I think communications were certainly a barrier. Again, the public health infrastructure, we talked about the data already that was not there, but I'll say we really try to make sure we were thinking about access as testing became more available. We actually brought in our private sector partners and brought in, you know, mobile clinics partnering with the faith based community, going to places that were in people's neighborhoods, right. So that they could actually get to them and also, again, partnering with trusted community organizations. So that again, we could get beyond that barrier of distrust.

0:26:49.9 DK: And let me also say the distrust that many people have in these historically marginalized communities it's quite valid. I think really we should not be judging these communities for thinking Hmm. You know, what are they really saying? Is the government really looking to support me and I'd say particularly for, for African American communities, we know public health and medicine have done some egregious things in black and brown communities. And so that's why there's just this kind of hesitancy sometimes not for everyone, but sometimes there's this hesitancy, which is why it's so important. And this is what we really focused on at the state level have frequent conversations, make sure the data and the science we are frequently communicating that, working with trusted messengers and just having those places and spaces for people to have those conversations in an open non-judgmental way. And I think that we had some success there as far as really getting the message out and helping people understand what they could do to protect themselves.

0:27:58.9 DH: And then when you think about how important that was for us to have a response that was both universal in terms of trying to reach everybody, but also targeted in the same way responding to the disparities that ended up being an approach that was critical in terms of offering leadership for many other states and many other places. And in fact, at the national level, in the Biden administration, many of the things that Michigan did were lifted up as really important and useful practices. So can you talk about also the role of local and state policy making and implementation in terms of informing what happens at the federal level? 

0:28:53.2 DK: Yeah, you know I say there's one thing we've learned and not a surprise for many public health leaders, but I think there's some work to be done as far as coordination of our governmental public health system from a local state and federal level. So it's really how do I put it, the federal level at the national level, they have certain authorities and authorities, but they don't really have the ability to do things really at the local level, they kind of defer a lot of that responsibility authority to the cities and the states and counties. And every state is actually built a little differently. As far as the laws, there are laws on the books that give local health officials and state health officials authority. So in some states, actually the local health officers report up through like literally they're on the payroll of the state health department and their authority kind of comes through that.

0:29:54.0 DK: Here in Michigan essentially we have laws where oftentimes the local and the state health department have the exact same authorities. So, you know, not to... There's pros and cons of that, but the point of that is that there's really a lot of communication and coordination, even at the public health leader level at the national state and local level that really needs to be done. And I will say that does make it challenging because sometimes at the state level, at local level, we wouldn't exactly know what was going to come out as far as recommendations from at the national level. So sometimes I would wake up in the morning and I would see it on the news, unfortunately from a New York times article, just like waking up.

0:30:41.1 DK: So it's not like at some point, like the CEC would prepare us at the state level and say, This is coming, heads up. This is what you wanna think about. We will find out about it at the same time as the general public. And then of course be asked to speak about it. So again, we were always, I gonna say always, but sometimes trying to respond in that way. And so policy making again, local state, federal having to communicate across those lines understand different authorities, but where you do have authority and think that you can, we did this obviously at the state level when there's a public health emergency, which I don't think anyone would argue that the pandemic was or was not I think there's different kind of avenues you can take to protect the public and those laws differ across the state and between the local state and federal level.

0:31:32.4 DH: Right. Right. And I wanna ask you, and I think many of our viewers would be very interested in this, particularly our students. So when you're in this situation where you're trying to respond to an emergent public health threat, and you're still learning what it is and you're still trying to understand the science of it. You're trying to think about how to run a coordinator response. And then there are moments where you're hearing things in, and you're reading things in the New York Times and just getting informed in terms of how the communication is not flowing in the ideal way. And then you've got a press conference that morning. How do you think through how, as a policy official as a public health professional, how do you nevertheless push through to be able to act effectively and act and health [0:32:32.6] ____ so much sprawling around you that is in fact complicated uncertain contradictory, what did you learn from that kind of battle testing? 

0:32:46.2 DK: I will say that this was really mad though. Of course, I hadn't responded to a global pandemic before. But this concept of there's some type of crisis, there's a public health threat, we need to pull people together, understand what the threat is, understand why it happened, make sure we're communicating with transparency and speed to the public, of what we know, what we don't know, what we're doing, what they can do, and what next steps will be. That's kind of public health response, crisis communication, that's really what it is. And so I think, of course, this pandemic was an entirely different, another scale. But we were continually just constant communication, daily, multiple times a day communications with the public health team, the Medicaid team, a behavioral health system, the governor's office, other departments at the state level, departments at the local level. So there was really just a lot of communications, a lot of groups. We call them, there's an incident command system that set up and I won't get into, but this concept of emergency crisis response, and how different government and non-governmental departments work together, that's really what we were able to stand up making sure the governor and her team were always aware of making sure we had supply chain going.

0:34:11.8 DK: And also, I would say, anticipation. One thing that we always did was think about what are the next steps? If this happens, what are we gonna do? Who needs to know? If that doesn't happen the other thing happens, what are we going to do? Who needs to know? That you anticipate this might be six months, three months, six months from now? So we were never just sitting in the today, we were always... And I know I haven't been in the state I left in September. But I know the team is just great at thinking about what we have, anticipation, responding. That is what public health responses that we did in Michigan and other states as well.

0:34:51.3 DH: I wanna come back to our conversation around disparities and the word equity as the goal as the desire, I wonder if you can talk about, first of all, What does health equity mean, particularly in a... For our listeners just to understand the concept, but also, what does it mean in terms of trying to think about policy formation? Can you talk more about that concept? 

0:35:23.3 DK: Yeah, health equity is quite simply making sure that everyone has a fair and just opportunity to be healthy. And unfortunately, I would say across the globe, we don't have that. It's not good for most conditions where we see disparities, so a disproportionate impact of a certain health condition on a group of people that shouldn't otherwise exist. And we see disparities, it's often because of this disproportionate or disparate division of resources and opportunity. And so health equity is really about understanding that and then doing something about it. So ideally, to advance health equity, you really have to look at the infrastructure. So how are we making sure people have access to quality education? Quality food, environmental threats. We know that unfortunately, Black and Brown communities are more likely to be living in places where there's poor air quality, that was by design.

0:36:30.9 DK: So when you have, again, when you have these structural challenges, you are going to see health disparities. So when you're in a pandemic response, you have to know that they exist, we're not going to be able to fix air quality, or education jobs overnight, but you have to at least understand the challenges that people are facing in their daily lives and respond with, Okay, How can we make sure people can isolate appropriately in their homes? Do we need to send them anything? Do we need to think about virtual? Should we be looking at paid time off policies? So all those things have to come into play when it comes to addressing a pandemic of this magnitude? 

0:37:14.3 DH: I wonder if you can talk about the work ahead as it relates to COVID. We're at a moment where many people are commenting that the perception seems to be that the pandemic is over in a lot of ways. You see a lot less masking in public, you see people who feel like this was a thing in the past and they've moved on yet we're still seeing infections, we're still seeing serious illness, we're still seeing people who are not vaccinated. Can you talk to us about if you think about a pandemic as a lifecycle, this period that we're in right now, the emergent crisis where people are glued to their TV screens and thinking about this every day has largely passed, yet, we still have to fight this pandemic. Can you talk about that moment that we're in? 

0:38:14.7 DK: Absolutely. I'll talk about it from the infectious disease perspective, but then outside of that as far as forward-thinking risk response. So I think from an infectious disease perspective, again, early on, 2020, we anticipated, especially when we realized that our testing was behind and this was gonna roll out and be the pandemic that it was. We knew this was likely not going to be just over a few months, right. We knew just like the Spanish Flu of 1918, similar rollout. We knew this was going to happen. We knew what type of virus, I'm talking about "we" the scientific community again, this is what viruses do they mutate.

0:38:57.0 DK: They mutate, especially when you have such rapid and widespread of it, we knew it was going to mutate, we knew that our vaccines were going to have to change and we would likely need boosters. But you can think about it from the perspective of flu, right? The flu virus mutates constantly. And that's why we have to get a new flu shot every year. And so I think that where we are now, pandemic is certainly not over, there are so many things people should be doing to protect themselves masking, particularly when you have high rates of spread in a community, where you're going to be in large public spaces. Considering masking, we have vulnerable people in your home, right? Who are more likely to have severe illness, of course, vaccinations, getting your vaccine at the appropriate time and making sure you're up to date, those schools continue to be the bread and butter, things are important for people to protect themselves.

0:39:52.9 DK: But I think ideally, we get to a place where we've been with the flu, where at some point, maybe it will become seasonal, I wouldn't say it's a pandemic and seasonal at this point. But where we see this, kind of these increases and decreases, hopefully, we have vaccines, which we do today that are effective and decreases the severity of the disease and decreasing limiting the spread as much as possible. And we wanna of course, not get to a situation where our hospitals are overwhelmed. And so that's what we're going to continue to monitor and I anticipate that the virus will continue to mutate, because that's what viruses do. So there's kind of that infectious disease aspect.

0:40:34.7 DK: But then let's really think about what we haven't talked about yet, which is mental health. What I'm really concerned about is that, you almost think of this as like a disaster crisis, after, post response, where we know that across the country, 4 in 10 adults have experienced symptoms of anxiety or depression over the past two years of the pandemic, that was compared to 1 in 10 prior to the pandemic. We know that again, it sounds like just a number. Black people being almost twice as likely to die from COVID-19, particularly in the early years of the pandemic. That's not just a number what that means is that these communities have been disproportionately impacted more broadly. So if a child loses a parent, or a caretaker or when they have not been able to be in school... Those things, the mental health impacts of that are very far reaching.

0:41:34.4 DK: And I believe we'll be dealing with that for generations actually. And so we think about our response, we have to think about what's happened, right? So how are we responding from a mental health perspective, educational perspective, economic perspective, but it's also think about, there will be more pandemics, right? Again, that's just, there have been pandemics before there will be outbreaks... How can we really make sure, to what I said about we can't kind of snap our fingers and deal with air pollution and access to health care and education overnight. But we can do things now that if there's a new pandemic in five years, 10 years, whenever it comes, I don't pretend that I know when it will come. But it will come. Can we make sure the next pandemic, we don't see the disparities that we've seen. Because again, they were not a surprise, you would anticipate it if you know anything about the structure of society and how viruses spread. So what can we do as a society to make sure that does not happen again? 

0:42:36.0 DH: Right. Absolutely. And then when you think about the disparities, how you were able to respond to the disparities in Michigan, can you first talk about what kinds of results we saw through the efforts that you described? And then can you talk about the lessons learned around that, that you hope are replicated? 

0:43:00.6 DK: Right. So now we're going back a couple of years, particularly early on, when we identified the racial and ethnic disparities in cases and deaths specifically, and again, kudos to many people who acted, identifying it as a problem in the first place, pulling together the leaders, dedicating resources, changing policies, we actually in 2020 we saw that disparity essentially closed over the span of a few months, right? And this data is on the Michigan website. And so we always knew that was fragile, right? We always knew... I would tell my leaders like... Okay, let's not high five [laughter] and say the disparities are over because we know the structural reasons, this pandemic will be ongoing and of course, they did open up after that, but not quite as why.

0:43:55.2 DK: So I think that, again, understanding early that disparities will likely exist, measuring them and then acting with speed and intentionality, I think was really important. And so that communication is so key, policies that make sure that people have access to what they need, we built out testing and again, in communities so that they could have access to testing, know where the testing was, right? So removing barriers to access, supporting people, if they had to isolate or quarantine was critical. So all the things, the resources, human resources, the financial resources, the communication efforts... Equity will only happen when you're intentional. And so I think that was the lesson learned that I tried to share with others is you can't just expect it to happen and disparities are not inevitable.

0:44:54.9 DH: Right. Right.

0:44:57.6 DK: There's often this kind of, oh yeah, disparities exist, okay. But they're not... They don't have to exist, do something about it, you can actually close the gap and save lives, right? So I think that's really, really important.

0:45:09.2 DH: It's so important, disparities are addressable. And I think that so often we hear about it and it becomes first, it's an old story. It's background noise. Well, we knew that was going to happen. It is what it is and not recognizing that disparities are addressable. They are addressable. And I think that one thing that's so important, as I hear what you're saying is, the commitment has to be there. Right? So I wonder if you could talk about how you know kind of the big element that was really important for all of this was commitment. Commitment, from leadership, the governor's office, et cetera there are times where there's less commitment, there's times where there's not gonna be commitment and all the different historical moments and life circumstances we can talk about how do you build commitment? How do you get people to care? How do you get people to become invested? Those who aren't affected, how do you get them to care? Those who are affected, but are apathetic and are tired, how do you get them to care? How do you sustain commitment? 

0:46:27.6 DK: Right. You're right. I think you're, you're right. In the sense that commitment and it is particularly commitment from leaders it is so critical. And we had that, we've had that in the state of Michigan and it is something that I've been quite, I was quite proud of. We had that commitment in the state, from our government officials to address this pandemic, to respond, to address disparities, to highlight disparities, and to provide resources, to be able to address them. Because without that, we would not have seen, excuse me, we would not have seen the success that we did. So I think that commitment is very important, but I will also say it was commitment from non-governmental individuals as well. I'm currently the chief health equity officer for CVS health a company that reaches over a hundred million people every single day, health insurance of a pharmacy benefit plan.

0:47:25.8 DK: Obviously our minute clinic and retail footprint, but CVS actually stepped in very early and expanded, is the one retail arm that's provided the most test COVID test and vaccines across the entire country. They were great partners actually for me, in this state and in expanding those kind of locally based testing sites. So the point there is it's commitment, but not just from government it's from the public and private leaders, those partnerships, academia I would be remiss actually, if I didn't highlight how important our academic partnerships were, university of Michigan actually was a great, the school of medicine, school of public health, others information I would be remiss. I know there are many other folks, but that were great partners in actually analyzing the data, sharing the data we actually brought them in, right. There's no room for egos in public health.

0:48:23.0 DK: We brought in the experts at the university of Michigan. They were in our governor calls and we were giving updates on the data with the governor and other leaders in the state, you we saw some of the leaders from the university of Michigan in our press conferences. So again, university of Michigan, there were others, Wayne state who we have worked with hospital leaders, this commitment, really, I think I would say was what is phenomenal in the state of Michigan. And I really have to use this time to thank many individuals who supported me and my team and many others in this work. And I think collectively we were able to save lives.

0:48:58.7 DH: And what that highlights is, there's so many different roles to play. So for students who are trying to figure out what's gonna be my plugin point, there's so many different ways to plug in through government, through the public sector, higher ed, et cetera. There's so many different plugin points to address some of these challenges and to just understand the wide array of opportunity that's available to you. I wonder if you can talk about, we've spoken a lot about the challenges and the policy response and the impact of the work that has been done in the state of the Michigan and the work that still remains, and the lessons learned. I wonder if you can talk about where we go from here, as it relates to this challenge of how do we put public in public health, how do we help the general public understand that we are all in this together? 

0:50:04.0 DH: How do we help the general public understand that we all will be better suited if we better understand the issues, better understand the implications, are more... If we have a better understanding of when public health officials make recommendations, why it's important to respond, how do you think the public's reaction and the public's relationship to public health changed through this pandemic? Talk to us about the challenges. When I suspect there were moments where public health officials felt very challenged by the public, but also talk about the symbiotic relationship that we hopefully now have, and the ability for us to understand just how important public health is to our society.

0:50:56.5 DK: Yeah. I mean, I think now most people probably understand how public health, what public health kind of is.

0:51:04.6 DH: Yes, a lot of people probably didn't even understand what public health was until this pandemic.

0:51:10.0 DK: And now they do in their personal lives, in their professional. So I think every business probably understands now how they have something to do with public health, right. People probably know their local health official or know that there's a local health department, right? And people kind of know that, but I would say even before the pandemic, I think there were already relationships, but I think that they could have been stronger in the sense that I think that there should always be a connection between the local health department and local business leaders, there should always be a connection. And I did this in my roles between the local health department and your local doctors and hospitals, right.

0:51:52.9 DK: Some of this I deed when I was chief medical officer in Baltimore, we had, we responded to the unrest with the Freddie Gray murder. So there I convened many of the local leaders and we responded to providing food et cetera. So really, public health is always... Should always be that kind of leader in convening and making sure people have the things that they need. Similar in Detroit when I was the Detroit Health Commissioner, hepatitis A, [chuckle] many people may not remember that, I remember what hepatitis A in 2017, '18, I happened to respond to that convening health department's convening, providing vaccines again, we did this early on to the hepatitis A, to respond to the hepatitis A outbreak in Southeast Michigan, convening being present, hospitals, knowing that there are resources with the local health department or other communities, that's really, really important. But again, I think that there's work to be done, because I do think that unfortunately, again, because early on, I think the pandemic became somewhat political. I think that has hindered the pandemic response and hindered people's relationship in some places. In some instances, not everyone, but with public health and so I think we have to do some work on that.

0:53:18.2 DH: Absolutely, In terms of the challenges to the credibility that happened, the challenges to science, and the real struggle that I think happened in the early stages. I wonder if you can also talk about and this is my last question, you still treat patients. And I wonder if you can talk about that, in the context of how that informs your approach to public health, how you think having that patient contact helps in terms of understanding COVID in the pandemic, I wonder if you could just talk about that relationship between the very intimate relationship between patient provider, and then how it eventually funnels up all the way up to the highest levels of government, in terms of how we mount a collective response.

0:54:16.7 DK: Absolutely, I love, I practice emergency medicine at Henry Ford Hospital in Detroit, I love it, I love practicing emergency medicine. And I think it keeps me grounded as well, when you're in an emergency department and you're seeing people waiting in the waiting room. And you're seeing that you're limited with supplies, right? The fact that we had to save our N95's [laughter] And it was hard to get gloves and things early on in the pandemic. For me, when I'm in conversations at the state level, thinking about the supply chain it makes it not theoretical, right, you can really bring that lived experience and seeing that, yeah, it is mostly Black and Brown people coming into the ER, seeing that, you're pronouncing people dead from COVID-19 and you're trying to figure out how to take care of them medically how that relates to the state policies that you might consider. And so I consider it an honor, I'll tell you, it's been... My gosh, I practiced still and people still kind of recognize me and they say, Oh, you are the doctor from the state. And I'll tell you it's been such an honor because sometimes people say, Well, thank you, your press conferences, the information share was good. Thank you I'm now... I remember one time when we switched from telling people wear a cloth mask to the surgical or they KN95 mask and someone in the ER a shift I worked during that time said, I saw that you said it and I got my KN95 now.

0:55:52.8 DK: And so for me, it was also a way to kind of sense are people listening? What do people need to know? 

0:56:00.1 DH: The public health messages.

0:56:01.5 DK: Exactly, how are they receiving the public health messages and what's going on? Our hospital frontline workers, my gosh, just, I've have incredible respects and just so grateful for what they have done it and been through, I have lost a couple of people who trained me in emergency medicine in New York to this virus and what people have sacrificed their own physical health, their mental health, to be able to take care of patients. I don't know how we can ever repay our health care workers for that sacrifice in their commitment.

0:56:44.6 DH: Absolutely. We owe them a debt of gratitude. We truly do, we truly do. Dr. Joneigh Khaldun. This has been fantastic conversation and so helpful, enlightening, inspiring. Thank you for all that you have done and continue to do. Thank you for educating us and giving us a sense of what's happening behind the scenes and what was happening behind the scenes. It deepens our understanding. It deepens our appreciation, and hopefully deepens our commitment and our motivation to do more and to do better particularly as it relates to making sure that we all have access to good health. So thank you so, much for being here. Truly appreciate it.

0:57:32.9 DK: Thank you. It was a pleasure.