INTRO

PIPER

Welcome to another episode of Inform Me, Informatics! You may be a little surprised to see this show popping up in your podcast feed after we just put out an episode, given that we’re coming off a hiatus of a few months. But this time around, we’re talking about a breaking and timely public health topic: novel coronavirus, or, as it’s now officially termed, COVID-19, so we wanted to get this episode out to you sooner rather than later.

Unless you’ve somehow downloaded this podcast from a remote, off-the-grid cave in the Andes Mountains, it’s likely you’ve been hearing a lot about COVID-19 lately. This new strain of coronavirus emerged in China in 2019 and, at the time I’m recording, has had confirmed cases emerge in 89 countries all around the world, according to the WHO. By the time you’re listening to this episode, it’s probably even higher.

In the face of widespread public uncertainty and fears around this emerging disease, I wanted to better understand how informatics—and public health infrastructure more broadly—could help protect populations from outbreaks like COVID-19. I was lucky enough to get the chance to sit down with Dr. Patrick O’Carroll, the head of health systems strengthening here at the Task Force for Global Health. Among a long, illustrious governmental and academic career, Patrick is an alum of the U.S. Department of Health and Human Services, where incidentally he served as deputy to the guest on our last episode, Dr. Karen DeSalvo.

Patrick also literally wrote the book on informatics. Its title is Public Health Informatics and Information Systems, but around here, we just call it “the big blue book,” and it’s essentially a sacred text here at the Public Health Informatics Institute.

When we sat down to talk, I started out by asking Patrick if he could help define what exactly health systems strengthening is, and why it matters.

PATRICK

Well, as a topic, it’s really, really broad. I mean, depending who you talk to, you may get a different answer. So for many people around the world, health system strengthening is making sure people have access to primary health care, that there’s somewhere to go if you’re sick or your child is sick, somewhere to go if you need surgery, and so forth, and that there’s people there that have medicines they need and the skills they need and the tools they need and the bandages they need and so forth.

Here at the Task Force, we tend to think of health system strengthening more broadly than health care. In fact, we tend to work upstream on the prevention side of things. So, for example, health system strengthening would be making sure that all countries had basic data so they could decide where the priority health problems were, that they knew how many people are being born, how many people died, they knew what proportion of population were getting adequate immunization, for example, and they could do breast and cervical cancer screening to detect cancer early and do sorts of things that we think of in this country as a public health system.

And really, there shouldn’t be a bright line between the public health system and the healthcare system because healthcare is part of our public health system. But we tend to think of public health as where the preventive things we do for the populations as opposed to health care, which is for individuals. So it’s kind of a long answer, but for us health system strengthening has to do with population level things, Ministry of Health level programs, community programs that foster health and ensure clean water, clean air, you know, safe work environments. And then access to things we know protect the population like immunizations.

PIPER

Great. All very important. So when it comes to something like COVID-19 and potential outbreaks of COVID-19, how does health system strengthening and those processes help us protect against those potential outbreaks?

PATRICK

Well, this is actually a really good example of how it does. You’ve probably been reading in our country about all the many epidemiologists that are running around trying to do contact tracing and find out if there is this particular case, how many people that may have become infected by being in contact, in close contact with that infected person. Well, you don’t just start contact tracing with no training. There has to be people who know what that is and how to do it. And there have to be information systems in place to transmit that information securely.

But first of all, to do that first detection, you need a good laboratory system. And that’s been one of the challenges in this particular case is to get testing out broadly enough, quickly enough to determine who’s been infected because you don’t know who to quarantine and who to isolate if you don’t know who’s been infected. This is also a season when there’s lots of other colds going around, when influenza is going around, which is a very serious illness. And there’s no easy way for the citizens to determine the difference between them. So health systems in our country and some of the fundamental components are epi and laboratory systems. And so they are obviously essential to controlling an outbreak like this and detecting it, controlling it, and making sure it doesn’t come back.

But in addition, we also have systems for developing vaccines. And that takes a while. Even now it can take like a minimum 12 but it’s more likely 18 months to develop a new vaccine for a novel virus. But that’s much faster than it was in past years. And that’s to develop it systematically and safely and to make sure that it’s effective and then get it distributed widely within 12 to 18 months is really astonishingly fast by past standards. That system also can’t be invented on the fly. It has to exist and the partnerships in the industry have to exist in advance. So the health systems that allow us to launch an action are many and varied and they can’t be invented at the last minute.

PIPER

So the CDC is now starting to provide some preliminary information on how individuals can respond to COVID-19 if outbreaks occur in the U.S. So they’ve been talking about washing your hands more frequently, staying home if you have the symptoms, avoiding touching your face, things like that. So what would you say is the washing your hands public health infrastructure? What’s one thing that U.S. jurisdictions could do right now to have a readiness for potential outbreaks?

PATRICK

Of course, there isn’t just one thing, but if you could only do one thing, I think what’s really, really critical right now is really good communication, good risk communication, which is transparent and honest and timely and authoritative and ultimately accurate and frequent.

And so, when people are wondering what to do about it, we say wash your hands on Tuesday. We need to say wash your hands on Wednesday and wash your hands on Thursday. We need to keep coming back to that. And of course, those are the same things you do to prevent influenza or any other person to person spread of infection. So I think that communication, we just can’t overdo it enough. And it isn’t only washing your hands but the other things you mentioned as well, sort of self-isolating, minimizing travel to places that you know has rampant infection. Cities have to make determinations about whether to close schools or whether to close conventions and things like that.

So it isn’t enough just to make the right decisions. You have to communicate those decisions and communicate them very effectively so that people feel empowered and they sense the care that government has for people, that they’re not being ignored, and that they understand the reasons why that’s being done. And under those conditions, people don’t panic. They’re concerned but do not panic. It’s when people feel that they’re being misinformed or they don’t know what’s going on and then there’s a vacuum and then that’s always filled with concerns and anxiety, that’s when you get into trouble.

But to go back to the first thing you asked, what’s the washing of hands for public health infrastructure? I sort of have a cutesy answer to that, which is that a hand has five fingers. There is no just washing your hands for public health infrastructure. You have to invest in that in advance. And there’s five elements here that I just think are unbelievably critical. And we’ve talked a little bit already about epidemiology. You have to have trained epidemiologists, hopefully experienced epidemiologists in place, on the ground, used to working in the community, known to and by the community before you start. So epidemiology is critical.

Second, we’ve already talked about, laboratory capacity. You absolutely have to have skilled laboratory people in the public health labs and ultimately in private labs as well because laboratory science is absolutely critical to epidemic control. There’s no question about it. I started by talking about communications, that’s also critical. It’s one of the fingers on your hand after epi lab is communications. But another big part of this is planning. We know epidemics happen. They happen first of all every spring and every fall. We have epidemics of the common cold or influenza.

And then we have novel epidemics regularly. So we know there’s going to be epidemics. We have to plan for them. We have to have policies in place and stepwise measures that we’ll take when the first case happens in our community and when this community spread starts to happen, where it’s not clear who got it from who, what are our plans under those circumstances? So planning is another finger on the hand, if you will. And the fifth finger is leadership. And ultimately, you really need authoritative, skilled leadership.

And that doesn’t mean someone who knows everything has the answer to every question, but someone who has a handle on those plans, who knows when to turn to their epidemiologists and their communications professionals to help them do their job best, but ultimately leads the public health response on behalf of the community, someone that they can hear and know is trustworthy. And someone who’s got experience in public health and has done this a few times, ideally, to be in a leadership position.

So the public health infrastructure is not just washing your hands, but you know, there’s five fingers of the hand, you know, the epi lab and so forth. Those are the elements that make up a strong public health system. If you have strength across the board there with leadership and communication and planning and epi lab, you’re going to be ready for anything that comes down the line.

PIPER

If a jurisdiction is looking at the five fingers on its hand and it determines, “Oh, well, this finger might be a little weaker than the others,” what are some things or some strategies that a U.S. jurisdiction could deploy to sort of get up to snuff?

PATRICK

Right. That’s a really good and complex question. Ultimately, that’s a governance question. The citizenry can make it clear they want that. Our elected representatives respond to pressure from the citizens. Our news media ought to be asking the right questions about that. “Do we have strong laboratory capacity? If we don’t, why not? How do we get it? What are you going to do, Governor, what are you gonna do, Mayor, to get us that?” Those are questions that we have to ask our leaders. It’s never a question that I don’t think they’re important. It’s often a question of competing priorities.

And the other part is important too, education and transportation, and they’re stuck trying to balance a budget. And it’s understandable. Sometimes they make decisions that we in public health might refer to in a slightly different way. But COVID-19 and diseases like that remind us that you really don’t want to scrimp in this area. These are things we really need to invest in. Because when something like this comes down the pike, and they do regularly come down the pike, we just have to be ready. It’s too late then to say, “Well, let’s throw some money at this and solve the problem.” You need to have built a system in advance.

PIPER

Do you see any sort of weak points that are common in U.S. healthcare infrastructure or public health infrastructure that you would point out as sort of vulnerability for a disease like this to take hold?

PATRICK

I think if we asked about where we’re most vulnerable in our American Public Health System, I would say that I think we have erred in the direction of relying too much on federal and state public health, and not put as much investment as needed into local public health capacity. At the end of the day, it’s the local public health people that start to detect an outbreak and start to control the outbreak and the state backstops them and has all kinds of expertise. And it’s the state public health lab that has the deep edge on doing laboratory testing and absorbing new tests and so forth.

But I think we’ve invested heavily in our federal health infrastructure. If you look at the budgets of CDC and FDA, not that they couldn’t be greater, by the way, there’s lots of work to be done, but they’re relatively well funded. And many of the bigger states are pretty decently funded at the state health department, but again, not as much as they probably need. But it’s at the smaller counties and districts and tribes where we have not adequately invested in public health. And again, it’s easy to say the money has to come from somewhere, but the reality is we’re not doing it there.

So if you ask me where are we most vulnerable? Where are we weakest? It’s often in our smaller counties and tribal areas. Counties like Seattle and King County are facing right now a big challenge with COVID-19. But Seattle and King County have very strong county health department as is New York City and Los Angeles County and Chicago and so forth. But it’s these smaller cities where we tend to scrimp and not put as much investments as we probably ought to in my judgment.

PIPER

So what would your recommendations be for how informatics and information technology in general could be deployed in a public health context to protect populations from something like COVID-19 outbreak?

PATRICK

So these days, we have one way to reach almost every citizen that we didn’t have 25, 30 years ago and that’s cell phones, smartphones in particular. And so I think we can use those and they are being used in fact to communicate information. So a lot of what we need to protect the citizenry is communicate to them about what the current situation is, what the best guidance is now, how to keep your children safe, what’s going on with cancellations of conferences or sporting events or school closures or whatever it is. So that kind of from central knowledge communication to the populace is something where we can use very basic IT, you know, just communications platforms, websites and cell phones and so forth.

I think what we could do in the future that is really an interesting idea that several people have talked about is enabling citizens to be of use to the public health response. So not so much just empowering them to protect their families, but actually empowering them to help guide the leaders of the community as to where disease is occurring. So if, for example, people had an app that allowed them to say, “Everyone in my family is safe,” or, “My family just got back from Italy and two people are sick but we think it’s just a cold,” if there was something like that and it has to be developed and tested and made sure there’s not too many false positives, you don’t want it to be somehow misused for the benign purposes, but if you could find a way to make this both secure and safe and reasonable, it would give us an almost amazingly granular picture of what was going on with, say, upper respiratory illness in the community and block by block around the city at any given time. We don’t have anything like that.

And in the old days, we’d build a surveillance system that was active, that went out and knocked on doors and gathered information with paper and a clipboard and so forth. But nowadays with even a reasonably good sample of the citizenry saying, “I’m willing to be part of this and share anonymously what I’m seeing in my own family,” it might be a really cool idea for how you could monitor the spread of upper respiratory illness in a particular community over time. I’m not sure it’s a great idea. I think it’s worth testing.

PIPER

That is really interesting. I love the idea of crowdsourcing the surveillance aspect. And it reminds me of some initiatives using Twitter data, you know, seeing if people are describing their symptoms on Twitter and doing symptomatic surveillance that way, but more sort of active and proactive on the part of the population.

PIPER

That’s great. That’s really interesting. And it kind of comes back to communication, which you mentioned first.

PATRICK

Yeah. That really is very central to controlling an outbreak.

PIPER

So what do you do in situations where the best practice that’s being communicated aren’t always feasible to the audience receiving them? You know, we could all stand to wash our hands a little bit more but, for example, if you’re telling someone to stay home if they have symptoms of COVID-19 but maybe they’re in a position where they’re an hourly worker depending on their day’s wages, what can public health do to help kind of bridge those divides when it comes to making sure that people are empowered to make healthy choices?

PATRICK

That’s a really good question. But implicit in the question is what can public health do about it? I don’t know that public health is in a position to do much about some of those related societally unequal situations that we find ourselves in. Just in today’s New York Times there was this discussion about what the government might do. The government might in fact do various things through regulation or through laws saying, “We want all employers, even for this particular virus to let workers stay home and to, A, keep their job, and B, provide essentially access to this behavior without financially penalizing them. And then we’ll give tax breaks to companies that have some percentage of workers out so that they don’t bear the full burden and that sort of thing.”

Other countries do that and we could do that, frankly, for workers in general or we could do it in the context of a very scary outbreak like existing right now. Those are policy issues. They’re very complex. But there’s evidence from past research that when people did things like this to try to minimize the spread of influenza, that had dramatic effects on decreasing like up to 18% in a short period of time the actual spread, the rate of spread of influenza in certain communities.

So I think there are policy things we can do. There’s larger, more equitable things we can do in general having to do with making sure everyone has access to healthcare and that’s, of course, the subject of political debate. But public health people can do is, all we can do is say what the best practices are. And unfortunately, not everyone will be able to undertake them all. But I think the basic ones which is washing your hands, covering your cough, staying home if you can when you’re sick, minimizing access to…going to crowded places and stuff when you don’t know what’s going on in the epidemic, these are things a lot of us can do, some of those more than others.

PIPER

So I’ve often heard health system strengthening described as sort of building a firewall that will block out diseases. And I feel like we saw that a little bit in the Ebola crisis where Ebola would cross a country’s borders and then maybe stop a little bit. Would you say that’s an accurate metaphor or is that how you envision health system strengthening?

PATRICK

Yeah. Until you eradicate disease, you haven’t stopped it. You’ve just got to be prepared for it. So a firewall is probably not the best metaphor in my mind. I’m not sure I can give you a better one off the top of my head. But it’s more a matter of some of the diseases we work on, let’s say here at the task force like trachoma, in some diseases, that it’s just rampant. Everyone has this eye disease called trachoma and it spread from the person eventually by touching and flies, transported from person to person. But at some point, if you treat enough people and we do this with the strategies that WHO has put out in a particular village, we’ll say, we essentially don’t have trachoma in that village for a while until the next person visits with trachoma and brings it back to the village.

So the trick is, it’s not enough for us to reduce that prevalence so low. What’s necessary at the end of the day is a strong health system so that when that new case shows up and infects one other person, they have access to healthcare. It’s quickly recognized as trachoma and they’ll treat it. So you wouldn’t call that a public health problem. That’s just an occasional clinical manifestation of an infectious disease. And we see that kind of thing in this country all the time, but our system exists so that when it happens, we quickly nip it in the bud. And even if there’s a new epidemic, we can sort of quickly detect it and work to try to nip it in the bud. So it doesn’t prevent it from showing up. It gives us the capacity to quickly identify it and control it. And that’s really what the public health system does.

PIPER

As Patrick and I talked about some of the issues surrounding COVID-19 and its spread in the United States, he emphasized a couple of points of caution for all of us to keep in mind as we figure out what to think about this emerging disease and how to evaluate what we’re hearing about potential outbreaks.

PATRICK

this epidemic is occurring in a political season. Of course, that season is getting longer and longer. So of a lot of epidemics occur in political seasons. But epidemic control, we really ought to seek to not make this a political football and to not be scapegoating. Both of those are kind of natural tendencies I think. We’re highly political people and many people are, so it’s naturally is this an opportunity to make points or to score points against the other guy, and so forth? I would caution us all to resist that temptation.

The other is to when we’re in the midst of something and we’re kind of scared by it is to want to point to somebody whose fault it is. And we probably ought to try to avoid that too. And there’ll be plenty of time for figuring that out later and doing it better the next time. But in the midst of it, I think we’re wasting cycles talking about that when we should be focusing on the mission, which is to control the outbreak.

PIPER

And finally, with great interest, I asked Patrick the million-dollar question: how do you define public health informatics?

PATRICK

So this is an interesting question because the word informatics itself seems to be…there’s so many definitions as to make it almost useless as a word. I like it. I think I know what it means. But so many other people I think don’t use that word and nobody knows what that means or we’re all thinking something different when you say it. Having said that, we did try to define this in a few…a number of years ago, and me and a few other people when I was working at CDC. And our sort of formal definition of it was that public health informatics was just simply the thoughtful and deliberate application of computer and information science and technology to the discipline of public health, which was to protect the public’s health.

But the two words I added to that, it wasn’t in our original description, it was the sort of deliberate and thoughtful application. And to me, instead of asking what public health informatics is, let me talk a bit about what I think an informatics professional is as opposed to, say, a computer scientist or a computer science professional or an epidemiologist and an epidemiology professional because they’re all involved in informatics and often contribute to informatics.

But to me what makes someone an informatics professional is they go beyond the what of saying information system to the why. So if someone comes to them and says, “I want to build this immunization registry and here’s what I wanted to do,” and they say, “Okay, I’ll build that for you.” Well, they’re a builder. They’re an engineer. What makes them an informatics professional is if they say, “Tell me why you’re building that. What is it you’re trying to accomplish in building that?” And depending on what they say, the informatics person may say, “Well, to be honest, I think you’re going a long way around the barn. There’s a better way to do that.”

Or, “What you’ve asked me to build won’t get you there. I can build it and you’ll pay me and my company is happy. But I don’t recommend we do that. There’s a better way to get where you’re going.” Or, “I think the money that you’re about to put in this might be better spent if the idea was to increase immunization, it might be better spent here.” That doesn’t mean you get to make those decisions for them. But an informatics professional is organized by their mission, which is to apply this information technology in a way that actually improves health. It’s not just to apply the information technology in a way that supports their company’s bottom line.

And I think that really is important because you can point around the world and certainly in the U.S., a number of extensively successful information technology projects for public health. And if you go back five years later, they’re no longer working because they weren’t built with sustainability in mind. So was that a successful project or not? Like they delivered the software on time and on budget, so, sure. But an informatics professional would say if the goal was to promote health, it didn’t promote it for very long, and then it fell apart. It could have been done differently. You could have built capacity in that country to support it or you could have used locals to develop this offer and have them develop the expertise to actually grow that software and other software. And you’ve actually strengthened their health system, to use that term again, as opposed to develop them a product and handed it to them.

And so for me, that’s how I distinguish what makes an informatics professional is that wanting to know why and then working with partners to once they understand the why to really help the partners get there and then use the information technology and computer science to help get to that goal. But the goal is what we’re about, not the application of technology.

PIPER

A huge and heartfelt thank-you to Dr. Patrick O’Carroll for taking the time to sit down with me and share his perspectives on a rapidly evolving and critical public health issue. CDC is also regularly putting out updates about COVID-19, and, along with the WHO, is the best source you can use to keep up with validated and current news on all things coronavirus.

This podcast is a project of the Public Health Informatics Institute, which is a program of The Task Force for Global Health. Visit phii.org to learn more about all of our informatics work! You can also find us on Facebook and follow us on Twitter @PHInformatics. The music used in this episode was composed by Kevin MacLeod.

If you know of an innovative or interesting public health informatics project or story you think would be a good fit for the show, let us know on PHII’s social media or email us at podcast@phii.org!

Stay healthy out there, informatics fanatics, and don’t forget to keep those hands washed and those faces untouched! I’m Piper Hale, and you’ve been informed.

BUTTON

PATRICK

I heard someone say COVID-19.

PIPER

COVID-19!

PATRICK

I think that was just patently wrong. I’d go with COVID-19.

PIPER

Okay.