The Cost of Cutting Public Health (Pt. 1)

Mati Hlatshwayo Davis: [00:00:14] Hello and welcome to Let's Talk ID. I'm Dr. Mati Hlatshwayo Davis, member of the IDSA board of directors. Joining me today to discuss the impacts of layoffs across the federal workforce are Dr. Judith Guzman Cottrell and Dr. John T Brooks. Dr. Guzman Cottrell is a professor of pediatrics in the division of infectious Diseases at Oregon Health and Science University in Portland, Oregon. She served as the pediatric director of the hospital's infection prevention program from 2004 to 2015. In 2015, she established an independent consultancy called Infection Prevention Consulting of Oregon, or IPCO. That same year, she became a contractor with the Oregon State Health Department, serving as the state's medical director for Ebola preparedness. Her work with state public health partners has been ongoing for the past decade, including measles, Covid 19. She is a member, was a member, I beg your pardon, of the CDC Health Infection Control Practices Advisory Committee, or HICPAC, from 2019 to 2023 and a member of the Isolation Precautions Workgroup until it was terminated on March 31st. In addition, she served as the medical lead for Oregon Project First Line until her contract was abruptly terminated in March of this year. Dr. Brooks is also joining us, is an internist and clinical infectious diseases expert who worked for 26 years as medical officer and epidemiologist at the US Centers for Disease Control. Prior to his retirement in 2024, he served for ten years as the chief medical officer to the CDC's Division of HIV prevention. Dr. Brooks also led CDC teams during emergency responses to anthrax, SARS, influenza, HIV, Ebola, Zika and mpox and served for two years as the chief medical officer for CDC's Covid-19 response. Welcome, Judy and John.

Judith Guzman Cottrell: [00:02:18] Thanks for having us. I'm really excited to be here.

John Brooks: [00:02:20] Terrific to be here. Thanks.

Mati Hlatshwayo Davis: [00:02:22] So I am an outgoing and now officially former director of health for a major city. I have been telling people for the last couple of weeks that it has actually been horrific to watch public health and academic medicine be dismantled in real time. I haven't seen anything like this in my career. I don't know if that resonates for you. Um, so I want to start us off with a first question to kind of, you know, really talk about what this has meant. How are you seeing the federal cuts affect infectious diseases programs in real time, particularly in communities that were hardest hit by Covid-19? I'll come to you first, John.

John Brooks: [00:03:04] Well, that's a really important question, because I think all of us who work in infectious diseases realm, whether it's as a clinician, a researcher or someone in public health, is experiencing these cuts in real time. I think it's been very, very disruptive. You know, when I think about how it's affected us in our community, I kind of break it into two categories that you alluded to. The first is for public health infectious disease programs at the state and local level. And here I've seen these cuts affecting them in two predominant ways. First, in the enormous amount of HHS termination of public health grants and in particular, a series of public health grants totaling $11.4 billion that were awarded during the height of the Covid 19 pandemic. They're under court order right now. That is the administration's under court order, and there's an injunction on clawing back those funds. But they were being used by many programs to supplement surveillance, pandemic preparedness, outbreak response, vaccination programs, health worker education, as well as public health infrastructure improvements. That's been taken away or stopped. And then secondly, there's enormous uncertainty about the future of funding in the present environment. In fact, HHS has proposed substantial reduction in federal funding in the infectious diseases space.

John Brooks: [00:04:24] And that's reportedly led to both some preemptive cuts in staff and programs. The other area you brought up was sort of the more academic realm for fellowship programs and programs, conducting federally funded research. And here it's a sad but very simple impact. With the loss of funding, research stops unless alternative funding can be obtained. But really, unless that can take place, that money that has been spent is wasted. If there is no finding that can be derived from the data that have been collected so far. Now, it's hard to know right now. I think a lot of specifics about how many programs have been affected, and folks are gathering that information, I'm sure. But what I can tell you is when I've spoken to friends and colleagues in the field, it's very clear the pain and disruption have touched a lot of programs and that it's widespread, that it's affecting basic research, clinical research and public health research. And it's mostly affecting projects that were flagged as being somehow engaged in the DEI space, or programs with DEI focus in terms of infectious disease physician recruitment.

Mati Hlatshwayo Davis: [00:05:29] John, it's a lot. And to hear you sort of lay it out in that list. Judy, your thoughts here?

Judith Guzman Cottrell: [00:05:34] I want to go back to that $11 billion funding cut that John mentioned. To the media, HHS said these were Covid pandemic response funds. And I just repeatedly kept seeing and hearing in the news feeds, the pandemic is over and HHS will no longer waste billions of dollars responding to a non-existing pandemic. One critical point that I feel that was really not made clear to the public is that the funds received, sure, the funds received by all those 50 states were initially for Covid response, but once the Covid emergency ended, each state was able to decide very strategically how exactly to spend these leftover funds. And these were all based on state level, individualized needs assessments that was approved. Every state program had to come up with, you know, basically a budget and rationale for how they were going to spend that leftover money with individualized needs assessments. So I'm in Oregon and, you know, as you mentioned, I've been working with my state health department for a decade now. So at the state level for us, we suddenly lost about $117 million in those Covid era grants and funding. Yes, the impact is already being felt. Living in Oregon, we have nine federally recognized tribal communities. Throughout the pandemic, of course, like a lot of disadvantaged communities or marginalized communities, a lot of time was being spent on just making connections with them, establishing partnerships. We also have a large Hispanic or Latino population in Oregon, many working in the farming industry, and these communities are also already affected.

Judith Guzman Cottrell: [00:07:19] So, for example, with some of these funds, Oregon lost a grant that established a new equity office within our public health division. This equity office provided technical assistance and training to many rural health care providers to tribes, and it trickled down to local public health departments, community based organizations, on how to improve health in communities experiencing these inequities. So it's very intentional. Very local planning and decision making of how the funds were going to be spent. And then, you know, as a pediatrician, I can't not think about vaccines, right? This is like the bread and butter of what we do. Prevention. And we lost multiple immunization related funding for clinics in again, local and tribal communities were not only Covid 19 vaccines but all vaccines were being offered. And these funds were also paying for really just establishing that trust, establishing equity in access to vaccines, keeping healthcare providers trained on best practices, educating our community partners on the importance of immunization. Funds were being used to actually create a help desk to support healthcare providers that they could call anytime if they had a question about vaccine administration, storage, documentation. All of these things were taken away. And finally, the funds were also used to create informational material in multiple languages to meet specific community needs related to vaccine education. So it's been devastating, and for sure it's a already in real time being felt in every state.

Mati Hlatshwayo Davis: [00:08:59] I remember the day that I got my first four contracts cut, and what I kept thinking over and over again is if this isn't the name of efficiency, right? If this is in the name of cost cutting, it is the opposite. There was no due diligence. It felt like they saw these names. They saw Covid 19 and just cut. Where, for me, one of my contracts for Covid 19, for exactly the reasons that Judy outlined, was a food program for seniors in partnership with the YMCA. And the language was specific. Shut it down today. Invoices within two business days. Those are the types of programs that were at stake. And so the lack of due diligence, it felt rushed. Ask a local health director. I am in the business of efficiency. I inherited less than 1% of the city's budget. I'm sitting on 2%. My whole job is efficiency. So thank you so much for really making that clear, because I agree with you, Judy, that I don't think the public gets it. And I do think for how horribly politicized this is, we actually agree on a lot of things. We do want to make America healthy again. We do believe in efficiency. We don't like wasting money. This is not that, though.

John Brooks: [00:10:13] I'd just like to highlight also, Judy, from what you said. And Mati, you know that this Covid 19 money also was preparing us for what was coming next. All of the things that Judy just described are part of being prepared for the next infectious disease threat, which we know is coming. I don't know where it is. History shows it's going to be on its way. So in the vein of the purpose of these Covid 19 funds, which was to improve preparedness, that it too was one of the major goals. And that's been taken away from us. This cut has really undermined a lot of the trust, perhaps, that you were able to begin gaining with the communities being served by these funds. You know, when it's cut off, they feel abandoned. That becomes a very hard trust to regain, particularly after what we went through in Covid 19. I don't think the cuts are over, by the way. I mean, we can talk about this in a minute, but there are a lot of big cuts coming. If you've been looking at the proposed budgets. It's pretty clear that there are some very major cuts coming in the infectious disease space as well.

Mati Hlatshwayo Davis: [00:11:10] Well, John, I love that. Let's segue to that question. And I'm going to go there next actually. So in your view, what does real public health preparedness look like and how do these cuts now and future, and I've had a chance to review the budget that you're speaking about, John, what position does that put us for for future pandemics? And for everyday health threats like measles? I just announced the first case of measles in Saint Louis two weeks ago. What are your thoughts here? I'll go to you first and then Judy.

John Brooks: [00:11:37] Yeah. I mean, infectious diseases cuts across all aspects of society. As you just pointed out, we often think of it as these infections like measles or TB, preparedness, but clean food, clean water, a safe hospital space, all of these things, by the way, we often take for granted because we don't see them. Somewhat to our detriment because we can't crow about, oh, have you seen what we prevented? You know, that's what we want it to do, by the way. It works best if it's invisible and you don't have to do anything. But man, you know, we are going to be in a really bad place, I think, for being prepared for a public health emergency if we continue with cuts that are being proposed. I mean, the ideal situation would be that we provide resources to reduce the chronic underfunding and staff shortages that I'm sure both of you and Judy have experienced in public health departments. These public health departments, even before, even after Covid 19, but certainly before, were operating on a shoestring and it was very hard to recruit staff. You need specialized training, so not easy.

John Brooks: [00:12:33] We also would need to modernize all of our data systems. We saw how valuable that was during Covid 19. What we need to continue modernizing data systems for like disease reporting, surveillance, as well as for data analysis and sharing or dissemination of those findings. And that's all could be at risk if we don't continue what we need to do. We also need to ideally continue to stimulate innovation in disease detection, communication and response. There are brilliant people with great ideas about things to do. Think about the whole novel idea of wastewater monitoring a few years ago. These kinds of innovative developments take us to the next stage of being prepared to identify, detect and respond to a outbreak that may be occurring or the next pandemic. And then lastly, and I'm not sure how we go about doing this, but we can talk about this maybe later, is restoring trust and faith in public health that we are legitimate, credible communicators and that what we have to say is in the best interest of all of us. You know, that is being so challenged right now that it's going to be a bit of a hard row to hoe I suspect.

Mati Hlatshwayo Davis: [00:13:37] This can and will cripple public health response in real time. I don't think people realize we lost 125,000 public health workers at the end of 2021, at that time projected to be a quarter of a million by the end of this year. And now we're laying off even more. And what it is, is if you then break that down by the years of expertise, by the years of experience, they're within, you build in wasted money and resources because you have folks who may not have that experience, who are just flailing and doing more to try to get to the heart of an issue, especially when we think about disease surveillance and disease investigation. Judy, your thoughts here?

Judith Guzman Cottrell: [00:14:17] When I think about the states, even the counties that I have thought have really the best public health preparedness, these are programs that always seem to always have their finger on the pulse of what infectious diseases are circulating in their communities. They have the capability to really quickly detect novel infections or an outbreak. And they have the ability to maintain an infrastructure so that they can respond quickly. And of course, we can't just focus on emergency response. We have to focus on prevention. That's part of surveillance. And, you know, in Oregon, similar you know, as John mentioned, a lot of the funding was being used to add laboratory capacity and modernization of surveillance data systems. You know, we're trying to get away from paper reporting fax machines. And, you know, one of the really devastating parts of these abrupt terminations of these grants is that many states were in the midst of modernizing their programs, but they're not there yet, and they needed them funds that were just taken away to complete that modernization. So now it's even more money lost, more money wasted if they're not able to regain that funding because these modernization of surveillance systems take years and years of funding, not just, you know, one drop in a hat. Another grant that we had in Oregon was being used to, you know, increase surveillance testing in response to respiratory viruses. And all of a sudden that's gone away. Um, sadly, I think, you know, we can look at the current Texas measles outbreak as an example of what does happen. Here's an example of what happens when public health preparedness is stripped down to nothing. And to make it even more complex, you know, now we have government leaders who are really, really good at making parents question the safety of childhood vaccines that have been around for decades.

Judith Guzman Cottrell: [00:16:12] Um, as of this week, Texas has reported 722 confirmed cases so far. And you know, that number is staggering. I mean, you know, when you look back at other past years where we had, you know, lots of measles outbreaks, you know, like 2019, I think there were a lot, including in the Portland, Oregon area, about a thousand cases in the entire year. This is 722 cases in one state, and we're only five months into 2025. And you know, as you know, 722 is probably just the tip of the iceberg. There are many more people who had measles that never sought care, didn't get tested, so they're not included in that number. We all know what really good, robust public health preparedness looks like. We're also witnessing in real time what it looks like when it's dismantled. And, you know, as was mentioned by you, Mati, it's just really breaking my heart that we're losing so many of our best public health leaders. Every day, I think, man, it just can't get worse. And the next day it keeps getting worse. Getting so tired of getting emails from my most beloved and trusted public health friends and colleagues that are retiring early or just outright leaving their jobs. Many of these people were terminated. They didn't even have a choice. And it still doesn't make sense to me because just like you said, these are collectively so many years of expertise and we know that the next big outbreak is going to happen. It happens every five years. You know, 2010 was H1n1, 2015 was Ebola, 2020 was Covid 19. For now, it feels like it's measles, even though I, you know, but I feel like it's going to be something else!

John Brooks: [00:17:52] We had a little bump of mpox, but that thankfully passed.

Judith Guzman Cottrell: [00:17:54] Because of good public health infrastructure.

John Brooks: [00:17:57] There were certainly shortcomings. It can never be fast enough, I get it, but compared to many other responses, really able to rapidly connect with the affected communities with whom we had trust to listen to them, to learn the right messages, learn from what they were doing that we could share with others. Because a lot of folks know the right thing to do in their own community. We just have to listen and we can augment that with our interventions and then to make it work, you know, and it's a nice example of something that's worked well. Two things I want to just add here. First is everything you've just illustrated, Judy, is also happening in the academic and federal side as well, that people are, there's this extraordinary loss of institutional memory. I think it must have been, Pasteur said, chance favors the prepared mind. In terms of infectious diseases medicine in general, but particularly infectious diseases and public health, that prepared mind knowing to recognize that something's a little off or that I need to, hm that doesn't sound right? We're losing that skill with the people who are leaving, and it's not something replaceable. You can't put in, you know, a new piece of code into the software to fix what you've taken out. The other thing that's happening is that the folks are making these cuts ostensibly for the purpose of saving money, and I think all of us can acknowledge these short term savings will be soon outweighed by considerably greater costs, both in suffering, time and money by illness that could have been averted. Maybe one thing we need to do is to better illustrate for people, although we do it all the time, find better ways to illustrate, particularly for policymakers. How do you show people that averted cost and what the consequences will be down the road in this short term savings?

Mati Hlatshwayo Davis: [00:19:37] But both of you kept hitting the head on something, and I think we've been getting a bad rap for, you know, not being accessible somehow. You know, that trust was damaged during the Covid 19 pandemic. And I hear that, you know, I got to hear from some really amazing communications specialists about the moveable middle folks who really wanted to be engaged with, who don't want to feel like they're being judged for asking what they believe are valid questions. And so I know that we can do that because like you said, John, and you said, Judy, we've done that before. I hope that we can reach the public in saying that this is not an us versus you. We want to sit down. We want to hear your concerns. We want to hear where maybe you think we haven't been doing a great job of engaging with you. What we can't do is lose lives, especially the lives of children. Because of this valid and sometimes invalid mistrust and distrust. Right? But we do want to hear from folks. So let me pivot now to our academic medicine and research field. What does it mean when clinical trials are interrupted and grand structures are dismantled midstream? I know that we know this in our environment, but I think it's important to really make this accessible and clear. What does that mean?

John Brooks: [00:20:53] I think this is a really important point to make, and not just for our colleagues and the folks listening in to this who may be infectious disease professionals, but for the general US public as well. When you interrupt a clinical trial by withdrawing its money or canceling the grant, that research stops cold stop. That's what they're having to do right now. When that research stops, the staff are laid off. They go on unemployment or if they can't find another job. But often the folks are highly specialized in what they're doing, and the jobs may not be readily available. Study participants are informed that their participation is no longer needed, and we have such a hard time recruiting study participants in the first place. It doesn't do us a lot of good to start turning around and saying, oh heck, we don't need you anymore. You know, that's kind of a little bit antithetical to what we are trying to do. The collection of data and of specimens ceases if there isn't sufficient money put into analysis, or if analysis hasn't been done to date, then that's all wasted material. Because if you can't do the data analysis, you can't get the finding that you need to share to make the whole research enterprise worthwhile. If the work can't be completed in a new source of funding can't be obtained, that knowledge is lost in all the money and time that's been invested is essentially wasted. When you do this to a young researcher, this can really impede their academic advancement. Many people depend on doing these kinds of trials, doing this kind of research to demonstrate the capacity to become a leader in advancing infectious diseases in public health. And when you cut them off like that, it doesn't send a very good message to the community folks we are trying to bring up to into the next generation.

Judith Guzman Cottrell: [00:22:26] Yeah, I think one thing that the public needs to realize is, um, a lot of times clinical trials are literally the only way that a patient has access to a specific medication, a specific testing analysis that can help to direct their treatment. Clinical trials are incredible, especially, you know, incredible ways for people with rare diseases or high risk diseases like cancer, autoimmune diseases, etc. to have access to medications that they otherwise will not have any access to. So if the funds are halted and the study is halted, then the patient's health suffers because there's no other way they can get that treatment.

John Brooks: [00:23:14] That's true in a somewhat different way. Even in phase one and phase two clinical trials. You know, often when you get to phase three, we have something that we think is going to work, and we're going to compare it ideally to an existing therapy that's the equivalent. But sometimes there's nothing and it's a placebo but whatever. But you know, there's phase one and phase two trials also were critical because they give us the early insight as to whether this is something that might work. And when you halt that, then you're halting the opportunity for discovery of cures and interventions that may, down the road many years from now, be what saves the life of our children or our grandchildren. And so it all stages of the development of some intervention in the course of a clinical trial, we all suffer.

Mati Hlatshwayo Davis: [00:23:54] Join us for part two, where we'll discuss the impacts federal cuts will have on the progress we've made, as well as what we should be demanding from our federal leadership, academic institutions and local governments.