Dr. Tyler B. Evans: Pandemics, Poverty, and Politics

Episode Transcript
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(00:02):
Hey everybody, welcome back to Healthy, Wealthy, and Smart. I
am your host, Karen Litze, owner of Karen Litze Physical Therapy, located
in New York City. And today we are going to
be talking about the social and political drivers of
pandemics, from the plague to COVID-19 of
public health. And so I'm really, really excited to

(00:25):
have on the show this week, Dr. Tyler
Evans. He is an experienced and passionate infectious diseases
and public health expert who has been on the front lines of
major disease outbreaks around the globe. He is also the
CEO and co-founder of Wellness and Equity Alliance, a
national alliance of public health clinicians and supporting operations

(00:48):
committed to transforming healthcare delivery to vulnerable communities.
His latest book, Pandemics, Poverty, and Politics, Decoding
the Social and Political Drivers of Pandemics from
Plague to COVID-19 is available now. Dr.
I'm so happy to have you here. Now, before we get into the

(01:11):
bulk of our conversation, can you tell the listeners a little
bit more about your background and what
led you to infectious disease and to working with
Sure, happy to. I guess
my life can be organized into a few different chapters. Let's put it

(01:31):
into three to four chapters. The first chapter was
my youth, which was shaped by
a number of different factors, mostly by the
sort of the untimely loss
of my family. I lost my family between my
father to my mother to my grandparents, sort of lost everybody

(01:54):
by the age of 21. And so, you know, that was naturally traumatic.
All the series of different sort of traumatic events, not
one sort of event. And so but that was naturally traumatic, which left
left me on my own for the most part. Right. So I had to figure
it out, you know, at a very young age. And and

(02:14):
so that in conjunction with other sort of adverse challenges
in my childhood, my mom drinking
a fair bit. So chronic alcoholism. as well as some depression and
other elements, really allowed me to sort of
understand, you know, what
sort of adversity feels like, what sort of calamitous conditions sort of feel like. And

(02:37):
so when I kind of put those all together, in addition to having
two daughters at a relatively young age, by the age of 24 for
both of them, I had some real life
experience. I was able
to get into a pretty prestigious university. The

(02:58):
stars aligned that way. Sometimes I don't really know how that happened. I
actually got a GED. I worked
my tail off to get into University of Southern California. That was
sort of a success story for me. I just always knew
that education was going to be the path to success for me. I
stuck to that. During my

(03:20):
college years, my undergrad years, I started spending time in
places like Mexico, Tijuana on the southern border. And
that profound disparity
between the United States and Mexico in
that sort of area was very much an eye opener for me. So

(03:41):
that sort of laid the groundwork for my
future state, my future me. And so
that was sort of the first path. The
second phase started off with my graduate studies where
I started spending a lot of time in Africa. This is still in

(04:01):
the late 90s, early 2000s when
I was spending time in places like Uganda and South Africa. At
the time, there was a big international spotlight on HIV
and AIDS and organizations like MSF, Medicines
Sans Frontieres, Doctors Without Borders. started becoming increasingly more
sort of well-known. They ended up getting a Nobel Peace Prize. And

(04:22):
we're working on an essential access campaign. So
I got out there as a grad student, just doing some sort of summer internships
and whatnot, and was just fortunate enough to kind of get into these
experiences where it was just profound eye-openers. And
I ended up seeing a bunch of folks that did not have
access to, that were HIV infected and did not have access to the medications. unfortunately.

(04:45):
So these sort of these coexisting sort of reality between
the sort of the global north and the global south, having all these medications, because
back in the 90s and early 2000s, that's when the medications really
started to sort of accelerate in terms of technological development. The problem was,
it was completely out of the hands of the majority of the folks that were infected
with it or were at risk of getting infected. And

(05:06):
so literally, like almost 80% of folks could not access the
medications. So working with organizations again
like Doctors Without Borders and the UN agencies and whatnot, I
started to kind of see how the collective voice
of physicians and healthcare professionals could actually make a difference in
people's lives. So that for me was a turning point. That was

(05:28):
a big sort of light bulb moment for me. You
know, I had been traveling since I was like, 7 years old take places like
Kenya and China and and South America. So I had
already sort of connected to to folks of the global South. So
that's sort of chapter 1 and chapter 2 really sort of connected and then sort
of led to sort of chapter 3. started

(05:50):
working after chapter two and chapter three, working
as a grad student in a number of different places, spent half
of medical school living in the Middle East. I lived in Israel
and Lebanon, worked in the Palestinian territories for almost every
weekend. I worked in
places like Ethiopia and Kosovo and other places. And

(06:13):
that started to concretize my interest in
moving into this space further. And
that leads me to the sort of the final chapter, chapter four, which is really like
why infectious diseases, it connects more to back to sort of,
you know, chapter two, which is really the HAV piece. And
if we, if I'm going to have any particular sort of impact in

(06:34):
the global south, connecting to infectious diseases, and
all of the sort of the public health challenges that lead to infectious diseases,
particularly challenges with sanitation and hygiene, problems with
sort of immunization campaigns, which is what
we're dealing with right now, problems with sort of just medication delivery,
workforce development, all these sort of challenges really, you know,

(06:59):
can sort of find themselves in this sort of Venn diagram of
what infectious diseases sort of is all about. So,
but I particularly wanted to work in infectious diseases in the global South, not
so much in the US. And so I really kind of focused on
tropical medicine and in HIV, because that was
my main focus. So spent part

(07:21):
of my fellowship and training with the London School of Hygiene and Tropical Medicine, as
well as parts of East Africa, really getting sort of exposure to that
particular sort of area of infectious diseases. And then
in the US, most of my focus since then has
been on HIV and what we now describe as syndemics. So
how does HIV connect synergistically to other

(07:43):
co-infections or co-epidemics like
hepatitis C or like STIs,
syphilis right now being a sort of big one, particularly among women
that are of reproductive age. as well as
how is it all kind of influenced by the social and political drivers
of determinants, which is a lot of what the book is about, and particularly

(08:06):
how does behavioral health, including mental health and substance use,
Yeah. I mean, what an amazing journey you've had. Has
there ever been a point in any one of those chapters where
you were ready to throw in the towel and say, it's just, it's too much,
right? It's too much. It's too hard. I don't know if

(08:28):
Yes. Yes. A number of times. Totally.
I almost quit med school and residency at
least half a dozen times. Partly
for at one point during med school, I left,
I was at Boston University and I left, I dropped out of med school. It's very hard to
get in less than the status, less than 2% of

(08:50):
folks get in nowadays. And so I got in,
but I had just came back from India working with UNICEF. And
working with, you know, some of the sort of poorest and most vulnerable sort of communities. And
I'm in a place like Boston with a lot of sort of wealth and privilege. And so
that sort of disparity was just, I couldn't reconcile that
at that stage. So I needed more. So I dropped out, moved

(09:13):
back to the global South, moved to Thailand, started working on the book, same book. Took
me about 20 years to write. And
then ultimately, it's a long story, but ultimately I got accepted
to two other universities in the course of the next six months. I had totally forgotten that
I had actually applied to them. I was actually gonna go to the PhD route. And
then I said, all right, the universe is calling me back into medicine. So there was that.

(09:36):
There was a few times during residency that I just wanted to
drop out just because it wasn't, what I was learning
wasn't aligned with what I knew to be important. So
I was learning medicine in this context of
United States-based, hospital-based medicine, which was
not the medicine or the healthcare that I wanted to practice. And

(09:58):
so that sort of disconnect, that sort of a cognitive dissonance was
a challenge for me. But ultimately I finished it out because you got
to just stay the course, finish the training. And
then I ended up kind of creating my own path where I was able to really kind of focus on
what I think matters. So yes, so
yes to those. And then I've been in certain other

(10:20):
sort of, you know, spaces where, you know, it has been too challenging.
And I actually did quick, like, for example, I was with Indian Health
Service, where in Wyoming with the Wind River. providing
direct clinical services to Northern
Arapaho and the Eastern Shoshone. I was also the community
health director. It

(10:42):
was tons of good folks out there, so
much profound need, but the system was so deeply
disjointed and disrupted, it really allowed me to think you
know, how systems come into
play and how, if the system is so broken, if the system is

(11:03):
so dysfunctional, then our time trying
to fight from within or whatnot will ultimately just lead
in, you know, lead in sort of
us spinning our wheels, right? and utility. We
have to work within systems that actually allow
some traction. And that doesn't have to be in a very wealthy place. It

(11:26):
has to happen in a place where there is a realistic
opportunity for change and impact. So that was a
realization for me. And I'm actually quite glad that I've
done it. And actually now with my own organization, We're very
close to standing up tribal health programs ourselves, where

(11:49):
Amazing. And what advice would you
give to, let's say, other residents or
other interns that might be in
the same headspace you were in of like, I
Yeah, well, I love that question. I would say, A,

(12:10):
stay the course as much as you can. B, phone a friend. Don't
do anything. Don't jump ship yet.
Talk to a mentor, talk to
peers, but especially mentors. Hopefully, folks have their mentors
and they can talk to them. You know,

(12:31):
three, try to medicine and healthcare in
today's world allows a lot of creative adaptations
of what was once a sort of like, you know, conventional, almost
sort of monolithic sort of model. You know, now there's
a lot of opportunities to kind of spin off from the sort of the conventional healthcare

(12:52):
space could be research could be It could be public
health. It could be direct clinical care. It could be
research. It could be teaching. It could be a lot of different things, the
business of medicine. There's a lot of different elements out there, so many different
elements. There's tech. There's just so many opportunities out there. Just stay
the course. before

(13:16):
you then talk to a friend, but don't just jump ship without
talking to a mentor or peers, because you put so
much effort into getting there. While a lot of
folks, and this is a big problem in medicine in the United States, a
lot of med students and residents that come in, come in
not necessarily for the what I and others believe are

(13:38):
like the most sort of ideal or optimal reasons, right? They come
in a lot of times because they're sort of pushed by their family. A lot
of times just because they can, because they're graduating at the top of their class and
whatnot. People just like, oh, you should just be a doctor or, you
know, whatever, a scientist or an engineer or something. without actually
thinking it through. And particularly folks

(14:00):
that go from just undergrad straight to graduate school, we
see that happen straight to residency. We see that happen all the time. So
if you could take your gap years or whatnot, if I'm talking to residents versus
me talking to undergrads, it's going to be a different conversation. Sure. Undergrads or
whatnot, or grad students, I would say, take some gap years. Spend some
time. Explore the world. See what's really out there.

(14:24):
For a lot of folks, I really strongly recommend
taking a health policy or
public health master's degree or at least some courses to
really understand the macro before you get into the micro. Because when
folks are going into their clinical training, whether it's
a physician or physician associate, nurse practitioner, physical

(14:46):
therapist, et cetera, a lot of times it's a technical skill.
You're going to trade school. You're not
learning anything about the way that health systems are set up and
how you can operate in that. A lot of times, folks
do get burned out as a result because they went in thinking, oh,
I'm going to do X, Y, and they have all these aspirations to

(15:08):
come save the X or save the Y. Then they
find out how challenging that is unless they really understand the
systems. So understanding the macro, and it
could be through experience, doesn't have to be through a graduate degree, but
one of the two for folks who have not yet gone into medicine
or whatever their final graduate degree is, spend some time

(15:29):
really understanding the scope and the context and the outer sort
of layers of what you're going to be working in. as
opposed to sort of after, because it may not be for you. And I know
after I've given this advice, a lot of folks don't end up going into kind
of like direct clinical care. They'll end up going into like a PhD or
a DRPH or sort of connect to the macro.

(15:53):
Yeah, I mean, I think it's great advice. Burnout is obviously, I don't
know how big it is in the physician community, but I know it's a pretty big
deal in the physical therapy community, especially coming out of COVID. So
I think that's great advice to just
kind of know what you're really
passionate about and how the system works and how your passion can

(16:16):
interact with the existing systems and how you can
Just a quick response. It
is quite prevalent in residency. I actually published on this.
Residency burnout, super prevalent. Definitely
far more prevalent in the clinical

(16:39):
specialties that focus more on direct patient care. That
could be family medicine, that could be emergency medicine tends to be number one.
Family medicine and even internal medicine will
definitely be at the top. It's particularly the
specialties where there's a lot of
administrative burnout. Burnout

(17:03):
is based upon three different factors. scales,
instruments, to essentially grade it. And the
most important one is emotional dissatisfaction. There

(17:24):
might be a word there that I missed. It's been a while. But that
was the most important. Then there was depersonalization and one
other domain that I'm forgetting. But essentially thinking
through those three domains, the major piece is
the disconnect, the emotional disconnect from what you're actually doing.
Yeah. Yeah. That makes perfect sense. When your

(17:47):
expectations are not even remotely being met, it's
really depressing. Then you're thinking,
well, what am I doing? What's the point, right? Yeah.
Yeah. Great advice. OK, now let's get
to a little bit more about your book and
about what you do. So like

(18:08):
I said in the book, part of it is looking at
pandemic responses through history, plagues
to covid. And you can expand a little bit more about
what your role was during covid. But based on
your research, what are the most striking
parallels between how societies dealt

(18:31):
with these plagues or pandemics in
the past versus now? And have
we learned anything from history or are we still making
Well, great questions. I will start with Is
it okay if I just kind of start with the way that the book is laid out because I think we'll

(18:52):
kind of respond to it. So the book is laid out into three different sections. So
just to kind of recap the name of the book, Pandemics, Poverty, and Politics, decoding
the social and political drivers of pandemics
from the third plague to COVID-19. So the first
section really is just all about social medicine, why it matters, what

(19:13):
the social determinants of health are, and how that sort of
all unfolds. A lot of folks, particularly in healthcare, were
inundated with the concept of the social determinants or the SDOH, but
not a lot of people really you know, can sort of
go through all the different layers, including myself. I mean, it really, as I
studied the book, I really needed to get into like the social sciences of

(19:34):
all the different sort of, you know, sort of layers that lead to the social determinants.
So that, so kind of peeling back those layers of all those different domains
is important. So that's the first sort of section. Second section is
looking at every relevant pandemic. And
I define pandemic in a particular way. But
outlining every particular pandemic as it's defined, from

(19:56):
the third plague and the sixth cholera pandemic, which
were around the same time, around 1899, to the
present, essentially, which is COVID-19. So we are not
out of COVID. I know a lot of people say, oh, and COVID happened. We are
not out of COVID. We're out of the pandemic. of COVID. But,
you know, that may always come back. And so we,

(20:18):
you know, COVID now is endemic, and it will sort of,
you know, stick with us. And so anyways, so the second
section is looking at all of these pandemics, and
I lay out, you know, a number of them, again, starting with those
two that I just described, in addition to sort of like the 1918, which was the
most well-known one, most infamous one, the

(20:39):
1918 Spanish influenza did not actually originate in Spain. And
as well as a number of other flu pandemics, the
1957 Asian pandemic, the 1968 Hong Kong flu, as
well as the H1N1. And
then I look at Ebola. I look at HIV, of course, which is

(21:01):
still ongoing. And then, of course, COVID-19. And
then I look at the current top infectious disease killers, contemporary
infectious disease killers across the globe. And so
for each one of these, I basically kind of outline the sort of the
history, some of the social political determinants, and then I give a reader a

(21:22):
rubric or a grading instrument to basically determine whether or not
they agree that there are five different points that
they can kind of see sort of across the spectrum of
all of these diseases. Okay, and so then the reader it's
it's it's self guided, you know, but ultimately, I hope I I
write compelling enough arguments that that they do believe that at least majority of

(21:43):
them were strongly influenced by the social and political drivers
or determinants. And then we get to the third section. Okay, now
that we've got your attention, what do we do about it? And
so And so to your question, you
know, it is what we have seen throughout history has
been this very consistent sort of thread, which

(22:04):
has been which has been that, you know,
either governments have not worked in collaborative
sort of ways with other government agencies. And there's at least at
least two to three different concrete examples of that, particularly
examples of the Chinese not working in collaboration with
the WHO. and other sort of organizations. There's a

(22:24):
lot of reasons for that. I'm not demonizing the Chinese government at
all, but these are just examples of... I
believe, mistakes at the time, not collaborating.
When we're dealing with infectious disease outbreaks, they
clearly can sort of pass through borders.
They don't recognize borders. And so if

(22:45):
we have these elements in place, particularly certain
policies that essentially discriminate against
migrant communities, that essentially lead to
more impoverishment or whatnot, there's more inequities, you're ultimately gonna
be more of a diffusion of these infectious
disease outbreaks that lead from epidemic scale from

(23:06):
local outbreaks to epidemics. And so
that's really the sort of the common thread throughout
all of these. HIV, Ebola, all
of these in sort of in our life has certainly
sort of shared some common sort of contributors. And

(23:28):
it leads to something our ongoing
inequities in these systems in the US and
globally, these chronic health inequities lead
to something that I describe as population stress. It's
these inequities, it's all of the things that lead to the inequities. It's

(23:48):
a lot of the chicken and the egg, but it leads to this
pressure cooker of systems or
nations that do not have functional
infrastructure in place, and part of that's political, part of that's
social, then the more gaps that we see leads
to those inequities. When we look at poverty, for example, there's

(24:11):
absolute versus relative poverty, and I talk about this in the book. When
we're looking at absolute poverty in places like Sub-Saharan Africa,
most places in Sub-Saharan Africa, absolute poverty. across the
board categorically poor. There are certain countries like South Africa, which
is distinct African country, where we see profound
inequities between the rich and the poor. Most of that's white versus black. When

(24:33):
we see that, we see a significant increase. That
is graded by the Gini coefficient. We can rank that very
clearly and then correlate that with disease outbreaks and
whatnot. What we find is in places like South Africa,
in places like Brazil, with profound inequities, we see
criminality increase significantly. We see political activity

(24:55):
increasing significantly. During apartheid, when apartheid was
sort of coming undone, the decades that led to that,
lots of political unrest, led to what I believe was
the sort of increase spread
of HIV. Meanwhile, it was all under the radar. We didn't even know that HIV
existed, right? All this political activity and

(25:18):
sort of unrest was sort of unfolding. And so, you
know, virulence, basically the spread of the
spread of viruses, and the sort of the the the
sort of the pressure cooker The barometer of how
viruses both infect and cause disease,
which is pathogenicity, is

(25:41):
accelerated by stress. That's
from a basic immunological principle. The herpes virus very
commonly will manifest as a blister, for example, when people
are stressed. Stress can be a lot of things. I describe that
as population stress. When there's all
this inactivity, when there are systems and people not

(26:03):
aligned, when people are dealing with food insecurities and
all these other pieces that lead to immunocompromise, then
ultimately it leads to the perfect conditions for an infectious disease
outbreak to become an epidemic and ultimately from that epidemic to
then cross borders into pandemics because
that population stress, because it just became, it was just a pressure cooker,

(26:25):
Right, right. And, you
know, in your experience working with these populations and in
different parts of the world, what,
what helps to, what, if anything helps to contain
that pressure cooker? is

(26:49):
It's definitely possible. I mean, parity, equity
leads to... Equity and equality are not the same,
right? Correct. Equity is, especially
health equity, will will lead to basically more sort
of even conditions, less disparate conditions, which
ultimately will lead to sort of more harmony, better,

(27:13):
you know, and again, it's getting back to the social determinants, right? So looking
at education, looking at transportation, looking at sort
of childcare, looking at all these different elements, looking at
our income, of course, looking at food security, looking at
all these different elements that we can sort of, you know, measure and
rank, if we have more parity, more

(27:35):
even distribution of these services, Scandinavia
is a perfect example. Scandinavia, yes, smaller
countries, a little bit more homogenous countries,
yes. But these are often
the reference for more equitable
conditions and less risk for pandemics taking

(27:57):
place. Other examples that
are not exactly as harmonious as the Scandinavian countries,
but other countries that have really good public health infrastructure and less
inequalities, Singapore, Korea, Japan,
to some extent. And when it came to the COVID-19 pandemic,

(28:18):
a lot of these folks, like Korea, was
one of the countries in the very beginning that had pretty profound incidents
of infections. And they jumped on that really quickly, partly
because, and I explain this in the book, partly because they had experience
with prior outbreaks and pandemics

(28:39):
or public health emergencies of international concern. like
the SARS of COVID-1, which was 2001, as
well as MERS, for example, Middle Eastern Respiratory Syndrome, which
actually got out of the Middle East, historically
would be sort of described during the Hajj and

(29:00):
during basically mass gathering events,
particularly in the Middle East, and
Mecca, Medina mostly. And then it would travel to
other countries like Korea, So
I describe Korea as basically a concrete example of
that strong public health infrastructure, not a lot of inequities, but

(29:27):
Yeah, you beat me to it. That was my next question was, could you give some good
examples of where there is some sort
of medical and health equity? So you sailed right
in before I could even ask the question. Yes,
yes. Now, as you've discussed, you've
been out working with Doctors Without Borders, you've been on

(29:48):
the front lines of major disease outbreaks, including
Ebola and HIV, you've worked with refugees,
asylum seekers, marginalized communities. So how
do working with those populations, how
does it shape your understanding of these

(30:12):
preventable diseases and why they continue to
kill millions of people? even though they are
preventable and we live in a world with lots
of wealth and lots of technology. So I
think a lot of people think, well, why isn't this solved? So,

(30:35):
Well, I mean, I think there's two questions there. One was
the questions I heard. The first question was being on the front lines of
some of these epidemics, pandemics, outbreaks, different
definitions to these three pieces. How
did that kind of change my thinking? And

(30:56):
so I think I've been fortunate enough that I've
been able to kind of experience these
emergencies through both that
sort of frontline perspective, so on the ground, boots on the ground, sort
of individual perspective, working with direct clinical, direct
patient care, in addition to working with the systems, right,

(31:19):
to oversee it. And now I kind of describe, I still see
patients as often as I can, but I
work more with sort of, you know, systems and communities. And
so I kind of treat the system as my patient now, I
often describe the system as quite sick, right? It requires
a lot of convalescence. I'm

(31:40):
spending more time on that because I've sort of acquired
a specialty in systems convalescence.
It's the first time I've used that. And, and,
but anyways, but having the sort of the connection between the two being
truly on the front lines being in the foxholes, and not just in

(32:02):
the ivory towers and sort of, you know, academia just
kind of like hearing about it. It made me
emotionally connect to it. It's not abstract to
me. This is real. I've seen babies have
died in my arms. I talk about this in the book. Babies have died in my arms.
I've seen the mass destruction

(32:24):
of villages. I've seen a lot of things that I wish I could unsee, but
the reality is they're there. And so I emotionally
connect to them. And that drives me. When
I am now I run an organization wellness equity Alliance, we focus
a lot on at risk youth and places like New Mexico, New Mexico,
we're working with with with carceral populations reentry

(32:47):
populations people that are in jails and getting them
out of there down in Southern California we're working on street medicines providing
direct clinical services. to the unsheltered and housed. Many of these
folks are migrant workers and sex workers and
whatnot. Again, I continue to
see these patients, but working again from the macro level, I'm
able to connect the two. For me, I'm

(33:12):
not disconnected from these pieces. I'm very much
connected. My heart's very much into it. I'm part Italian, so
heart means a lot to me. Yeah.
That was the first question, I think. Yeah. The
response to the second question was,

(33:33):
how do we have effective responses
Some of these preventable diseases. We've got wealth
and technology, so why
When we were coming out of the COVID-19 pandemic, a lot of the

(33:54):
thought leaders really tried to distill the
messaging. What did we learn? What did
we get out of this? The way that I
teach or discuss is I learned
five different pieces. One was that we
cannot look at infectious diseases through one sort of monolithic lens,

(34:17):
right? Like, it's not just COVID-19. It's not just HIV.
It is these cascading impacts.
It is these syndemics, getting back to that word again, these
syndemics where you have a number of epidemics that
are working together, not in an additive fashion, but in
a synergistic, multiplicative fashion. So that

(34:41):
is really key to, that's a key sort of outcome of
the pandemic. And a lot of those syndemics, again, are
influenced by the social and political drivers. So
if we take the, if we just try to study and
identify surveillance and response to just the disease, we
will fail. right? We need to, we

(35:03):
need to basically zoom out and understand the social and political context
in which these diseases emerge and try to address those. And
those in like in, in real time during gray skies, we
need to basically set up, you know, mass, um,
we called them pods during the COVID-19 pandemic points of dispensing, set
up mass pods that have community-based organizations working with air. So

(35:24):
there's a friendly face. There's known sort of, you know, messengers, people
And then that's gray skies. During blue skies, we need to be setting up,
you know, different sort of, you know, more kind of
sustainable communication channels. So I'll get to that
in a second. But basically, so first part, really framing the
disease as a syndemic. Number two, understanding the

(35:48):
importance of health equity. You know, if we do, if
we continue to have these inequities, which is what our entire conversation is about, we
will continue to see these preventable diseases, literally
vaccine preventable diseases, scale, which,
I mean, even become a reality to begin with, right? Like
even become outbreaks, which are, again, we're preventable by definition, number

(36:10):
one to number two, ultimately scaling to become epidemics and
then beyond that transnational borders becoming pandemics. So
that's the importance of health equity. Third, that community and
multi-sectoral partnership. It can't just be
the doctors. It can't just be the insurance companies or
the health plans. You got to have the community-based organizations. You have
to have the faith communities. You have to have the special

(36:33):
interest groups. You have to have the unions. You have to have these folks that represent and
have the faith and trust of these communities and have everybody at the table so
you can have that sort of like effective dialogue. And it needs to start at the
very beginning. You know, you cannot do this sort of midstream, right?
You need to start those conversations at the very beginning and hopefully have that sort
of consortium ahead of time. And then finally, the importance of public health

(36:56):
emergency response and resilience. It's
not just, it's not enough. So that's, that's what we in public health
called FEP, public health emergency preparedness. It's not enough
to do these drills in the abstract, you know, watch a webinar or
something like that. We really have to be prepared. We really have
to have to understand how to kind of activate our contingency plans and,

(37:17):
you know, sort of what to do. So, so super, super important. you
know, to get those done. So that's sort of what we learned in
terms of like, that's sort of more the strategic sort of, you
know, outcomes in which, you know, we need to sort of focus on. In
terms of like the more individual tactical pieces, you
know, there's, I break these into sort of six different components. The

(37:40):
first is, Karen, is effective leadership, right? So we
have been lacking that for sure. And it's getting worse with the current administration.
We need to have effective leadership. We need to have somebody who's who's
got the helm, you know, who knows exactly what they're doing, and
who's working again with those community and multi sectoral sort of
partners. Now that could be I make

(38:01):
the argument in the book that the US Surgeon General. has
a lot more teeth. We don't often hear about that, right? Like we
hear a Surgeon General with cigarette warnings and whatnot, but
the Surgeon General is really under a more responsible administration.
Surgeon Generals really have the capacity to get a lot done because
they have the US

(38:23):
public health personnel that are working underneath them.
So there's a lot of traction, a lot of teeth that they could potentially have.
CDC, a lot of people say, oh, why can't CDC do it? CDC is an advisory agency.
CDC does not actually have a lot of operational capacity. And
they're removing even more any sort of operational
capacity that they did have. So effective leadership. Uh,

(38:47):
clear and consistent messaging number 2 clear and consistent messaging needs to
start from the top in the very beginning and then you need to communicate effectively
with your state leaders, your community leaders, you know,
and there needs to be just basically like a chain of command that goes through these different channels.
We need to set up the consortiums ahead of time. There are some. some
sort of scaffolding that does exist right now. And I talk about this in the book and

(39:09):
we get very technical, but there are
agencies. So we're not starting from scratch that we could really set up
for success, but there needs to be coordinating sort of elements to
these agencies so that they know that they are working with one another. We
have to have workforce development. We have to make sure that we
are focusing on certain workforce

(39:32):
where we are struggling with inequities, particularly
in terms of representation of those clients. A big
one is behavioral health. Behavioral health, we define that as
psychiatry, addiction medicine or substance use disorder treatment and prevention, and
behavioral health counseling. There are profoundly under-representation

(39:55):
of these public health or healthcare professionals in general, and
definitely a profoundly anemic representation of
black and brown. communities in the
behavioral health workforce. So we have to think differently. So at Wellness
Equity Alliance, we're working a lot with community health workers or certified peer
support workers that do look and talk like the

(40:16):
communities in which we need to get to. People that have lived experience, but
have opportunities to get some certifications or trainings. So
it's clear that we do that. We already talked
about this, but having clear and consistent messaging. I
often make the example of
if a patient is in the ER, really more

(40:37):
appropriately the ED, and you've got two docs that are openly
arguing about the diagnosis and the treatment, that person's confidence
in that system or that institution is going to go downhill. Totally.
So you got to have clear and consistent messaging. You have to
all be on the same page. And here's the good news. There's science,
right? Science has existed for centuries, right?

(41:00):
We have all this evidence, evidence-based medicine. So we shouldn't be making this
stuff up. We should just be following the science. We're not doing
that enough. The last two things, data-driven. We have to be data-driven as
much as possible interventions. So that evidence-based medicine model has
to, again, kind of follow the data. And then finally, the
models need to be innovative. We cannot continue to work

(41:22):
on these clinical models. You know, the brick and mortar, the white coats and
all that, that doesn't work for at least one third, if not
more, of the United States and well beyond the U.S. It
just does not. There's good evidence for that. A lot of folks, especially
for prevention, they don't want to be sick. For folks, I work a
lot in HIV, so for folks that are at risk of HIV, particularly

(41:43):
the healthiest, the ones that are out there having a good time, they
don't want to come in to get PrEP or to get antibiotics or
So let's get it out there. Let's make it as easy as possible. Same
thing with the unsheltered unhoused. They don't want to be bothered. They've chosen a
different path. So meet them where they're at. So that's really a lot of what
we do, Wellness Equity Alliance, is we identify innovative clinical service

(42:07):
delivery models that really meet folks where they're at in a really meaningful way.
Yeah. It's a lot of moving parts, but
it sounds like there's some structure there
to get it done. It just, and that
takes us to our next to the next thing I want to talk about.
And that's sort of the political decision making and

(42:29):
public health where, you know, maybe things start
to break down a little bit, right. different
viewpoints you've got within
the United States. We're both in the US, within the United States and
across the world. So what are some key political factors

(42:49):
that can determine whether a society protects
its most vulnerable members? And
we could say during a health crisis and outside
of a health crisis. Because it should be protecting those
most vulnerable all the time. So

(43:10):
what how does political decision making and public
health all play a role in everything that we've talked
Yeah, well, I love all your questions, Karen. We could talk for a while. So
the way that you just said that you kind of delineated between during
crisis, during not, we talk in like emergency management, we'll say blue skies
versus gray skies. So blue skies during normal, whatever

(43:33):
normal is, days, non-emergent sort
of days, and then gray skies as being sort of during emergent days.
Um, so yeah, I mean, so, so, you know, great questions. It's
ultimately how do we, how do we have the.
how do we basically coordinate enough political
buy-in to ensure that there

(43:58):
is focus on kind of closing the gap on some of these inequities? I
often talk about the systems in the United States, the healthcare system
in the United States and public health. So just to be clear, healthcare,
public health, different, right? A lot of different systems
in the U.S. that they should, now these two, they're different, they
should interact. They don't, they don't as well as they should. There

(44:21):
are certain examples, there are certain concrete examples where they do, they
do interact a little bit more effectively. But as a general rule, and
my organization worked during the pandemic, we administered over 2 million COVID vaccines. So
we worked with, in over 10 state health departments. And
we have good examples, I'm not gonna get into that here, but we have good examples, we have not
so great examples of where there was a little bit more integration between

(44:43):
healthcare and public health. So it's all
these cracks in the pavement, it's all these cracks in the system
that are a significant challenge and a lot of that is political. So
when we look at basically where we did well in terms of vaccine penetrance,
when we look at mortality, when we look at a lot of these other correlated social
determinants, we see a lot greater correlation with

(45:08):
red states in terms of poor outcomes than we do with blue states. Now,
there's been increasing evidence that that's not actually true. But
in terms of the evidence that I have seen, it absolutely is true
in terms of certainly in terms of better sort of vaccination coverage.
Absolutely. Much, much better sort of penetrance or sort of coverage
in those blue states. And, you

(45:31):
know, in terms of those messaging, a lot of those things that I was just talking about, the
governance, the leadership in many of those states undermine
public health. And that is such a profound problem because and
that it's getting worse right now. Now is before it was state because, you know,
my my my my sort of message, you
know, to reviewers was during twenty twenty one to twenty twenty four. I

(45:54):
and many of others were feeling relatively more confident than
we were prior to the pandemic. Like, okay, the silver lining is
COVID-19. It was finally It
was an equalizer of risk. When
we're dealing with a lot of other infectious diseases, particularly pandemics, a
lot of folks in the global north, we describe that as mostly

(46:17):
OECD countries, mostly developed nations.
That's the United States, that's Europe, that's parts of East Asia, etc. They
mostly thought that they were not at risk. For
many of these, so for many diseases, your malaria, your TB, your
diarrheal diseases, et cetera. But

(46:37):
HIV to some extent crossed borders and made people feel as
if they were at risk. People definitely do not feel as if they're at as much
risk nowadays because we have such good, effective treatment and
prevention. Programs COVID-19 was that one that
really just crossed crossed all the all the all the sort
of borders all the sort of, you know, you

(46:57):
know, transform all different sort of social sort
of domains. While
certainly the most historically marginalized were the most at risk, that's the
whole point of the book, certainly other people
in the most privileged or the most disconnected from poverty or
other social drivers were at least one degree of separation away

(47:21):
from having some pretty profound experiences. So
many of us thought that, OK, equalizer of risk, the perception
of risk would have transformed or changed. Unfortunately, now,
with the current presidential administration, with the
secretary of the Department of Health and Human Services, I often describe

(47:44):
as the chief pseudoscience officer, They're doing
such a disservice. They are literally disrupting all of the work that
we have put together, not just the last four to five years. We're talking decades. They're
trying to dismantle or disrupt all of these sort of
systems in place. And it's super unfortunate because
there's so many people. It's not even a village. mass

(48:09):
tsunamis of villages coming together and really just
putting their life, their careers into this thing and
building out these systems and the research and everything that's been
implemented. So we understand what we should be doing. Unfortunately,
now the political sort of those

(48:29):
with political agency are removing all that. And it's super unfortunate because
public health, and I say this all the time, I say this in the book, it's part of
the reason why I write the book, public health needs to be depoliticized. There
is no reason why public health should be politicized. There's no reason. It
is there, it is literally there for the common good. It is like any other
sort of common agency, like law enforcement, like fire

(48:52):
service, et cetera. You may have
politically distinct perspectives
of how law enforcement and fire service or whatnot should operate,
ambulances, hospital systems. But the reality is, I think most
people would agree that they should exist in some capacity. Public
Yeah. It is there to protect our

(49:15):
public, our populations. And if we do
not invest in it, even if you feel like if your politics say,
I don't really care about you know, the homeless or I don't really care about migrant communities.
OK, fine. That's that's your political belief. You're totally entitled to
that. The problem is once these once
all of these social and political sort of collisions come

(49:37):
together, it will ultimately impact the system in which you are consuming care.
And that's exactly what happened with the 19 pandemic, that folks that were having,
you know, their wives, uncles, whatever, were having heart attacks or
other normal blue sky stuff. They couldn't get into a hospital. They
could not get into an ICU. And as a result, they died. So there's COVID-19
was not the, my father included, you know, COVID-19 was

(49:58):
not the reason, it was not on your death certificate, but
it was ultimately the social and political sort
of driver of a lot of that morbidity and mortality. If we
don't focus on it now, and we don't invest in
it further, and we have these further recessions like we're currently having, it
will get significantly worse. And so what we're seeing right now with

(50:18):
this political administration, even though again, Red states, blue
states, it shouldn't matter. It's for everybody. Ultimately,
people will find that those inequities are
going to flare up even further. And so the next infectious disease outbreak
is going to even be that much worse. And that's unfortunate. But I still have
hope. I still have hope. We were talking about this before. I still have hope. I

(50:41):
do believe that the pendulum will swing back. And
I think that the more disruption, which is clearly intentional
at this point, basically breaking up the
CDC Advisory Council on Immunization Practices, basically the
subject matter experts. in
the room on immunizations and just healthcare in general, you

(51:03):
know, breaking that up and all these other sort of things that are happening, you know,
removing certain vulnerable populations from, you know, the formularies
of health plans and whatnot. The point is to disrupt
as much as possible. It's clearly the point. There is no other sort of, there is no
alternative explanation, but our hope in
health care and science is that the science will ultimately overcome.

(51:25):
And public health, which is driven by science, will ultimately overcome. So
we believe that the pendulum will swing back. And as people, unfortunately, there
will be more people that get hurt in the immediate
future. But as that continues to happen, people will continue, blue and
red states will start to voice their concerns. And
so all of the impacts on Medicaid and all the safety nets

(51:46):
and the infrastructures that we have for this country, the pendulum
coming back. And I do believe that we will be in a better place
in the future. I don't know when that is, but at some point in the future,
and hopefully at the very least, people will get out there and vote and understand
how their vote leads to not just sort
of political decisions that, you know, that are looking at

(52:08):
sort of tax breaks or whatnot. They absolutely will impact their access to
Yeah, absolutely. And I always think of, You
know, those folks who live in more rural America, which
by the way, I don't have to tell you this, it's a lot of America.
So what happens when those public health
initiatives and those rural hospitals start

(52:31):
to disappear? So to your point, you may think, well, this
isn't gonna affect me. Well,
it probably will when you have to drive 200 miles
100%. We talk about this often. Rural
health is one of our strategic priorities. That

(52:54):
is the reality, Karen. You just hit the nail on the head. When it comes
to rural, which is a lot of the 47's base, the reality is they felt
they had certain opinions about the world and whatnot and
that's fine. But
from a healthcare standpoint, and that's all I can really talk about is from a healthcare or public health standpoint,

(53:16):
when you are making those political decisions, you are voting against
yourself in terms of access. So what's happening right now,
rural critical access hospitals, this was an initiative that had been pushed by
HRSA and SAMHSA and a number of other federal alphabet
agencies. Those are all
getting disrupted right now. So folks that could have

(53:38):
had access to some life-saving measures, that's all
going away. And so people
are reliant on getting to hospitals, to your point,
that are literally 200. I used to work on
the Wind River Reservation where
the closest local community hospital was

(53:58):
at least 80 miles away. The closest academic medical center was
about 300 miles away in either Denver or Salt Lake City. So,
so if you really needed a life saving sort of, you know, you could get airlifted, but
think about the cost of that right so these folks that are these rural
sort of areas are absolutely getting you know these critical these these
clinical services which could have been advanced in my organization does

(54:20):
do that. Now, we're going
several steps back. Now, again, leaving with
the positive news, with the good news, I think
organizations like Wellness Equity Alliance and other organizations that
are big thinkers, they will think about how they can
do more and how the public-private partnership can work together more

(54:41):
efficiently. Because the people will continue to get sick, and they're going
to get sicker the more that we roll back this infrastructure. But
with organizations like ours, we're really thinking through innovation, working again
with the public sort of infrastructure, we could kind of come in there
and try to provide as much sort of

(55:01):
It's a lot of work and to your point, it
takes a lot of innovation. It takes a lot of manpower and
it takes a lot of coordination, which a
lot of that might have to a certain extent already
been in place, but now because it's being disrupted so

(55:21):
much, for me,
it's the unknown. Because we don't
quite know what's going to happen if more things are
rolled back and dismantled. And
so I think that's the part that's a little unnerving. But
I like your point that, listen, the pendulum's way,

(55:42):
way over here. It's gotta swing back. And perhaps
with organizations like yours and maybe other private public
partnerships, when that pendulum swings back, it
might be even better than
Yeah. So I'm still hopeful, too. I'm still hopeful. So

(56:06):
aside from this, maybe more coordination between
a public and private partnerships, what's the path forward? Where
Um, well, I mean, where we go is just getting back to, to kind of,
you know, what we were describing earlier was we have to, we
have to focus on those six or seven different buckets. You know, one

(56:27):
is we need more effective leadership. We're kind of right
now we're, we're a little drained. We're in a little yeah, we're in a
funk in terms of our current leadership. So we got to we got to
work on that again, pendulum as the result of
sort of this this sort of anemic leadership right now. I
believe that more effective leaders will come out. And

(56:48):
we'll have I think it's essentially creating sort
of like a pipeline for So
that's a key one. We have
to coordinate those
consortiums between the relevant stakeholders. That has to happen now.
Now, again, given all the challenges, I think there's going to be a lot of

(57:11):
formidable barriers in the next three
years. Hopefully something will change, but we'll
see. But yes, we need to have the consortiums
of the communities that reflect, again,
mostly, importantly, the most historically marginalized. So

(57:31):
that's the homeless. Those are the sort of Immigrants, those
are the LGBT plus those are a number of other kind of special interest
groups. So we need to have effective community leadership
of them and make sure that they are connected again with that
effective leadership from the federal to the state to the city county level. There
are agencies or organizations out there. That is

(57:52):
their mandate, that is their job. Organizations like NACCHO, National
Association of City County Health Officials, ASTHO,
the Agency for State and
Health Officers, Association of
State and Health Officers, as well as a number of other
organizations that bring people together. So that is their mandate. They have funding to

(58:14):
be coalitions or consortiums. So that's
a key piece so that when we are in gray skies, we can just activate it. standardized
infection prevention control models. Those are
our models need to be standardized. We cannot have diverging opinions
when it comes to like masks and vaccinations and
whatnot. This is not like, we're not making this stuff up,

(58:37):
right? There's tons of evidence to support this, overwhelming
evidence to support all these things. If you have questions, if
you have questions, if you have concerns, don't go to your echo chamber, don't
Don't, don't ask Twitter X or whatever it is. Yeah.
Don't go to Google. Like talk to your, talk to your primary care providers. If

(58:59):
you do not have one, try to reach out to your local FQHC, talk
to your public health professionals that those talk to the experts. Don't
just make this stuff up and then go into your echo chamber. Cause this is what's what's constantly
happening and that gets borax and all this other kind of like, you
know, nonsense. Yeah. The
interventions that we have, they have to be data-driven. So they have to

(59:20):
be evidence-based. We should not be implementing anything that does not
have that sort of capacity. And we did not, not just
not at baseline, but also continue to have M&E monitoring
and evaluation to see that our implementations actually have
traction. Workforce development, we cannot continue to,
you know, think that the solution is creating

(59:42):
more doctors or medical doctors. That is one
of many solutions. And there are a lot of reasons why we
don't have enough medical doctors. And that's a long explanation. But
my point is, we need more alternative workforce. So
getting back to the rural piece, our organization has experimented with
community paramedicine, for example. So community paramedicine, you completely

(01:00:03):
divert the whole two to 400-mile trek to
a local hospital, basically having the paramedics work with
the physician through telemedicine
or something like that, and then having the standardized standing
orders for the community paramedics to be working directly
with those folks and then connecting them to a primary care provider, either

(01:00:27):
locally or through telehealth or something like that. So community
peer medicine, definitely a
really interesting workforce that we could cultivate.
Street medicine, innovative. Working with, it's a
lot of community health workers. It's community
health workers that are trained in behavioral health. Absolutely essential that

(01:00:49):
we expand that workforce. Behavioral health, there's not enough of them. And
it's not just not enough of them, most of them don't look like the communities
in which I am currently serving. And that is that is a
that is a natural disservice for these folks. You
know, finally, innovation in the clinical service delivery models, we
can't continue to think that. the same models are going to work.

(01:01:10):
The brick and mortar just doesn't work for a lot of people. A lot of people want
to come into clinics. A lot of people don't want to make an appointment. A lot of people don't want
to come into hospitals. They want to just have
it as easy and low barrier as possible. So we have to think about as
much innovation as we possibly can. Telehealth is one
example, community paramedicine, street medicine. There's a lot of different modalities

(01:01:31):
Yeah. Amazing. All right. So as
we start to wrap things up, where can people find more
Sure. Thanks for asking. So the book could
be found at, so it's published by Johns Hopkins University Press.
So it could be, you could just Google Johns Hopkins or pandemics,

(01:01:52):
poverty, politics, and you can order it there. Number two, Amazon
is always your kind of default. So get it on Amazon. And
then it's on Barnes and Noble as well. In
future state, if we get enough requests, maybe you'll even get out to
your local airport bookstore, local
brick and mortar bookstores. Those sort of exist. I know they do,

(01:02:14):
but your kind of smaller sort of mom and pop bookstores and whatnot. And
then in terms of just kind of reaching out, wellnessequityalliance.com, wellnessequityalliance.com,
feel free to kind of noodle around there. If you are
in New Mexico or California and you need help, reach out. If you feel

(01:02:35):
like there's any interest in kind of partnering on certain things, research, et
cetera, feel free to reach out. If not me, somebody else
will respond. And then finally, I have my own, website, tylerbeevansmd.com.
Perfect. And for all of you listening, if you have not already been taking
notes, whatever platform you're listening on right now, you can

(01:02:56):
just scroll down to the show notes and we'll have direct links to all of
those, uh, sites that Dr. Evans just spoke
about. So before I let you go one more question, it's
when I ask everyone knowing where you are now in your life and career, what
Sure. So I mean, I would get back to that conversation that we were having before, you know,

(01:03:18):
like for the, for the students, for the residents, if,
if you are, if you have a, if
you have sort of creative potential and you're going into, you're going into area that
sort of stifles you, stifles your innovation and, but
something continues to move you through it, don't stop, you

(01:03:41):
know, continue, continue the course, talk
to your mentors, talk to your peers. You
might need to take a knee. You might need to just take a
few years and do something really unconventional and
really cool and have more lived experience, and then come back to
it. But that's what I would have said,

(01:04:02):
and it would have probably saved me some money and some time.
But for me, the journey was this tangential
or circumferential journey. actually ended up
to provide me with, um, with, with a lot of good insights. So yeah, I'm
not, I'm not displeased that I, that I took a longer path, but, um,
but yeah, I would, I would have told myself to, you know, definitely stay the course don't

(01:04:27):
Yeah. Great advice. Well, Dr. Evans, thank you so much for
taking the time out coming on the podcast. Great information.
What I'm so happy to have had you on. So thanks so
And everyone, thanks so much for tuning in. Have a great couple of days

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Dr. Tyler B. Evans: Pandemics, Poverty, and Politics

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