0:00

to Public Health On Call, a podcast

0:02

from the Johns Hopkins Bloomberg School

0:04

of Public Health, where we bring

0:06

evidence, experience, and perspective to

0:08

make sense of today's leading

0:11

health challenges. If

0:16

you have questions or ideas

0:19

for us, please send an email

0:21

to publichealthquestion at jhu .edu. That's

0:24

publichealthquestion at

0:26

jhu .edu. for future

0:28

podcast episodes. It's

0:31

Lindsay Smith Rogers. Dr.

0:33

Scott Harris is the Alabama State

0:35

Health Officer, a position he's held

0:37

for the last eight years. He's

0:40

also the national president of

0:42

the Association of State and Territorial

0:44

Health Officials. He joins

0:46

Dr. Josh Sharfstein to talk about

0:48

his experiences in public health, the

0:50

challenges of the present moment, and

0:52

his plan for the possible arrival

0:54

of measles. Let's listen. Dr.

0:58

Scott Harris, thank you so much for joining

1:00

me today on Public Health on Call. How

1:02

are you doing today? Thanks for having me,

1:04

Josh. I'm doing well. Thank you. Just glad

1:06

to be with you. So I'd like to

1:08

start by asking you to introduce yourself to

1:10

our audience. You are the health commissioner for

1:12

the state of Alabama. That's right.

1:14

I'm a physician. I'm an adult,

1:16

infectious disease doctor by training. And

1:18

I came to public health. only

1:20

about 10 years ago, which

1:22

for most of my career, I was

1:24

an HIV doc. I was practicing here

1:26

in Alabama, but did a lot of work

1:28

with local public health and eventually found

1:30

a position as a local health officer in

1:33

the part of the state where I

1:35

was living. And now I've been in this

1:37

role running the department field for about

1:39

eight years. Well, that's a long

1:41

time for a public health officer. And that's

1:43

a big transition from clinical care into

1:45

public health. Tell me what drove

1:47

you to change jobs? I

1:50

really enjoyed my clinical work. I

1:52

miss that, you know, under state law

1:54

in my state, I'm actually prohibited

1:56

from having any other employment. So I

1:59

can't actually take care of

2:01

patients anymore individually, unfortunately. And

2:03

I really miss that. But the

2:05

longer I was in private practice or

2:07

when I was employed by a

2:09

hospital system, I came to realize that

2:11

I wanted to try to make

2:13

an impact on a larger scale instead

2:15

of seeing an individual patient one

2:17

at a time, which is you know,

2:20

wonderful work. I wanted to see

2:22

if I could make a difference in

2:24

a larger way. And public health

2:26

offered me that opportunity to address population

2:28

health, to work on policy, to

2:30

work on systems of care. And

2:32

it was, you know, after 25 years

2:34

of private practice, it was also nice

2:36

to have a change and new challenges

2:39

and new things to think about. Did

2:41

you anticipate a global pandemic? No,

2:43

I probably wouldn't have changed. I

2:46

was in this job just

2:48

a couple of years before the

2:50

pandemic began. you know like

2:52

all of us we you know think

2:54

that we're prepared or we always imagine

2:56

the possibility that it could happen but

2:58

we weren't really prepared at all and

3:00

I was at the point where I

3:02

was still you know learning people within

3:04

my organization and certainly learning how to

3:06

navigate the healthcare landscape in my own

3:08

state having to learn really for the

3:10

first time how to interact with federal

3:12

partners that was you know new to

3:14

me and that's something I had done

3:16

in my previous life so I was

3:18

pretty green in that respect, but we

3:20

all had to learn rather quickly. Yeah,

3:23

and what did the pandemic teach you? I

3:25

mean, so many things, and you

3:28

know, you try not to sound too

3:30

cynical about it, but when I've

3:32

been asked that question, I think the

3:34

number one, the number one lesson

3:36

in the pandemic is that the facts

3:38

didn't always matter, you know, and

3:40

maybe a better way of saying that

3:43

is that the messenger became as

3:45

are more important than actually the

3:47

message. Over

3:49

time, there was

3:51

so much disruption in our

3:53

country. We've seen this lack of

3:56

trust now and not only during

3:58

the pandemic, but in other aspects of

4:00

society. And we have

4:02

people, unfortunately, kind of aligned

4:04

in these almost tribal

4:06

arrangements. And so we

4:08

learned that really important lesson

4:10

of trying to have people who

4:12

can deliver good messages about

4:14

public health, good advice, good education,

4:17

but who aren't, you know, the official public

4:19

health state government people, because some folks

4:21

just aren't interested in hearing from us, you

4:24

know. Yeah. Who have

4:26

you worked with to get good

4:28

information about health issues out to

4:30

people in Alabama? I would

4:32

say there are some groups that we haven't done

4:34

well with at all. But generally speaking,

4:36

people, you know, they do tend to

4:39

trust the people they know, right? And

4:41

that's you know, sort of the good

4:43

news and bad news of all the

4:45

information, misinformation that's going on

4:47

out there. But we work closely

4:49

with provider groups. You know, people

4:51

certainly, in most cases, believe

4:53

their family physician, their child's pediatrician,

4:55

you know, the practitioner that's cared

4:58

for them. We found people within

5:00

the education system, you know, educators,

5:02

teachers, administrators who

5:04

have typically, you know, many years

5:06

of relationships with a family, say, you

5:08

know, with a succession of children

5:10

and a family, those are people that

5:12

get trusted. communities of

5:14

faith are important in the

5:17

state. You know, Alabamians are

5:19

probably above average in identifying

5:21

as belonging to a faith

5:23

community. And so we found

5:25

a lot of people willing to share that

5:27

message with us in that context. And,

5:30

you know, there are other individual groups.

5:32

We have, you know, a big urban, rural

5:34

divide like a lot of the country, but

5:36

we're primarily a rural state. And so

5:38

in small towns, you have a lot

5:40

of cutability with professionals that have just

5:42

been there and have been well known

5:44

by people. And so pharmacists, for example,

5:46

play a really important role in getting

5:48

message out to people. But

5:50

so do social organizations, you

5:52

know, the Rotary Club or the

5:54

Coanas and these organizations actually

5:56

still play an important role in

5:58

a lot of small towns. And so

6:00

we found them willing to help us a

6:03

lot as well. kind

6:05

of like back to basics to find

6:07

the people who are trusted. Yeah, that's

6:09

right. You know, it just become this

6:11

maximum public health about identify your trusted

6:13

messenger. You know, we all hear that

6:15

phrase and know that, but we really

6:17

had to learn that. You know, I

6:20

think early in the pandemic, we just

6:22

assumed if we just rolled out the

6:24

best science, then sure, everyone would listen

6:26

and do what we recommended. Obviously,

6:28

that wasn't a case. Well, so

6:30

you made it through the pandemic, and

6:32

now we're in a different kind of

6:34

storm. You're not just leading your health

6:36

department, but you are the president of

6:38

all the health officers in that association.

6:41

So what's going on today? Yeah,

6:43

so it's just a very uncertain

6:45

funding environment, as you know. that

6:49

would be enough in a way

6:51

to really constitute a crisis when we're

6:53

seeing funding changes that happen without

6:55

our knowledge or consultation and they're wiping

6:57

out entire service lines and they're

6:59

all these subject matter experts that we've

7:01

interacted with on the federal level

7:03

who is suddenly unemployed and

7:05

unreachable, that would be

7:07

enough. And at the same

7:09

time now we're also dealing with alternative

7:12

views about what we feel

7:14

like is established science, you

7:16

know, whether you're talking about

7:18

immunization science or other things,

7:20

suddenly we're confronting a lot

7:22

of, anyway, confronting a lot of

7:24

misinformation coming to us through official

7:26

channels. And that can be really

7:29

challenging to message. You mentioned

7:31

the role I serve. So this

7:33

year, I'm very fortunate to be

7:35

president of the Association of State

7:37

and Territorial Health Officials, or ASTO.

7:39

We're you know, a nonpartisan association

7:41

of red states and blue states

7:43

and US territories and freely associated

7:45

states. It's hard

7:47

to get a consensus among all

7:49

the governors who lead those states, but

7:51

among health officers, you know, we're

7:54

pretty similar and we pretty much believe

7:56

in the value of science and

7:58

we think we understand good public health

8:00

practice. And so it's really

8:02

a difficult environment now, in some ways,

8:04

even more so than during the pandemic. I

8:07

want to break down some of the

8:09

things that you talked about. You mentioned the

8:11

changes in funding. One

8:13

of those changes was recently

8:15

the federal government stopping abruptly

8:18

the COVID spending. Did that

8:20

impact you all in

8:22

Alabama? Yeah, so

8:24

here in Alabama that amounted to

8:26

almost $200 million in funding that

8:28

we thought we had in our

8:30

department that was suddenly removed sort

8:32

of overnight. You know, we arrived

8:34

to work on it Tuesday morning

8:36

to learn that these 200 million

8:38

dollars in cuts that happened the

8:41

day before. And, you know,

8:43

we had around 150 FTEs that were

8:45

being paid for with those funds,

8:47

not to mention the actual programs that

8:49

they were working in. And, you

8:51

know, suddenly we had no ability to

8:53

pay them because the money

8:55

was gone. You know,

8:57

we're all used to transitions. I've

8:59

been here long enough to have

9:01

been through a couple of presidential

9:03

transitions and every new administration has

9:05

their own priorities. You know, that's

9:07

how our democracy works, they get

9:09

to set the plans for their

9:11

term of office. But what

9:14

was different about this is just the

9:16

abruptness with which money was withdrawn. It

9:18

was literally done in secret. It

9:20

was as though they did not want

9:22

us to know what the changes

9:24

were going to be. And it

9:26

just makes it really difficult, obviously, to

9:28

plan not to mention the fact

9:30

that these are real employees with

9:32

jobs and families and lives that

9:35

who really see disruption happen. overnight. Yeah,

9:37

what were the consequences in Alabama?

9:40

What were some of the consequences? Well, we

9:42

had a number of programs being

9:44

paid for with what were COVID

9:46

funds, but really were used for

9:48

a variety of things, including infectious disease

9:50

responses that were ongoing. So we

9:53

had money set aside to plan for

9:55

things like measles testing, you know,

9:57

which is going on now for upgrades

9:59

to our public health laboratory. We

10:02

had programs that were focused on

10:04

infection control for a number of different

10:06

populations. We helped one of our

10:08

academic medical centers to operate a program

10:10

for training infection prevention specialists in

10:12

hospitals and nursing homes to

10:14

help them understand infection control.

10:16

We had groups of social

10:18

workers working with independent living facilities

10:20

where you have developmentally

10:22

disabled or intellectually disabled individuals living

10:24

independently, but we would work

10:27

with them on various health things.

10:29

We had some of our

10:31

emergency preparedness programs working at community

10:33

resilience and preparedness. Anyway,

10:35

all work stopped, you know, in all those

10:37

programs. Well, all of it

10:39

until we're able to secure additional funding.

10:42

all the things that I mentioned stopped completely.

10:45

We also used it for things like outbreak

10:47

response. You know, we have FB's who

10:49

do outbreak investigations. Clearly, we're going to continue

10:51

that work, but we've got to figure

10:53

out where the money's coming from. you

10:55

know, we're still trying to sort that out.

10:57

We had a number of staff who

10:59

were simply conditional employees. That is, they knew

11:01

they were coming on board just for

11:03

the duration of the grant, except we expected,

11:05

you know, another 15 months or so,

11:07

at least in terms of our largest grant.

11:09

But those employees are gone. We've

11:12

had some vacancies in other areas that

11:14

we've been able to shift some people

11:16

around, but the work they were doing in

11:18

their programs had to stop. They have to assume

11:20

new duties when they go to these new roles.

11:22

So we will have some cuts, some

11:24

layoffs, but the absolute numbers

11:26

not clear yet. And there may

11:28

be other cuts coming down the

11:30

pike from the federal government. Yeah,

11:32

you know, as we're speaking today, you

11:34

know, I'm seeing these stories in the national

11:37

press about billions of dollars more that

11:39

are expected to be cut from HHS. And

11:41

it's just, I don't

11:43

know how we'll continue to operate in the

11:45

manner that we have. You

11:47

know, on one hand, we have

11:49

literal statutory responsibilities to do certain

11:52

public health actions. We're required to

11:54

do them. But At the same

11:56

time, we've frequently relied on federal

11:58

funds to make those activities possible in

12:00

our state. And we're generally speaking a

12:02

state that doesn't fund public health that

12:04

well at the state level. And

12:06

so it's going to be, I don't

12:08

know where the money's going to go. And you're not

12:11

alone in that. There are a lot of states that

12:13

rely on a lot of federal funding. You

12:15

mentioned that there are a number

12:17

of people who have in the

12:19

past helped the state of Alabama

12:21

in responding to different public health

12:23

challenges who may no longer have

12:25

jobs in the federal government. Can

12:27

you tell me more about that?

12:29

Sure. I was really just thinking

12:31

about specific programs with which we

12:34

interact that suddenly have had these

12:36

layoffs. A number of project officers

12:38

for various programs just simply aren't.

12:40

there anymore. A number of

12:42

people we worked with in immunizations. We

12:44

know the lead program at

12:47

CDC, for example. We

12:49

understand a lot of maternal child health

12:51

folks at HRSA have been let

12:53

go. We work with a number of

12:55

people at ASPR, you know, as part of

12:57

our preparedness efforts. The

12:59

reorganization Again, it's not

13:01

unusual for a new administration to

13:03

reorganize or shuffle the pieces around. But

13:06

what's unusual is for things to

13:08

happen this abruptly with no warning. And

13:11

those of us who are actually

13:13

the boots on the ground implementing

13:15

federal policy are the last ones

13:17

to find out what the changes

13:19

are. And that definitely sounds frustrating.

13:21

And it's all happening in the

13:23

middle of a big measles outbreak.

13:26

Yeah, absolutely. really

13:28

are worried about that. Three of the

13:31

four states that surround my state have

13:33

had individual measles cases, although not full

13:35

-fledged outbreaks yet, but it's only a

13:37

matter of time. We fully expect that.

13:39

We're trying our best to be prepared

13:41

for that, but it will be in

13:43

my state anytime now. So

13:45

what are you trying to do, given

13:47

the funding restrictions, given the loss

13:49

of some, maybe some of the technical

13:51

support that you've been getting, what

13:54

are you thinking as measles gets

13:56

closer and closer to Alabama? Yeah,

13:58

you know, part of it is just

14:00

trying to view things strategically as the

14:02

leader of the organization. It's, you know,

14:04

I'm thinking about how to keep my

14:06

team working hard and keep their morale

14:09

up and keep their spirits up. You

14:11

know, these are dedicated public health people

14:13

who've been here for a long time.

14:15

I mentioned to you, I came to

14:17

public health only 10 years ago. Most

14:19

of my senior staff have been here

14:21

for decades and mean, I've spent their

14:23

whole careers in public health and it's

14:25

a real discouraging time for them. as

14:28

for all of us. So I'm

14:30

trying to make it clear to

14:32

them that we're going to find

14:34

a way to get the work

14:36

done. You know, we care very

14:38

much about protecting Alabamians health and

14:40

safety while we got into this

14:42

work. So I feel in a

14:45

way like I'm doing a cheerleading

14:47

somewhat, not insincerely. I mean, I

14:49

really feel that way. But that's

14:51

clearly a big part of it.

14:53

Yeah, you may need to dust

14:55

off your file with all the

14:57

Rotary Club contact information and all

14:59

the providers, local providers, local groups,

15:01

and kind of go back to

15:03

basics to get people to recognize

15:05

critically important facts about measles and

15:07

vaccination. No, no, that's

15:09

absolutely right. You know, the wrinkle

15:11

there is that a lot of

15:13

the nonprofits and community organizations we

15:15

work with ultimately receive federal funds

15:17

that we pass to them. And

15:20

so those organizations are seeing their own

15:22

challenges as well. Most

15:24

of these local type organizations can't really

15:26

afford to miss a paycheck. They

15:28

don't have really deep financial resources. And

15:31

so when there's an interruption in

15:33

federal funding, it affects their work even

15:35

more quickly than it does us

15:37

in governmental public health. Well,

15:39

Dr. Harris, I have to say. Alabama

15:41

is very fortunate to have you there at

15:43

the Health Department, and the country is

15:45

fortunate for your national role. And I really

15:47

appreciate your taking a few minutes to

15:49

tell us all about it. And good luck.

15:53

Josh, thank you very much. It was a real pleasure to

15:55

be with you. from

16:00

the Johns Hopkins Bloomberg School of

16:02

Public Health, produced by Joshua Sharfstein,

16:05

Lindsay Smith Rogers, Stephanie

16:07

Desmond, and Grace Fernandez

16:09

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and Phillip Porter, with

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support from Chip Hickey.

16:19

Distribution by Nick Moran.

16:21

Production coordination by Catherine

16:23

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If you have questions or ideas

16:32

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16:39

jhu .edu for future

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