EP. 85: THE (SMALL-P) POLITICS OF HEALTHCARE

Oct 24

WITH JOSHUA SHARFSTEIN, MD

A Vice Dean at the Johns Hopkins Bloomberg School of Public Health and former Secretary of the Maryland Department of Health shares the highs and lows of a long career in health policy and where he finds fulfillment amid the intricacies of politics.

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Episode Summary

For many people, the idea of politics in healthcare conjures up hyperpartisanship, where power and party loyalty trump public interest. But Joshua Sharfstein, MD is passionate about politics and health care because to him, these are opportunities to bring together wide-ranging expertise and navigate seemingly irreconcilable interests to implement changes that change the lives of millions. Dr. Sharfstein has led a career reflective of this passion. He has served as the Secretary of the Maryland Department of Health, the Principal Deputy Commissioner of the US Food and Drug Administration, and the Commissioner of Health for Baltimore City, and is currently Vice Dean for Public Health Practice and Community Engagement at the Johns Hopkins Bloomberg School of Public Health. Over the course of our conversation, Dr. Sharfstein discusses why public health matters, how he handles partisanship in politics, and his career highs and lows and lessons learned on effective crisis management.

Joshua Sharfstein, MD is Director of the Bloomberg American Health Initiative, Vice Dean for Public Health Practice and Community Engagement, and Professor of the Practice in Health Policy and Management.
Previously, he served as the Secretary of the Maryland Department of Health and Mental Hygiene, the Principal Deputy Commissioner of the U.S. Food and Drug Administration, as Commissioner of Health for Baltimore City, and as health policy advisor for Congressman Henry A. Waxman. He is an elected member of the National Academy of Medicine and the National Academy of Public Administration.
In this episode, you will hear about:
• 2:16 - How medicine and politics ended up being a twin focus of Dr. Sharfstein’s career
• 5:07 - The milestones of Dr. Sharfstein’s career in healthcare leadership
• 8:39 - Why healthcare arouses such intense partisan political feelings
• 13:51 - How public health’s messaging and communication must change in light of current advancements in information technology
• 18:42 - The formative public health crises that Dr. Sharfstein has dealt with throughout his career
• 26:33 - Ideas for strengthening the US’s weak public health system
• 29:28 - How COVID-19 revealed the flaws of our public health system
• 33:55 - Dr. Sharfstein’s advice for clinicians who are interested in working in public health
• 38:00 - Sustaining drive and momentum amid bureaucracy in public health
• 41:56 - A sampling of the unsafe products that Dr. Sharfstein has successfully gotten taken off of the market
Henry Bair: [00:00:01] Hi. I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives, those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] For many people, the idea of politics in health care conjures up hyper-partisanship, where power and party loyalty trump public interest, often also at the expense of health equity, trust and policy efficacy. But Dr. Josh Sharfstein is passionate about politics and health care because to him, it's about the opportunities to bring together wide ranging expertise and navigate seemingly irreconcilable interests to implement changes that improve the lives of millions of people. Dr. Sharfstein has led a career reflective of this passion. He has served as the secretary of the Maryland Department of Health, the Principal Deputy Commissioner of the US Food and Drug Administration, and as Commissioner of Health for Baltimore City, and is currently vice dean for Public Health practice and community engagement at the Johns Hopkins Bloomberg School of Public Health. Over the course of our conversation, Dr. Sharfstein discusses why public health matters, how he handles partisanship in politics and career highs and lows, and lessons learned on effective crisis management. Josh, thank you so much for taking the time to join us and welcome to the show.
Jeff Sharfstein: [00:02:14] Thanks so much for having me, Henry.
Henry Bair: [00:02:16] To kick us off, can you share with us what initially drew you to a career in medicine?
Jeff Sharfstein: [00:02:21] So I'm one of those kids who grew up in a medical family. Both my parents are doctors, and I'm the oldest child and oldest grandchild. So I had the heavy weight of expectations. And reportedly when I was five and someone asked me what I wanted to be when I grew up, I looked at them with all seriousness and said, do I have a choice? I actually was a social studies major in college. I worked on political campaigns during college summers, but I kept my options open with pre-med requirements, and I figured that would keep my parents off my back until I really had to make a decision. And then a funny thing happened in the summer after my junior year, where I was actually doing pretty well on the politics track, and I was working for a political consultant, actually in a paying job, and I got brutally disillusioned with politics. And I remember the consultant said to a congressman, I know they're lying about you, but we have three times as much money, so we'll be calling him a liar three times for every one time they call you a liar and we're going to win. It was a moment when I actually started to look forward to my summer weekend volunteer position, which was an assistant to the nurse's aide at D.C. General Hospital. So I had this, like, kind of high flying in my mind, at least political job during the week. And yet I was looking forward to being the assistant to the lowest person in the organizational chart on the weekends, where I just was seeing so much and learning so much from someone who had actually been a supermarket checker, but had a really strong sense of ethics, and I found myself actually deciding to apply to medical school.
Henry Bair: [00:04:02] Wow. So going into medical school was the intersection of politics and medicine always somewhere in the horizon, like on the map? Or was it were you so disillusioned with your experience there in politics that you kind of wanted to go away from it entirely, and then eventually you kind of found your way back? Right.
Jeff Sharfstein: [00:04:20] Well, I mean, the arc of my career is sort of bringing more politics into my medical world, maybe not going as far as a political consultant again, but but really realizing I did have a lot of interest and, and maybe a little bit of capacity in the politics area and then bringing that in. And it started the year after college because I deferred my entrance into medical school, I spent most of the year in Central America working on public health projects and really falling in love with public health. And then at the end of the year, I worked for Public Citizen on a whole bunch of different projects that brought together health policy and politics. And, you know, got me pretty interested in the intersection. So I came with a pretty strong start going into medical school, which led immediately to some interesting conversations in medical school.
Henry Bair: [00:05:07] Well, when we look at your career, you've had so many different just honestly, truly impressive leadership positions throughout public health, right? I'm wondering if you can trace for our listeners, just broadly speaking, like what were some of the milestones throughout your public health leadership career?
Jeff Sharfstein: [00:05:24] Well, I think I really had to fall in love with public health. I had a lot of, you know, some experience in that year before I went to medical school. But then in medical school, I got involved in a whole bunch of different kinds of activities. Probably one of the milestones was writing a paper with my father in the New England Journal of Medicine as a second year medical student, calling out the American Medical Association for giving political contributions to people who oppose the American Medical Association's own public health positions. You know, so that was something that built on my time working in politics. Like I knew how to find political contributions. At the time, there was no website. You had to go to the Federal Election Commission and look it up. And I did that, and I saw that people who were getting a lot of money from the AMA opposed the AMA on tobacco and gun control and other key topics, reproductive health. And so that was pretty exciting to have an article in the New England Journal to be talking to a whole bunch of reporters. And that kind of opened my mind. Like, you can do interesting work, and it doesn't even matter if you're a medical student. People will call you and listen to you.
Jeff Sharfstein: [00:06:28] You know, you don't have to be at the top of the medical chain in order to have an impact. The other really critical experience I had as a medical student was I spent a couple of months at the Food and Drug Administration working for Dr. David Kessler in his effort to regulate tobacco products. This was the effort that was struck down by the Supreme Court before Congress passed the law some time later, but I got really involved in the legal analysis. That the agency was doing to demonstrate that nicotine was addictive. As a basis for regulating tobacco products. And that was just fascinating to me. So I really had to fall in love first. Then quickly my career would be coming out of my pediatric residency. I did a general pediatrics fellowship where I worked at the World Health Organization for a period of time, and at the state health department in Massachusetts with Dr. Howard Koh, who's been incredible teacher and mentor to me. And then I went from there to work on Capitol Hill with Congressman Henry Waxman, where I worked for five years on the Government Reform Committee as staff. Five years in, I told Congressman Waxman I was applying for a job that I didn't want and I wouldn't get as the health commissioner of Baltimore City had been living in Baltimore and commuting down, but I came up with or was given really a lot of great ideas.
Jeff Sharfstein: [00:07:47] I heard a lot of great ideas from people in Baltimore and in DC, a lot of them from Congressman Elijah Cummings. So I knew from working for him on Capitol Hill, who was Baltimore's congressman, and I was chosen to be the health commissioner. So I went from working on Capitol Hill to being the health commissioner for the city of Baltimore. I did that for about three and a half years, and I had been involved with President Obama's first campaign and was on the transition team and was chosen to be the principal deputy commissioner of the Food and Drug Administration. So I was the acting commissioner. And then after Dr. Hamburg was confirmed, I was the principal deputy commissioner. I did that for a couple of years and then became the health secretary for the State of Maryland for governor O'Malley. He was the first mayor that I worked for, had then become governor of Maryland. I did that for four years before coming to Johns Hopkins. So that's my career in a nutshell.
Tyler Johnson: [00:08:39] So one of the things that I wanted to ask you about, I think you are probably maybe the most or certainly one of the most in terms of the guests that we've had on the show, one of the people who has been the most directly involved in the intersection between politics and health care. It's so interesting to me, if you think back over the last, let's say, 30 or 40 years of American politics, and you think on the national level, at least of major health care initiatives, right? So if you think way back to when, like Bill Clinton was president and initially appointed Hillary Clinton to try to sort of revitalize or revamp health care in the United States, and then you can skip forward, as you mentioned, to when President Obama was president and bringing everybody to the table and then eventually proposing Obamacare and getting that law passed. And then, of course, you think most recently, right about everything that came along with the pandemic response, which you could make an argument that we didn't really have, at least during the Republican administration at the beginning of the pandemic, we didn't really have much of a so-called national response to the pandemic. But still, you had things happening on city and state levels.
Tyler Johnson: [00:09:47] But the thing that's so striking to me about that. So, like, if we take Obamacare as an example, if you, like, stood on a street corner today and you stopped people on the street corner and said, tell me five interesting and important changes that Obamacare made, I bet you could find virtually no one who could answer that question with any degree of sophistication or even accuracy, right? And yet, if you had somebody standing across the street on the opposite street corner stopping people and saying, give me your opinion of Obamacare, I'm sure you'd have all kinds of people who would have all kinds of super strong opinions about why they either think that it's really fantastic, or they think it's like, you know, the spawn of the devil or something, right? And so I guess all of that is just a way of asking, why do you think that health care, which most often the kinds of stuff that we're talking about in health care initiatives, are awfully technocratic and, frankly, kind of dull, and yet it arouses these hugely passionate partizan political feelings on both sides of the aisle from almost everybody. Right. Why do you think that is? Like what? What does your career tell you about that?
Jeff Sharfstein: [00:10:59] So when I think of politics and health care, I think of small p politics and big P politics, and by small p politics, I'm thinking of things that haven't crossed into this hyper partizan world where the politics is really how do you get something done? There can be pretty significant interests, interested parties involved, you know, how do you get transparency at the Food and Drug Administration? How do you get cough and cold medicines to be appropriately regulated? How do you put in place a great HIV prevention strategy? How do you get things to happen? And some people can get really frustrated with that small P politics because they're like, well, this is the right thing to do. How come it's not happening? You know, don't tell me I have to go meet with people or explain it or alter my approach a little for this person or for that person. But to me, I find it fascinating. I find it challenging. And I think that level of politics is really rewarding because when. You have a good day. Something great moves forward. You have lined up what can happen with what should happen. And there are all kinds of victories you can get. Then there's the big P politics. And that's where something gets swept into the current of the Partizan world that we have always been in, but which has gotten pretty intense lately. And that is not pleasant. You know, I don't find that pleasant. There may be people who are just, you know, cultural warriors or really want to jump in and throw elbows.
Jeff Sharfstein: [00:12:27] And I don't feel like I'm drawn to that. But I have been in the middle of that at times and it can be very, very challenging. It's very challenging personally. Now for people who are getting threatened and or with all the misinformation, disinformation that's out there, it's very difficult. I can't tell you why some issues kind of cross into that world completely. You know, I think Obamacare did, in part because people really hated President Obama. And so this was his signature achievement. And so they decided that these particular topics, some of which are like crazy, innocuous good policy ideas, you know, we're going to be, you know, cast as some nefarious communist plot to subvert America. But I think it had a lot more to do with that than it did with any of the policy substance. I also think a lot of that is true also for Covid. Covid happened at a really terrible time for misinformation, a terrible time in our country's politics. And so it was just a sort of a sitting duck for getting politicized. And that, I think, had a lot of negative consequences. I don't look at these hyperpartisan things and think, what a great opportunity. I think, like, oh, you know, it's not great when people are making decisions based on their political affiliation and not based on what is just a reasonable course of action for their families.
Tyler Johnson: [00:13:51] One thing that I wanted to build on with that, you know, often in economics, they'll talk about the either virtue or the problem with thinking about every individual as a rational actor. Right. Like that originally was sort of the basis for economics is, of course, everybody will always act rationally all the time. Right? But it occurs to me that you mentioned the sort of the, you know, that it was the kind of perfect storm when Covid hit in terms of the cultural context in which it happened. And it seems to me, and you alluded to this, that one of the greatest difficulties that is facing democracy and public health and sort of all of the things that come together in your career is the advent of what many people, in the light of President Trump's election in 2016, have called the post-truth world right. Like there was the guy whose name I think was Kessler, I want to say at the Washington Post who when Donald Trump started, he had started this during the Obama years. But when Trump started to be president, he was literally counting individually all of President Trump's lies and then trying to, like, refute them line by line in the Washington Post and after a while, I think he effectively just gave up because it was just like you couldn't even sort the lies from the truth because there was no lie in truth. It was just words, right? Like it was just whatever it was. And more broadly now, with the advent of political polarization on social media and then arguably even more so, if bots are going to be writing a lot of what is on the internet, it seems like it's going to become increasingly difficult to even get people to know what is true. Like what are the facts, right? Like, is a vaccine safe or is Obamacare a communist plot or whatever? How do you see your role as a sort of public health advocate, or the role of any public health advocate, like, how is it going to have to change in light of the huge cultural and technological changes that seem to be overtaking the world?
Jeff Sharfstein: [00:15:48] Well, I completely accept the premise of your question, which is that these challenges really are going to force public health health care to change. And in fact, we didn't talk very much about what I do at Johns Hopkins. But among other things, I teach classes. And one of the classes I've been teaching is about the changing information environment and its implications for public health. Teach that with Joanne Keenan, a journalist. It is amazing when I think back to being a health commissioner of Baltimore City. You know, back then, the Baltimore Sun had 4 or 5 health reporters. We had multiple reporters at local TV who covered health news. And when I wanted to get the word out, I could have a press conference or do a press release and reliably it would be reported. And that was the basis of our press strategy. Now you know the Baltimore Sun is much smaller. There certainly aren't 4 or 5 dedicated reporters. There are other news outlets, but there's also a lot of stuff online that people are reading that may just not be true at all. And the approach can't just be to do a news release or a news conference. It has to be to engage with all of these channels and to find ways to get good information to people that they really need. And it's probably no longer the one news release comes from the health commissioner model. It's got to be a whole bunch of partners who are trusted in the community, who people are going to listen to.
Jeff Sharfstein: [00:17:18] So we have to think about networks, faith leaders, business leaders, community leaders who can in turn recognize that the health commissioner is someone to be trusted. And and so people can get information. And and the role of physicians is really important here. People often have a good relationship with their physician and that connection in communications between public health and health care has got to become a lot stronger for us to face up to what's happening now. Having said all that, I do want to make one other point, which is I do think there's a lot of change that's necessary in public health and health care, but we cannot think this is all our fault. You know, I read a lot of essays where it's like, here's where public health completely dropped the ball in communications, you know, or the single thing that this person did wrong in communications that made the whole misinformation epidemic possible. And I think that's wrong. That's not make sense to me, because we are actually dealing with a different set of circumstances. There are actually people who are intentionally trying to subvert the success of a reasonable public health effort, and we have got to fight that. But we have to do it in a way that we're not. So, you know, reflexively self-critical, that we blame ourselves for every loss. You know, I do think that we can do better. We should do better, but we have to have a clear eyed view that we need attention to the things that are going wrong, too.
Henry Bair: [00:18:42] So we've talked a little bit about the Covid pandemic, and I know you teach many courses and have written a lot about crisis and emergency management. And I'm wondering, can you share with us instances of public health crises that you managed during your public health career that really illustrates your conception of what it means to be an effective health care leader?
Jeff Sharfstein: [00:19:07] That's a very good question and kind of tough to answer. You know, every day is a crisis of some magnitude and the kinds of jobs that I had, you know, and so I feel like the book that I wrote, the Public Health Crisis Survival Guide, kind of talks about the little crises, the big crises, and particularly if you don't pay attention to crises, you're not going to be in one of those positions for very long. No matter what your strategic plan is, people really expect crises to be dealt with. That's kind of the nature of crises. You know, I can think about a plan that we had for adverse weather in Maryland, and we all were excited to execute it. One of the parts of it was that each of the dialysis centers in the state had to have a plan for backup power. And I remember as the storm got predicted, I turned to someone on the health department staff and I said, like, well, are the dialysis centers ready? And she checked and she said, they are ready. They have their backup power plans. And then the governor called me and said, are the dialysis centers ready? And I called again and they said, don't worry, we've got it. And I said, you know, let's just be sure, let's get them all on the phone.
Jeff Sharfstein: [00:20:17] So we got them all on the phone. Governor's asking and they're like, we are ready. We are ready. We are ready. And then the storm hit and, you know, a whole bunch of them had no power and no backup power. And I was like, well, what happened? And they said, well, you know, we had a plan, but the plan was to get the generators from North Carolina, but they needed them in North Carolina, you know, and, you know, none of the plans were robust. They didn't have on site backup power. And suddenly I had to go hat in hand to the governor and the emergency operations center and be like, um, actually, remember when I gave you my personal word that, like, the dialysis centers were good, they're not good. And we have got to, like, mobilize special power arrangements to get them. Otherwise people are going to start dying of hyperkalemia. That was a low moment. So I guess maybe the things that have stuck with me, maybe the low moments, you know, I certainly remember the absolutely miserable launch that we had of the health benefit exchange in Maryland, which turned into a crisis for us ten years ago. Now, can you.
Henry Bair: [00:21:14] Share with us what that was for listeners who may not be aware?
Jeff Sharfstein: [00:21:17] Well, this is where when Obamacare took effect, some states work with the federal exchange, some states built their own. We very much wanted to build our own because we wanted particularly a really strong integration with our Medicaid program. We felt Medicaid was just a really important part of the health care system in Maryland we were expecting. One in every five Maryland residents to be receiving health care coverage through Medicaid. And we want it to be super easy and a great experience for people on Medicaid. And that would have been really hard, certainly off the bat, going to the federal exchange, because we would have to build a whole new Medicaid system in addition to the federal exchange. So we wanted to do it ourselves. That all came from a good place. It was very, very hard to get right out of the box. And we made some mistakes. And our contractors also certainly made some mistakes and misled us. Eventually they settled for tens of millions of dollars and paid the state a lot of money back. But when we launched, the exchange really didn't work. I immediately became worried that it wouldn't work in time. By the time people actually needed coverage, it was a mad scramble to fix. We wound up unplugging the system that we built and actually adopting the Connecticut system, actually adapting it so that it would work with Maryland Medicaid. I think when Connecticut built it, it didn't really work with Connecticut Medicaid, but we built it for Maryland Medicaid.
Jeff Sharfstein: [00:22:39] And a year later, we've had a great system, and it's just super easy for people to sign up for great health coverage in Maryland just from their phones now. That was our vision, and it came to pass, but a year after we wanted it to. And that year was tough. One of the really critical things that got us through in Maryland was that we had built a very inclusive process for launching health reform. We actually work with the insurance brokers. We work with the insurance companies quite productively. And so when things went south, I really wasn't expecting this, but they came forward and said, how can we help? And for the Small business exchange, we just collaborated with the brokers and they did it without needing a website. And for the individual exchange, the insurance companies agreed to take people who called and said, look, when you get the computer stuff fixed, we'll put them in the system. And that's what they did. And so we were not a state where people actually lost coverage because of the problem. I became obsessed with not wanting an IT disaster to be a public health disaster. And it was very hard. But we we did avoid that. And eventually we rebuilt the exchange with the new system in a way that has actually worked out great, but many lessons learned in that process.
Henry Bair: [00:23:51] So thus far you've shared with us some stories of failures. Can you share with us some success stories?
Jeff Sharfstein: [00:23:58] Well, I remember these difficulties. I remember overcoming them too. So we failed that first storm, but we were able to put in place a much better system for future storms that hit us in Maryland. And then similarly, the exchange, like I said, did get fixed. So I remember that part. But I think one of the key things that I learned was that something that can appear to be a crisis in the moment can also be an opportunity to raise policy issues that are really important. Couple examples. We had an outbreak of flesh eating bacteria. I think it must have been strep in a day spa in Maryland, where people were going to get like liposuction and other other treatments. And when we inspected, it was just a horror show. Now you may think, okay, that's a bad news story. You shut it down, you move on. But I started thinking like, you know, well, what's behind this? We weren't alone. There were many states that had these men spores with problems, and we had no preventive regulation of medspa. We had only the regulation of the physician's license, which was after a problem. You could take away the physician's license. But what about preventing it? And so we work with legislators to pass a law. And now there's regulation up front with quality standards for those kinds of facilities. We had someone in Maryland who was a radiation technologist who was giving hepatitis C to patients because of an addiction, and, you know, you find the person, they're no longer providing health care services.
Jeff Sharfstein: [00:25:35] That person wound up, I think, incarcerated, and you're notifying the patients. You're doing all those things. But like what was happening, it turned out this is somebody who had bounced from hospital to hospital with all kinds of issues and nobody really warning anyone or taking action to help him. One of the reasons for that is that staffing agencies for radiation technologists had no reporting requirements in the state. And so, you know, you take a case like that, you frame it, you explain what the policy issue is, and then you get a change. And so what I became more comfortable with was every time there was like a problem out there. Well, how do you prevent it? How do you take the information from a problem and the momentum that's generated from a problem to make a change that's lasting? And that that I think stuck with me and I think is obviously one of the bigger questions with the Covid pandemic, like, are we going to be able to take the energy of this, this disaster, a lot of it, negative energy and turn it into something that can better protect the country in the future?
Tyler Johnson: [00:26:33] So if you were doing that, what would be at the top of your list? In other words, what are the lessons that you think are most important to turn that negative energy into positive, preventative or preparatory energy for the next time around?
Jeff Sharfstein: [00:26:46] Yeah, that's a great question. I've thought about it a lot. I think number one would be strengthening the public health system. We have a very, very weak and haphazard public health system in this country. And the weakness of it shown through in many different ways in the pandemic, underfunding old technology, inadequate laboratory capacity in many places, we can't do under stress many of the critical things that are necessary to keep populations healthy. And we have allowed that to kind of fester at our own risk. And then we had a disaster. Why so many Americans die? I think a major reason why so many Americans die. We need to rethink and rebuild public health. Public health can and should have a major focus on equity, to be able to be thinking about the challenges that are affecting particular populations and how to prevent them, and then to be there in emergencies to make sure that critical supplies are there, data is there resources there, and partnerships are there. And I worked a lot on the staff of the Commonwealth Fund Commission for a National Public Health System, and there are a number of recommendations there, some of which are moving forward. But just in general, I think we got a lot of work to do to get there. Now, when I teach about crises, I say that there are a couple of things that make it more likely that people will take recommendations in the wake of a crisis, and one of those is that people really trust the messenger.
Jeff Sharfstein: [00:28:13] Like if you've been an agency that's knocked it out of the park during the crisis, they're going to listen to you. That's not a great situation right now, because a lot of the public health institutions were battered during the crisis. I think we have our work cut out for us in this area, but it is just so critically important. We have to keep pushing and here and there in different places, you can see that it's working. And I'll give you one example, Indiana, not a state that you might put at the top of your list is states most likely to invest hundreds of millions of dollars more in public health, went out and invested hundreds of millions of dollars more in public health. And the governor had a task force that came together and said, we want to have a strong public health system that's focused on its foundational capabilities. Let's keep it below the big political radar. We want it to be able to do the critical things that public health can do. They had a great group led by Judy Monroe, the former health officer of Indiana. They did a great report, and it had a momentum that carried it through the state legislature. And so I think that it is possible for people to realize that that there was needless suffering from the pandemic and that decades of disinvestment and not a lot of expectations for public health have taken their toll. So I'm hopeful that at least in some places, we will see change.
Henry Bair: [00:29:28] In what specific areas did Indiana invest in public health.
Jeff Sharfstein: [00:29:33] Personnel, data systems, communications capacity? There's a report that outlines many of the basic gaps that had existed in the state. And I think that it'd be like in the health care system, you know, saying, well, we have hospitals with no emergency departments. We have hospitals with no surgery departments. We you know, we have health departments that don't do anything on smoking. We have health departments that have almost no data capacity. And so, you know, we need to have a standard for what public health protections people get, just like we have standards for what tertiary health care is. And not only should there be funding to achieve that standard, but there should be expectations that that standard is achieved. And if it's not achieved, then there should be consequences.
Tyler Johnson: [00:30:19] One of the things that really stood out to me during the pandemic there has not, of course, been that kind of public health emergency, at least not on that scale in the United States. For a very long time. And one of the things that was fascinating and sometimes frightening to watch was how did decisions get made? Right. And it often felt pretty haphazard and scattershot. Not that individual people weren't trying, but if you look at any sort of policy about masking or mandatory vaccinations or school closures or all of those things, it really sort of differed by state and sometimes even by race within the state. If you just had a magic wand and could control things, how when there's a real time unfolding serious crisis, how do you think those kinds of complex decisions would optimally be made?
Jeff Sharfstein: [00:31:16] It's a great question. And, you know, I did write a bunch of things during the pandemic, but there was one piece I didn't write that I really wish I had written. It was early on I thought about writing it, and it would have been about one of the lessons that I learned in the various jobs that I had, which is if you do something to people and don't really explain it, it's risky, because oftentimes people will be very upset because the first thing they hear is that you're doing something to people. If you can explain it to people first, doesn't mean you're going to necessarily succeed. But I think your chances are much, much better. And I recognized early on that. Look, some things just had to be announced. But at some level, I knew that that was not going to be a strategy that could last very long. And I really wish I had written about that then, because I think what we've seen is that there were a lot of arbitrary decision making that happened. And like the first stage was like decisions that had to be made. Then there was the second stage where a lot of places brought in, you know, advisory committees and had discussions. And that's where they set up, like the metrics for reopening and stuff like that. And then things kind of started getting wobbly as the politics kicked in. And some of those recommendations were just tossed out. I mean, like a state would announce the recommendation and set the standards for what the opening, you know, would be.
Jeff Sharfstein: [00:32:39] And then like a week later, they're like, we're open, you know, and none of the metrics had been met. And it was just like, what's happening, you know? And things were like listing back and forth and sometimes more restrictions were put in place without a full explanation, something that like, rarely happened. I don't know if it happened really once at the federal level was a comment period. You know, like, hey, we're thinking about what we're going to do for reopening. What do you all think? Here are three options. What are the pros and cons? Get people to appreciate the challenges that the public officials have before they have to make a decision, rather than just lead with one decision and have all the people who don't like it, you know, explain why. But not having had to grapple with the tradeoffs. And I think that that was a weakness. And it's not entirely the fault of public health officials, because I think once politicians, you know, elected officials got really excited about things. They like making decisions. And so, you know, it wasn't always even up to the public health official what to do. But in general, I think we could have done more listening, more advisory committees, more thoughtful explanations before the decision was getting made, rather than kind of scrambling to explain or justify after the decision was getting made.
Henry Bair: [00:33:55] Right. So a lot of what we've been talking about, a lot of the lessons that you've shared with us, I would say are very applicable to people who are already involved in public health, involved in public health leadership. I'm wondering, what advice would you have for clinicians, current or future, who are interested in participating, engaging in some respect with public health?
Jeff Sharfstein: [00:34:17] So let me tell you what I generally tell medical students, which is as a medical student, it's partly your job, and everyone knows it's your job, that if there is some weird symptom or weird constellation of symptoms, you've got to figure out what it is or at least come up with a good differential. And in my day, that meant spending the night in the library. You know, the medical students today are and literally photocopying things. You know, I know that's hard, maybe Henry, for you to contemplate, but like, you can't do it in your pajamas. But it also meant like and this probably means this today, if there was one case reported and it was in Australia, and it's the middle of the night and you're sitting there on the ward, you're calling the person who reported the case because they're probably up. It's, you know, probably during the day in Australia. And I've done that, you know, and that way on rounds you're able to say, okay, you know, this is someone with like a partial field deficit and a weird rash and, you know, and it could be, you know, these four syndromes. I mean, you know, that's your job. Now, there are all kinds of policy issues out there that it's really interesting to me. People in medicine generally don't feel like that's their job. It's like, well, I mean, the patient's homeless or there appears to be some degree of malnutrition. Or there's if you're lucky, you figure out that there's an issue with the housing hazard or even that they didn't get the drugs because they were too expensive, you know, and there oftentimes clinicians just stop.
Jeff Sharfstein: [00:35:45] That's just not my job to understand what's behind that or to think about what could be changed. The same analytic skills, the same tenacity, the same passion that people bring to figuring out the medical questions can be brought to those questions. And just like with the medical question, you don't have to know it all. You just you have to find the person who knows. You have to, you know, call the dermatology expert who's the expert in this particular kind of rash and has seen more of them than anyone else, you know, and then you learn that way you can call experts and policy, you can work with them. And then when you get breakthroughs for your patients or beyond, it's incredibly rewarding. It's as rewarding as figuring out that diagnosis. And once you start to do that, like success builds upon success and you get a lot of momentum. I, as a resident, became very interested in housing. I worked with Dr. Megan Sandel, Boston Medical Center and some other great co-residents of mine, and we became experts in local housing policy. And the attendings were like referring us patients. You know, we were getting the hospital lawyers involved and reading the renters code to people. And we understood that.
Jeff Sharfstein: [00:36:50] And we work with lawyers who could get involved. And, you know, we really helped some patients. And it was incredibly empowering to us as residents and of course, fed our interest in doing more. And, you know, I once gave grand rounds at Johns Hopkins as the health commissioner. And I said my most fervent hope is that the kind of famous rounds that you do, you know, as you're going around trying to figure out what's wrong medically with the patient, there is some version of that for the policy issues that contributed to this patient's illness and that there's the same incentives, the same resources, the same partners to really go after those. Because in medicine we see those challenges and there's so many opportunities. And I would just say to people, clinicians, that those opportunities are around you and you don't have to do it all yourself. Just think of it like a very weird set of symptoms that you need to figure out. And the more you start digging, the more you find allies you know, you'll find people who are so excited to hear from a doctor and you know great things can happen. And, you know, my career, I was on both sides of that. I was the clinician. I was the person getting the call in some of these jobs from clinicians, and we were able to do all kinds of things and change policy and all kinds of different ways.
Tyler Johnson: [00:38:00] Sort of a related question can I ask, one of the things that I have to imagine is a little bit I mean, I can imagine it would be challenging in an invigorating way, but also I can imagine that it would be challenging sometimes in just a challenging way, is that if you're a clinical hospitalist, let's say you see a patient who's sick, you evaluate the symptoms, you come up with a plan for what to do, you do it. And many times the person gets better in a day or two. Right? But even if you have a brainwave in the middle of the night of the best, most novel, amazing holistic health policy idea that's ever been thought of, right, you still are going to have to, as you mentioned earlier, collaborate and convince and take it through a whole bunch of bureaucratic levels and whatever, which may be more or less depending on whether you're working with the city or the state or the country or whatever. But it's still all going to be there, right? And then there's probably going to be a bunch of starts and stops and then maybe it gets. It's implemented, but not fully or not the way you envisioned it or whatever. So all of that is just to say, in the midst of all of that time and all of that work, between having a really great idea and then actually seeing the water get to the end of the row, and the people actually like benefiting from it, who live in your city.
Jeff Sharfstein: [00:39:11] That's exactly what I refer to as small P politics there. Right.
Tyler Johnson: [00:39:15] Yeah. And which you said that you love the small P politics. Right. But how do you like, sustain your own momentum or your own, like, moral drive through all that stuff?
Jeff Sharfstein: [00:39:25] So great question. And my answer is don't just do one thing at a time. Have a few things. Don't try to do everything. Have a few things. Have a few things in your portfolio, some of which are going to pay off more in the short term. And I remember when I was the health commissioner of Baltimore and we were trying to get clinics in the city to use buprenorphine. It was relatively newly approved. We have big overdose problem. We have a big overdose problem. But we were really interested in seeing the potential of buprenorphine to reduce overdoses in the city. And one of the clinics wouldn't do it. And we kept calling and we couldn't get their attention. And it was just immeasurably frustrating. And I must have looked particularly despondent because my chief of staff said, looks like somebody needs a pet press conference because winter is coming. And so we arranged for veterinarians recommend putting sweaters on your pets in cold weather, you know. And so we called all the it's like a dog whistle for all the journalists in like a 60 mile area. They come for the pet press conference and to see the pictures of the pets and sweaters. And then you get in if you, you know, make sure you get a flu shot. Et cetera. Kind of messages. And of course, that's I describe that as like the cotton candy of public health. You know, you're all over the news.
Jeff Sharfstein: [00:40:42] There's a big headline. You know, health commissioner urges sweaters for pets and cold weather. Whatever it is, we got in a few plugs for the flu vaccine. So it was it had some human, human centered parts. Now, if that's all you do, is the health commissioner, you know you're not going to get health commissioner, but nonetheless, it picks up morale to have a few dogs and sweaters running around the health department. And, you know, you need you need a little bit of that, like it's okay. And then I would go back out. Actually, after we did that press conference, I had another call with this clinic and they said. I saw. The cutest dog on that press conference. How can I help you, Dr. Sharfstein, with buprenorphine, you know, and I was like, wow, I was not expecting that. And so, like, I think at least for me in medicine, I mean, I'm a pediatrician, I appreciated that having a balance between kids who were growing and developing normally and kids who were sick was a good balance for me personally. I personally need that in policy, too. I need to work on things that are moving in the right direction that can pay off in the short term. While we're fighting the longer fights for the bigger battles. You have to, I think, do both to kind of keep your own balance.
Henry Bair: [00:41:55] Well, thank you for sharing that story. Definitely made us chuckle. Speaking of things that may amuse us, I've heard that you keep a collection of products on your shelf that you've helped pull off of the market. Is that true?
Jeff Sharfstein: [00:42:09] That is true. Somebody once called it my shelf of shame, but it reminds me of different projects that I've worked on over time. And now it's too bad this is audio only, but I can show you some of the products if you'd like to see them.
Henry Bair: [00:42:22] Yeah, sure.
Jeff Sharfstein: [00:42:24] So I mentioned one already, which is the over-the-counter cough and cold medicines for young children I worked on. We did a petition to the Food and Drug Administration. This is a dropper of decongestant and cough. You cannot find these for sale anymore. Now labeled for four and up. At the time they were down to six months. I think that was done voluntarily. But after an FDA committee advisory committee meeting where they voted in favor of taking them off the market up to age six, this might be a little bit before your time. This is a Four Loko can.
Henry Bair: [00:42:57] I am unfamiliar with that.
Jeff Sharfstein: [00:42:59] This is a product that was sold 12% alcohol by volume. It's like double the size of a beer. So there's like four beers worth of alcohol in here or more. It also has like five Diet Pepsi's worth of caffeine. And wow, there was like a national moment about this where young people were getting assaulted or, you know, having all kinds of problems with their cars crashes, blackouts, overdoses because the caffeine counteracts the alcohol. And you get kind of this state of wide awake drunk. And the FDA sent warning letters and they all came off the market. You can still find this brand, but it has been reformulated. We have some candy that was causing lead poisoning. This is actually a product. Can you can you read what this says here.
Henry Bair: [00:43:48] Nico? Water. Yeah.
Jeff Sharfstein: [00:43:50] This is nicotine replacement beverage. Doctor recommended smoking substitute.
Henry Bair: [00:43:55] Oh my gosh. When was this pulled off the market?
Jeff Sharfstein: [00:43:57] This was probably back when I worked in Congress that one around the same time as this product, which is a nicotine lollipop. And let's see, I have one other thing that I worked on. I don't know how easy it is for you to see this, but it's a contact lens and it's in the shape of a dollar sign. And when I worked on Capitol Hill, FDA deregulated Plano contact lenses because out of a kind of an ideological idea that the FDA should only regulate things that change vision or something that's just decorative shouldn't be regulated by FDA. And the result of that is that the sales of contact lenses in beach stores and gas stations like, skyrocketed, and kids were getting them and putting them in, and you could imagine what was happening. I understand you're an ophthalmology resident. Oh, yeah.
Henry Bair: [00:44:46] Yeah. We see complications from contact lenses all the time. I assume you had some cases of, I don't know, maybe some fungal infections, maybe some amoeba, maybe some bacterial keratitis.
Jeff Sharfstein: [00:44:58] You name it. In fact, I would carry around on Capitol Hill a folder and I would say, we can do this the easy way or the hard way. You can get your boss to sign on to this legislation, or I'm going to show you some pictures and they'd be like, we'll get them to sign on. You don't have to show me the pictures of the eyes of fungal infections, you know? But there was actually an optometrist in Congress who's now in the Senate, John Boozman, a Republican who was an incredible champion of that legislation. And we were able to negotiate a truce on this ideological question of what the FDA should regulate and reregulate these products. That was a piece of legislation that Congressman Waxman and Congressman then Congressman Boozman led. And so I have to say, at one point, I think I might have written a statement for Congressman Waxman that said, these companies see teenagers with dollar signs in their eyes going for the double entendre. And yeah, exactly. That was one time that Congressman Waxman said, I'm not going to be saying that, Josh. So I was close. But every time I see this, I think, you know of that story.
Henry Bair: [00:45:58] So you've pulled off, you've contributed or maybe even spearheaded efforts to pull off a lot of products off the market. I'm sure along the way you must have made a lot of enemies at some point. Did you have these encounters with the people who were like, who are running these, producing these, like, how did you deal with with those conflicts, you know?
Jeff Sharfstein: [00:46:16] I don't want to give the impression that any of these things were done cavalierly. Like we worked a lot on the evidence building the case. We often had very serious medical allies in this, like the ophthalmology issue. We had the AAU, the optometrists. They were all deeply involved. And so, you know, it wasn't just me running, running around, but you do have some interesting interactions. When I was a health secretary, Maryland was the first state to ban the sale of baby bumper pads because kids were asphyxiating. We also had concerns about reduction in air circulation, contributing to sudden infant death, and there was no utility to the product that we could really understand. Kids can't get, you know, with a modern crib, you can't, like, fall between the slats or anything. And so we put a regulation out to do this. And there was a baby bumper pad industry that was objecting to it. And we had this hearing in Maryland because there was a committee that can review agency regulations and was a bit of a showdown. We had the medical examiner testify about his concerns about how these contributed to deaths, and then the industry testified.
Jeff Sharfstein: [00:47:29] And the question that was asked by one of the legislators was, you just heard the medical examiner say that the baby was asphyxiated up against the baby bumper pad. What would you recommend the baby to do if it's about to asphyxiate against the bumper pad? And there was a long pause, and my recollection is that the industry representative said I would advise the baby to back away from the bumper pad. And and I was like, okay, you don't necessarily see that every day. And Maryland went ahead with its ban and Ohio followed. New York followed, and now Congress followed. And so those products are not going to be for sale. And they, you know, did they kill large numbers of kids? No. But like, you know, I'm a pediatrician, I'm a parent. Every baby is precious. And we don't want babies to die for things that they don't need to die from. And and so, you know, I think, like if you have a good case, you make it carefully, you make it with people who are truly the experts in the particular field. And then, you know, you're prepared to face opposition and to to win.
Henry Bair: [00:48:38] Well, with that, we want to thank you so much, Josh, for taking the time to come on the show, for sharing your stories and your insights. Yeah. And thank you so much for for all the remarkable work you've done in your various leadership positions.
Jeff Sharfstein: [00:48:50] My pleasure. Thanks for having me.
Henry Bair: [00:48:54] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.theDoctorsArt.com. If you enjoyed the episode, please subscribe, rate, and review our show, available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [00:49:13] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient, or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:49:27] I'm Henry Bair.
Tyler Johnson: [00:49:28] and I'm Tyler Johnson. We hope you can join us next time. Until then, be well.