SCCM Pod-519: Crisis and Chaos: Pandemic Perspectives

Improving health literacy is vital for addressing disparities in healthcare access and quality. Join Host Kyle B. Enfield, MD, FSHEA, FCCM, and Jerome Adams, MD, MPH, FASA, as they discuss the urgent need for health equity initiatives and innovative solutions to systemic healthcare challenges. Learn why providing accessible information and empowering individuals to advocate for their health is key.

Dr. Adams was the 20th U.S. Surgeon General when the COVID-19 pandemic began and had a front-row seat to the government’s response to COVID-19. Dr. Adams provided his perspective on that response in his book Crisis and Chaos: Lessons from the Front Lines of the War Against COVID-19, which was published in October 2023. The book examines the past three years since the pandemic began, but Dr. Adams said that it also applies to America’s future unless changes are made. He presented his perspectives during the 2024 Critical Care Congress in a thought leader session and shares additional insights during this podcast episode.

While Dr. Adams was U.S. Surgeon General, from 2017 to 2021, he led the 6000-person U.S. Public Health Service through responses to three category 5 hurricanes and an opioid epidemic in addition to the COVID-19 pandemic. Previously he was Indiana’s state health commissioner, where he addressed Ebola, Zika, and HIV crises. Today he is the executive director of health equity initiatives at Purdue University in West Lafayette, Indiana, USA, where he is also a distinguished professor of practice in the public health and pharmacy practice departments.

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Transcript:

Dr. Enfield: Hello and welcome to the 2024 Congress edition of the Society of Critical Care Medicine Podcast. I’m your host, Dr. Kyle Enfield. I’m sitting down today with Dr. Jerome Adams, MD, MPH, FASA, who is currently a presidential fellow and director of Purdue’s health equity initiatives. Dr. Adams served as the 20th U.S. surgeon general, which he has recently written a book about titled Crisis and Chaos: Lessons From the Front Lines of the War Against COVID-19. He also was the opening thought leader presentation at this year’s Critical Care Congress and gave an amazing talk that I hope we get to dive into today. Prior to being the surgeon general, he was the health commissioner for Indiana and led the state’s response to Ebola, Zika, and the largest HIV outbreak in the United States related to injection drug use.

However, as I’ve read recently on several posts about him, he describes his toughest and most important job as being a father to two teenage boys, Caden and Eli, a daughter Millie, and a dog Bella. Dr. Adams, as I said, opened this year’s Congress with an amazing talk that ranged on discussions of health equity, the importance of mentorship, and the mental healthcare crisis in healthcare today. Welcome, Dr. Adams. Before we start, do you have any disclosures to report?

Dr. Adams: I’m really glad to be here. As far as disclosures, in the time since you got that, we got another puppy, Ruby, so it’s not just Bella. That’s an important disclosure. Financial disclosures: I sit on the board of ATF Pharmaceuticals Company, which produces oral antivirals for COVID, hepatitis C, and also dengue. But beyond that, just really pleased to be here with you today.

Dr. Enfield: There are a lot of things I want to talk about, but as I told you before we started here, I reached out to a couple of friends about what they would want to learn from you and the question that came up from more than one person was, with all that you do, with all the travel that you’re involved in, how do you keep up with family life?

Dr. Adams: Well, that is a great question, and it’s a very relevant one. People talk about work-life balance. I don’t like that term because balance, if you think of a seesaw, one goes up and the other goes down. What I have tried to strive for is work-life integration. What do I mean by that? I’m here in Phoenix, Arizona, with you. My son, who is a college freshman and who I don’t get to see often, loves golf, and Phoenix is one of the golf capitals of the world. So he flew from Miami to meet me here in Arizona, and I’m spending the weekend with him.

Right now, as we’re doing this podcast, he’s out on a golf course, but I’ll get a chance to have a meal with him, spend a few nights with him, before he goes back to college. I also took that same son with me to Ireland for a work trip this summer, and he loves Roy McIlroy, so he got to play a couple of Roy McIlroy’s favorite courses. My younger son I took with me to an event that I had in Malaga, Spain, with the NBA Players Association. He loved it and, again, I got a chance to go to Spain with my son. So, as much as I can, I try to incorporate my kids.

I told a cool story earlier about my daughter at the White House and showing Bill Clinton a picture of my daughter asleep at the White House underneath his official portrait. Not everyone can do this, and, you know, we’re talking to critical care folks, you can’t always bring your kids into the ICU. But I really do try to make my family a part of my work life, whether it’s telling stories about them so that I’m thinking about them, or whether I’m bringing them along to situations where I can involve them.

Dr. Enfield: That’s amazing and definitely lessons for all of us. I think it also really speaks to some lessons in leadership because, when you bring that family as part of your leadership, it centers you and what you’re talking about. You’re not just speaking as the surgeon general but also as a father and a husband. I think that’s a great place to start from.

Dr. Adams: Well, that was key during the pandemic. It was really easy for folks to attack government and public health officials during the pandemic when they felt like this was some nameless authoritarian figure who’s telling me what I can and can’t do. What I tried to do was tell people, look, I’m a dad of three teenagers. My wife is mad at me for shutting down school too. And we’re trying to figure out how do we do virtual schooling when everyone’s fighting over the Wi-Fi and fighting over the laptops.

I have a wife who actually has stage 4 cancer. She’s got metastatic melanoma. Her care was delayed during the pandemic when we stopped elective cases. When people understand that I’m going through this just like you are, I’m trying to make it through the world as, again, a husband of someone who has a chronic condition, as a father whose kids are struggling with mental health issues due to sports and school being shut down, then they give you a lot more grace.

I think the lesson there for folks, and I talk about it in my book, is that we have to be our authentic selves. We have to help people know that we care and, in many cases, you and I are of the age where you were taught, keep work and life separate. You don’t bring that here. I think it’s incredibly important to do that because it matters and it also creates a connection. One of my favorite things is, people need to know that you care before they care what you know. You show them that you care when you can show them that you’re like them, no matter how different they may think you are. I’m a dad. I’m a parent just like you. I’m a husband, you know, or a spouse just like you.

Dr. Enfield: No truer words have been said, I think, on this podcast than the last ones right there. This morning, when you opened up Congress, I was really taken by a story you told about a young man who you cared for in the operating room after some gang violence who then came back to you again and again. In that story, there are two things that I really drew out from. I wanted to speak a little bit about both of them. The first one is you also connected to one of my favorite quotes. I get to spend some time in quality improvement these days and one of my favorite quotes is, a bad system will win against a good person every single day of the week and twice on Sundays. Talk about that bad system and that patient you took care of and what we need to think about differently in our healthcare system.

Dr. Adams: Well, I know a lot of our listeners weren’t there, so I’ll give a quick synopsis of the story. It was a young man who’d been shot and we had to take him to the operating room and it was challenging. It was challenging because he was a gang member and he had the attitude of a gang member. He was yelling, he was cursing, he was screaming. Oh my goodness, you’re trying to strip someone down in the trauma bay and inspect them, they don’t want you to do that. They put in his Foley in the trauma bay and, you think about a young teenage gang member and you’re trying to put in a Foley in them.

But when we were putting him to sleep, he completely changed in demeanor. He looked into my eyes, he starts crying and he says, please, please, please don’t let me die. I think one of the lessons there is that we’re all humans. You know, at our core, we all have the same hopes, dreams, and fears. We may come from different places in different contexts, but in that moment, he was just like one of my kids, one of my teenage boys who was scared going under anesthesia, at a time when he had a severe medical issue, in a very real sense may not have woken up again, and promised him I would take care of him.

I did. We got him through his surgery and his procedures and sent him home in about two weeks. But as I told folks, he came back two more times, once with a knife wound and another time with a gun wound. The first time he came back, I was, you know, a little quizzical. But the second time he came back, I began to get frustrated, and that frustration we can easily take out on our patients. You know, what are you doing wrong? Why do you keep coming back? Because, let’s face it, our jobs are hard. We’re up all night. We’re missing time with our family. We’re eating cafeteria food that’s bad for us. We’re missing out on exercise and things that promote our mental health, and we do it because we think we’re making a difference.

But if we don’t feel like we’re making a difference, then we start to question why we’re making those sacrifices. And that’s what I think leads to a lot of burnout. It’s not hard work. None of us are afraid of hard work. It’s hard work that we don’t feel like is actually giving a return on investment. So here’s the actual punchline. The punchline is that we did everything right from a quality measure point of view to take care of him, but we didn’t ask him, do you have a home to go home to? Can you get a job to support yourself through any other means beyond going back to participating in gang activities? Do you have conflict resolution skills or are you the child of a single-parent household with no father figure like far too many, especially young Black and Brown males in this country?

I challenged the audience and I challenge the listeners here to ask those questions about social drivers and to ask what you can do. Many intensive care programs, including the one where I work in now, have conflict resolution and violence prevention programs that they use to target specifically toward young people who’ve come in and been victims of gang violence or perpetuators of gang violence because we know that’s a critical intervention point where you can make a difference, but you can’t make that difference if you don’t understand the broader context of why they’re there and if you don’t care enough to go beyond.

Finally, got to say this, a bad system beats a good person every time. We pay you to do certain things that aren’t necessarily going to ultimately change someone’s overall outcome, but we don’t pay you to do the things that will. So we have to look at payment reform. Do we pay you for counseling people in conflict resolution? Do we provide the resources for you to have a program that will help someone get a job? One of the biggest ways you can prevent someone from getting into difficulty in the first place is by making sure they have a good job with good health insurance. If you do that, then they don’t have to look elsewhere. But that takes resources.

Dr. Enfield: Yeah. And building on that, the question I was going to follow up with that is really to talk a little bit about the mental health issues you see in healthcare workers today. You spoke early on during this podcast about, both of us are from a generation that you don’t bring home what’s at work and you don’t bring what’s at home to work. We were taught, from medical school on, bury those emotions because that’s not what’s going to get you through the day. But we really see, since 2020, mental health issues really coming to the forefront. And the tragedy of Lorna Breen, who took her life, from New York and many, many others that probably are unnamed to you and I, what do we need to do as a healthcare system to begin to really tackle that issue?

Dr. Adams: Two things come to mind when you mention mental health. One big picture and one more focused on mental health. When it comes to mental health, comes stigma. I often famously say stigma kills more people than fentanyl does. Why? Because stigma keeps people from admitting they have a problem either with substance misuse specifically or mental health issues more broadly. It keeps us from asking for help. It keeps us from being willing to offer help.

It wasn’t that long ago that I was out there trying to convince first responders of the need to be willing to carry naloxone because there was a stigma out there that, hey, you’re getting what you deserve. That’s just shocking to me that first responders, that firefighters and paramedics and police officers, weren’t willing to carry naloxone, which is why I put out my advisory search in general, calling on more Americans to carry naloxone.

I work a lot in that stigma space right now, working with the NBA and with the Pro Football Hall of Fame, trying to leverage athletes and their bully pulpits to normalize mental health and wellness. I think that’s incredibly important, addressing stigma.

I also think, and I’m going to be provocative here, but healthcare workers are some of the biggest hypocrites in the world. What do I mean by that? We tell other people to eat healthy and exercise, and you go in a hospital and you can’t find the stairs, you’ve got to take the elevator from point A to point B, and the cafeteria is filled with French fries and hamburgers and that’s all everyone’s eating. If you want to get the salad, it’s an old salad that looks terrible that costs you $15 to purchase. But yet we’re out there telling our patients, exercise and eat healthy.

The same thing goes for mental health. Fortunately, we’re developing a greater appreciation for the need to integrate mental health into overall healthcare. We tell our patients to pay attention to their mental health and wellness, but we often don’t pay attention to our own mental health and wellness. We need to normalize that within the healthcare training environment so that it becomes part of the routine. One of the most malignant places that you and I have experienced is the healthcare training environment. We tell people, suck it up. We tell people, you have to go through this. It’s a boot camp, but it’s a very malignant boot camp.

Now I don’t want to be too negative. One of the things that gives me hope is today’s young people. They are much more likely to acknowledge the importance of mental health, to say, I need a mental health break. They’re much more likely to say, hey, I’ve got to go to my therapist today. That’s something that people your age and my age would never in a million years acknowledge to someone openly. So I do think there’s hope and progress, but still a long ways to go before we get to the place where mental health is looked at in the same way as your physical health.

I often say, a long time ago we cut the head off from the rest of the body. We said, if it happens from your neck down, your doctor will see you now and your insurance will pay for it. But if it happens from literally the neck up, whether it’s oral health or vision health or auditory health or mental health, we say, oh, well, I don’t know if your insurance is going to cover that, and by the way, it may take you six months to get in to see a provider. We’ve got to change that narrative.

Dr. Enfield: Yeah, I hope everyone can hear all of that and take it home. I don’t think what you said was provocative at all. I think anybody who has gone into a hospital recently or for the last few years will recognize that we do say a lot of things as providers that we don’t take to heart. And we did a lot of things to ourselves. I know, in my own institution, from 2020 to 2022, a lot of us worked hours that were kind of crazy and didn’t take care of ourselves and sort of stuffed all the emotions in some sort of deep black hole that, being born and raised in Oklahoma, I call the fracking hole.

We’re just waiting for those things to erupt these days. I do think that’s an important thing worth talking about, and I think I share your same hope in some ways, that it’s going to be the people we’re training today who will actually say, what the hell is wrong with you people? You know, like, I’m going to go see my therapist now, and hopefully they will do something about it and also maybe change the cafeteria food while they’re at it.

Dr. Adams: Exactly. I mean, we’re doing that in our cafeteria. We actually made a concerted effort to make the healthy food more visible and less expensive. You can still get the French fries, you can still get the hamburger, because you don’t want to deny people choice. There’s a great book called Nudge, and it talks about how you nudge people in the right direction while still giving them the freedom to choose. If you haven’t read it as a listener, check it out. It really is a wonderful book. There are lots of things we can do to nudge people in the right direction.

I think that, overall, there’s a lot more that we could be doing to create that healthier environment and create a better system. One of the things I talked about during the SCCM conversation was some of the efforts that we took while I was surgeon general during the pandemic to actually address issues.

The point I’m getting to is, you brought up how people were overworked. I brought up the irony of the fact that in some places we had people who were overworked, but in other places, folks were having mental health issues because their work was shut down. You had surgery centers that were dormant for a year-plus. You had hospital clinics and dental offices that were completely shut down. One of the big problems from the pandemic was actually that mismatch, the fact that we weren’t taking people who had a lower workload and shifting them to places where they could help address shortages.

Dr. Enfield: One of the things you caught in your book that I think is a great question to talk about is you talk about, let’s take partisanship out of public health. I wondered if you could speak a little bit about how you can make public health less political when it is so heavily influenced by politics.

Dr. Adams: Well, that’s a great question. The first thing I would say is that, in some ways, it’s impossible to take the politics out of public health, particularly in the United States. Very quick story, but it drives this point home. I was in Switzerland and I had to give a talk to an international audience about the U.S. health system, and they gave me five minutes to do it. I said, well, what can I highlight that really drives home the point about the U.S. health system compared to other European health systems and international health systems?

I said, look, when you look at Berlin, Germany, and Paris, France, these are two cities in two completely different countries. They speak two different languages. During our nation’s last great world war, these two cities, Berlin and Paris, literally tried to obliterate each other off the face of the map. That’s how different they are. When you look at top health issues like women’s health, like the opioid epidemic, like universal access to healthcare coverage, like guns, the top health issues, those two places are more aligned than Boston, Massachusetts, and Dallas, Texas.

It’s incredibly important for us to understand how big and distinct the United States is. That creates a lot of challenges for us. But it also creates opportunities, opportunities for natural experiments to occur on a state-by-state basis. What’s an example of that? The prevailing wisdom was that reopening schools was going to be an unmitigated disaster for COVID. That was the prevailing wisdom. However, in the United States, we give the right to states to make healthcare decisions, and some states chose to open, and we saw that, hey, it wasn’t quite as bad as we thought it was going to be in terms of disease spread if we reopened schools the right way.

But we also saw that we had increased mental health issues in places where they waited too long to open. So I think we have to recognize the challenges in the United States but also some of the unique opportunities we have to improve care and improve our knowledge base moving forward.

Dr. Enfield: As the surgeon general, you faced a lot of criticism from everyone. I don’t think probably anyone liked you and that was probably not a great place to be. But when you think back about that time, what would you hold up as something you feel was a real success? What is something that you feel like you wish you had done differently or better?

Dr. Adams: Two great questions. So, a success. I am incredibly proud of Operation Warp Speed. Operation Warp Speed is statistically, categorically, the greatest public health achievement of the last 50 to 75 years in the United States. It’s fascinating to me how people will dismiss it and dismiss the administration’s contributions to it occurring.

Again, I’m a factual person. I’m actually an independent, I’m not a Republican or a Democrat, but we went from zero to shots in arms faster under the prior administration than what the current administration was able to approve those same vaccines for children. It shows you that the pace really did slow down significantly once you had a change of administration.

Every single booster or updated vaccine rollout has been just a disaster. It really has been in terms of communication and uptake. I don’t say this to criticize, I say this because I am proud of how quickly we were able to develop the vaccine and they weren’t politicized initially. I mean, in December of 2020, January, February of 2021, there was no antivax. People were fighting over getting vaccines. They were lying to get vaccines. They were doing whatever they could to get access to the vaccines.

I’m also proud of my contribution to Operation Warp Speed. I didn’t help develop the vaccine. I wasn’t in the lab. But where I leaned in was in terms of ensuring diversity in the clinical trials. So in May, June of 2020, both Bill Gates and Tony Fauci said it would be a miracle if we had a vaccine in 18 months, meaning 2022 before we would get a vaccine. That’s in May, June. They both are on record as saying that. Well, August, we had three different companies come to us and say, we may have a vaccine by the end of this year, Moderna, Pfizer, and J&J.

First thing I said was, well, what do the trials look like in terms of demographics? It was single digits in terms of diversity in those clinical trials. I knew that, not only were the people hardest hit by the pandemic most likely to be Black and Brown communities, but that the people who also have some of the highest degrees of mistrust in vaccines and new medical innovations are Black and Brown communities.

So we sat down with the companies and worked literally every single week, individually, myself, Francis Collins, and Tony Fauci. And by the time those vaccines were actually authorized, we were up to 30% diversity in those clinical trials. Not only were they some of the fastest and the largest in history, but they were also some of the most diverse in history.

That has led the FDA to now put out regulations saying every company has to have a diversity plan when they’re developing new vaccines. It’s led CMS to change some of their rules regarding diversity and access to clinical trials for people from Black and Brown communities. I’m incredibly, incredibly proud of that. It’s changed the way we will develop drugs forever. So really, really proud of that.

You asked a tough question though. I probably should have started with the tough one first. What’s something I wish I had a do-over on? One of the things I wish I had a do-over on was something that many people will famously remember. It was February, March of 2020, and we were facing shortages of PPE among healthcare workers. There was a run on masks. There was also a run on toilet paper. There was a run on meat. People were just going crazy. They were panic buying like they do in a crisis.

Tony Fauci and I sat down and we said, what can we do about this? What do we need to do about this? What people don’t understand is, in the moment, we were still thinking, because China had not been forthcoming with the information, that this was going to behave like every other respiratory virus, every other flu surge that we have every year. Every single year, there’s a new bug that comes up, and muscle memory is that it’s going to behave like the flu and it’s going to go up and it’s going to come back down again.

We’ve never recommended universal masking before for many reasons. We haven’t needed to. But also, in most cases, the advice that we give people isn’t, if you’re sick, mask up. It’s, if you’re sick, stay home. That’s why it was so different in 2020, because we had 50% asymptomatic, so you didn’t know if you were sick. But we didn’t know that at the time. And Tony and I both said, we’ve got to tell the public to stop hoarding these masks, because we legitimately did not believe it was going to provide a huge net benefit to tell the public to mask. But we did know that healthcare workers, who were taking care of known COVID-positive patients, were being put at risk. So that’s the context. I put out a tweet that said, please, people, stop buying masks.

I write in the book what wasn’t reported and what folks don’t remember. That’s not all I said. I had literally a three-post tweet where I laid out the reasoning for this. I said, if you are sick, stay home. Please save the masks for the healthcare workers. At the time, I was very much focused on N95 masks, which the general public did not have a lot of familiarity with and know how to use anyway, and which we usually traditionally have thought of as, you need a good seal for it to work.

For all those reasons, I put out a tweet. All anyone read was the first line. It went viral and had millions and millions of posts. It’s been used against me and will be used against me for the rest of my life because, two weeks later, information got out about asymptomatic spread, and I did what I think a good scientist should do. I looked at the new information and I said, OK, we need to change what we’re saying. But then they were, oh, my gosh, you’re a hypocrite. Oh, my gosh, you’re a flip-flopper. In hindsight, if I could do that over again, I would have had a lot more appreciation for social media and how people don’t read past the initial tweet or the initial line and how politically charged things were and how people would use what I said against me and ultimately change the narrative on a very important public health intervention.

It’s also interesting, and I mention this in the book, Tony Fauci said the same thing that I said, at the exact same time. This was he and I talking and he went on the news and said this. But all people remember is me saying it and they hold it against me. As you mentioned, Republicans hold it against me because then I became a mask promoter and they say I’m a flip-flopper and I’m a liar. And Democrats hold it against me and say, well, you knew all along that we should have been wearing masks and you told us not to. It’s just an example of a lot of things that were wrong with communication and politics during 2020.

Dr. Enfield: It also really speaks, during that time and also we now deal with patients with acute sequelae of COVID or long COVID, the fact that the science is evolving. One of the other lessons that I’ve seen in your book, as I tried to skim it and get ready today, was that science and health literacy must improve. I think that’s really important. But one of the areas that I really wanted you to speak to that relates more to something you said this morning as well, is the science and health literacy that we need for dealing with the inequities in healthcare, specifically asthma among Black and Brown men who are more likely to die from it, more likely to be exposed to environmental hazards from it. We know we can’t treat well because the drugs we have don’t work the same way as they do in a fellow asthmatic like myself.

Dr. Adams: Well, I am the head of the Association of Diversity in Clinical Trials. The reason why I took on that role is because, again, personally, as an asthmatic, I’ve experienced poor health outcomes because of lack of diversity in clinical trials. But also professionally, again, in Operation Warp Speed, I’ve seen the importance of making sure you have adequate representation in clinical trials so that people not only have the medications that work for them but also so they have the confidence in those medications and in the healthcare system.

I think that’s something that we have to remember. We have to be willing to admit our biases when it comes to different patient populations. Harvard actually has an implicit bias test that is incredibly eye opening. You can Google Harvard implicit bias test, and it will help you understand if you have bias toward people by race, by age, by gender. They’ve got over 10 different implicit bias tests. It’s amazing and humbling when you take those tests and you realize we have bias.

It’s not a bad thing to have bias. Bias is how you know that the bunny is okay to play with and the lion isn’t. You don’t have time in the real world to process everything through and to do an experiment. Is the lion going to eat me? Let’s do a randomized double-blind controlled trial. Bias is hardwired into us. It becomes a problem when we don’t recognize our bias and we don’t recognize the ways in which it can cause us to make unsubstantiated choices about how we interact with people and with the world.

Then you mentioned health equity. Health equity is simply making sure people have the resources to make good choices. As an example, a person in a wheelchair may need a ramp to get in and out of a building. That doesn’t mean we put ramps on every entrance and that we give everyone a wheelchair. That’s equality. That’s not cost-effective. It’s not practical. Equity is making sure we recognize particular people have particular needs and meeting those needs so that they can all participate in society or get in the building. We need to do that throughout healthcare.

We need to recognize Black and Brown communities have a lack of trust because of Tuskegee and because of Henrietta Lacks. So sometimes we’ve got to take a little bit more time with those patients and their families in order to get them to embrace our medical plan. We have to understand that Black boys are more likely to live in environments that are triggering for their asthma. We have to spend a little bit more time asking about their home environment and their social drivers if we truly want to prevent their next ICU admission for asthma exacerbation.

Dr. Enfield: Before we leave that topic, I also wanted to highlight the work you did with UVA Darden School of Business on the business case for equity. Can you just highlight some of the findings and what you mean by the business case for health equity?

Dr. Adams: Well, thank you for that. When I was surgeon general, I wrote a first-of-its-kind Surgeon General’s Report. Surgeon General’s Reports are kind of the big treatises that we put together to be our legacy from the time we’re surgeon general. Folks often think about Luther Terry’s Surgeon General’s Report on smoking, for instance. Dr. Murthy, the current surgeon general, put out one on the opioid epidemic when it first came out.

Well, I put out a couple of Surgeon General’s Reports, but the most unique one was called Community Health and Economic Prosperity, and it was making the business case for health. It was a report that I wrote not with medical professionals but with the UVA Darden School of Business, highlighting what I call the U.S. health disadvantage. The U.S. health disadvantage is the fact that we spend three to four times as much on healthcare as the OECD average. We spend about $13,000 per person on healthcare in this country compared to an OECD average of about $4,000 per person.

Yet our life expectancy has been lower than those countries since 1980, and that gap is only widening. I’ll often provocatively ask, in office, how many people think we need to spend more on healthcare to improve health? You’ll get a lot of hands raised, and I’ll say, no, we already spend more than anyone else and we’re getting terrible results. What we need to do is spend that money in a different way. We need to spend it building healthier communities and really trying to get upstream and prevent disease instead of waiting until people get sick and treat our way out of disease.

In that report, I make the case that doctors and hospitals can’t do this alone. We need legislators. We need business leaders. I’d rather have Elon Musk, Mark Zuckerberg, Bill Gates out there arguing for complete streets and for clean air laws and for parks and green spaces than to have the HHS secretary, because when the business community asks for something, people are more likely to listen.

Look at Mark Cuban. Mark Cuban has changed prescription drugs in a way that no one from a medical standpoint has been able to because he’s a respected business leader. I make that case that the business community simply can’t continue to sustain rising healthcare costs. It’s the number two expense for most Fortune 500 companies but also that they have a very specific and very important role to play in changing the broken system that we currently have.

Dr. Enfield: Hopefully they’re out there listening to you today, because I think a lot of people would agree with you. As we wrap up today, is there anything you wish we had talked about before we conclude this conversation?

Dr. Adams: Well, I will say to folks that my book is available wherever books are sold, Amazon, Barnes & Noble. It’s also now out on Audible if you’re someone who likes to listen. My book is very different than most of the pandemic books that have been put out there. I’ve read most of them. They’re very thick, they’re policy treatises, and they’re hard to get through. My book, you can get through in about two or three days, which is what most people have told me. I wanted it to be short. I wanted it to be personable. And there are a lot of fun stories in the book.

I talk about meeting Oprah Winfrey and Chef José Andrés. I talk about being mentored by General Colin Powell, and I talk about getting in a fight with Axl Rose. These things all happened to me when I was surgeon general of the United States. I never in a million years imagined I would be talking with these people, working with these people or, in some cases, arguing with these people. But I tell the stories not just to make it fun, but so that you understand it. I was a real person going through this.

We can finish where we started. I was a husband. I was a dad. I was someone who was still working clinically. I’ve continued to practice medicine the entire time. I was health commissioner of Indiana, surgeon general of the United States, and now I still practice in a level 1 trauma center as an anesthesiologist one day a week.

I try to weave that throughout the book because all of that is what makes me me, and all of that impacted the way that I saw the pandemic, and I hope people believe it. It’s not me trying to apologize or me trying to say that I was right. I’m very open about places I was wrong. But I want people to understand the context so that we can do better in the future.

I’ll finish with this data point, this story to drive home why we have to do better in the future and why I wrote this book. We’re gearing up for a pretty nasty presidential election here in 2024. Well, October of 2020 was the last presidential debate between Joe Biden and Donald Trump, and Joe Biden pointed out that, at that time, we’d had 200,000 COVID deaths, and he said any president responsible for this many COVID deaths should resign, should no longer serve as president, is disqualified from service, 200,000 deaths, October 2020. This is before vaccines, still not great PPE, still no availability of home testing, 200,000 deaths.

Fast forward to the end of 2021. And remember, we had vaccines available by December, January of 2021. So, vaccines fully available, PPE fully available, home testing fully available. We had 360,000 deaths under the first year of the Biden administration. I don’t say this to criticize the Biden administration, I say this because the premise that changing the president, the CDC director, the surgeon general, and the FDA commissioner was going to change our trajectory has been proven categorically false.

It’s been proven false, but we continue to focus on politics and not pay attention to health inequities and not pay attention to making the economic case for health and not pay attention to politics and partisanship and not pay attention to the root causes that continue to put us in the same position over and over and over again, surge after surge after surge, more and more vaccine hesitancy, lowering vaccination rates and uptake.

I hope people will read the book, understand why we made the mistakes that we did in 2020, why we continued to make them in some ways to a greater extent in years after that, and how we can do better in the future.

Dr. Enfield: Well, I want to thank you for sitting down with me today. I like the fact that you asked the provocative questions that are going to make the listeners and myself and others think both through your book and through this podcast and through all the speaking you’re doing.

This concludes another episode of the Society of Critical Care Medicine Podcast. If you’re listening on your favorite podcast app and like what you heard, consider rating and leaving a review. For the Society of Critical Care Medicine Podcast, I’m Dr. Kyle Enfield.

Announcer: Kyle B. Enfield, MD, FSHEA, FCCM, is an associate professor of medicine in the Division of Pulmonary and Critical Care at the University of Virginia. He received his undergraduate degree from the University of Oklahoma.

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