This interview took place on July 24, 2020. It has been condensed and edited.
Dr. Caine, you are an infectious diseases specialist, a Bicentennial Professor of Medicine here at IU, and you also serve as director of the Marion County Health Department. How do your roles as a clinician, a professor, and a public health director inform each other?
The multi-faceted and combined features of my medical education and public health expertise have provided diverse lenses to view the complexities of complicated patients. Each of my professional roles are predicated on my training, experience and commitment of performing my responsibilities as a physician. I am a clinician with years of specialized clinical preparation and experiential practice treating underserved patients, I provide care to patients at Eskenazi Health, the fourth-largest public hospital in this country which predominantly serves African American and Latinx patients, people with low-incomes, and other medically vulnerable patients. Many patients in our community experience health disparities related to the lack of health equity as well as limited access to healthcare and human service resources. I have had the privilege of taking care of patients who have major barriers to receiving healthcare and helping them to facilitate more patient-centric therapeutic solutions. Another important aspect of my University appointment is to train medical students, residents and fellows as a professor in the Division of Infectious Diseases. A significant part of my academic experience is dedicated to instructing and preparing diverse medical professionals to treat challenging patients with complex viral conditions which may negatively affect their immune systems and also have other co-morbid conditions, that are often compounded by negative social determinates.
My medical education and experiential teaching understandings include both individual (personal) and public health (population-based) subject matters and have accentuated my ability to practice and teach on subject important to positive health outcomes for vulnerable patients. Unlike many of my colleagues, the dual feature of my years in medicine and public health have equipped me to recognize the degree to which social determinants play a direct role in improving health outcomes and status, which is critical when addressing health disparities in disenfranchised communities. In Indiana, the minimum wage has been $7.25 for 25 years—and that is not nationally considered a living wage. This means that many of our residents must work two jobs to provide basic necessities such as housing, food, and pay other critical bills for running their family households. These family’s individual challenges are worsened by neighborhood deficiencies such as food deserts with no grocery stores that require ineffective public transportation to secure food; no green spaces for exercise or other outdoor activities; or familial or community violence. Other factors affect these patient’s unstable health conditions including lack of access to insurance, poor income insecurity, or anxiety and depression resulting from poverty and systemic racism.
The US health system is currently not sufficiently structured for physicians to recognize and/or examine social determinants during medical visits or have relationship with human service stakeholder’s, as a result many health providers are struggling with need to get a better grasp on and understanding how social determinate impact health. However, as the Director of Marion County Public Health Department, I have been trained to identify and take social determinants of health into account when treating a patient or reviewing their possible population-based factors and influences through patient-centric interventions. I recognize patient treatment trends, from the therapeutic aspects that are impacted from the surveillance standpoint, and monitor outbreaks related to infectious disease—tuberculosis, measles, HIV and sexually transmitted disease, shigella, and now, of course, COVID-19. I feel humbled and grateful for my years of combined public health and medicine training to address COVID-19, one of the most serious health challenges of this century. The joint achievements of public health and medicine for balanced interventions to prevent cancer and heart disease through smoking cessation program or reducing bodily harm related fatal car accidents through seat belts. Because of my training and experience in health promotion, prevention and treatment and the fine team of other experts I am confident we will be able to accentuate comprehensive care management for the treatment Black and Latinx patients and other vulnerable populations in disenfranchised communities to improve their clinical outcomes.
On July 23, you and Mayor Joe Hogsett announced that Indianapolis is stepping back from its reopening, and re-closing bars and imposing restrictions on social gatherings. Can you give us a snapshot of what’s happening in Marion County right now?
Across the country, we’ve recently had a significant increase in the number of new COVID-19 cases. Indiana like Texas, California, and 28 other states are experiencing sustained increases in the virus. Fortunately, Marion County implemented many preventive measures early in the course of COVID-19. For these reasons, we are not seeing the overwhelmingly high numbers that many other states are experiencing. However, recently our area has seen a resurgence in new cases, which indicates the wrong direction for the virus. Marion County, like other parts of the country, began the process of returning to more normal public life in the last three weeks and our communities have seen an increase in new infections and death. This suggests new infection outbreaks, and a significant amount of community spread. We must, once again, get the virus under control. It is important to implement data-driven community measures and “best practices,” such as a strict mask requirement when in public and social distancing, while medical and public health entities promote and systematically conduct early testing, monitoring, contact tracing, isolation and quarantine.
Through these measures our community can safely re-open, and all healthcare, human service and community-based organizations can make the necessary contributions for the wellbeing of all of our citizens suffering from the ravages of COVID-19. But there are certain sub-populations of patients that experience undue burdens of this viral infection, and affirmative steps will be important to overcoming the racial and income-driven disparities to maximize our community protective environments. It is also crucial to address the concerns of other, often invisible, vulnerable members of our community’s COVID-19 patients who are homeless or incarcerated. Marion County public entities with the shared responsibility for these populations are working together on a number of policies and procedures that will make it possible to maintain social distancing and proper ventilation in shelters and correctional facilities.
How do you approach making COVID-related policy decisions?
In hospitals, at Eskenazi Health, and in the Marion County health clinics, we rely on information and recommendations from a host of experts in public health, infectious disease, and patient safety organizations. We get guidance and feedback primarily from the Fairbanks School of Public Health and from our academic partners and local infectious diseases community, our patient safety coalition, the MESH Coalition and the US Centers for Disease Control and other disease-specific state and federal resources. We also must get input from the community and the very populations we need to address in order to have the type of policy that benefits everyone and not just the ones we think they need.
In addition to the information from the above-mentioned healthcare experts, I am in communication with the health officers in the 32 largest cities in the country as well as the clinical and professional personnel of small rural locations. The dialogue concentrates on outlining the similarities and differences to success COVID-190 interventions and outlining those things that do not work in particular localities. I look at what happened early in New York, New Jersey, Chicago, Los Angeles, Detroit, New Orleans, and Washington, DC, to shorten the learning curve for the serious issues affecting COVID-19 patients in our community. There are tremendous clinical and cost benefits derived from having reciprocal dialogue with cities that experienced crisis levels to their healthcare systems before we to determine the effective ways to use limited medical and other human services resources to address this virus.
Additionally, I have benefited from my relationships with colleagues in other diverse people serving public and private organizations. I’m a member of the National Biodefense Science Board, a federal committee that provides expert advice and guidance to the US Department of Health and Human Services on crisis management. They have been of tremendous assistance, as have my infectious disease colleagues in the National Medical Association, the largest and oldest network of Black physicians in the US on specific COVID-19 health disparity issues.
How has your long career in medicine, and specifically in infectious diseases, prepared you for this moment?
COVID-19 is an unprecedented and unanticipated occurrence that will have far-reaching consequences for all medical, public health, behavioral science and human service entities throughout this country. Certainly, over the past years in my positions there have been serious discussions related to the potential for pandemics; I have participated in wargaming scenarios and other simulation activities and preparedness exercises related to weather and medical crisis. And while these activities and discussions provide the solid foundation for addressing serious community-wide infectious disease management, COVID-19 has been unparalleled. Its level of contagiousness and rapid progression to serious respiratory complications highlighted that Marion County and US found it difficult to prepare for the specific healthcare staff and medical devices/equipment such as enough PPE in the national stockpile, ventilators, appropriate hospital beds, sufficient public health structure and staff to delays community infection levels and to treat patients for effective infection control and testing efforts.
Fortunately, I have not had to face this viral crisis alone. The Marion County Health Department has been able to coordinate very closely with senior leadership and staff of Fairbanks School of Public Health, the academic and local infectious diseases specialists, the Indiana State Department of Health and Department of Family and Social Services, social services, corporate partners and community-based organizations to maximize the use of resources to rapidly foster successful interventions and limit those that are problematic. The initial alliances will provide the foundation for implementing the steps associated planning and implementing major contact-tracing effort in partnership with Fairbanks School of Public Health under Founding Dean Dr. Paul Halverson and the City of Indianapolis. These efforts have also helped by leadership of Mayor Joe Hogsett and his outstanding team. The mayor has been a great listener and has evaluated all recommendations related to the potential benefits for the entire community. He is a receptive, quick learner, and has been committed to making important and pivotal decisions often on short notice.
We know that COVID is disproportionately impacting people in marginalized and minoritized communities, with respect to both infection rates and to mortality rates. What kinds of policies need to be put in place to address these disparities?
Ensuring that healthcare professionals and at-risk communities recognize the probabilities and danger of contracting COVID-19, and having a poor clinical outcome and possibly death, is a critical step to improving the health status of disenfranchised patient populations. First, we need to increase culturally competent promotion and prevention messages and provide more direct healthcare services and resources for people of color. That can best be accomplished by developing accountable changes in current policies and procedures so that resources and dollars can be directly allocated to minority-based organizations that traditionally serve people of color. This is particularly important for the new resources from the federal government in the most recent stimulus package. There should be a dedicated portion of these monies that are distributed directly to community-based organization, that are trusted or valued communicators for people of color. Enlisting the support and levering the positive relationships of community-based agencies to deliver complex COVID-19 messaging are important for reducing poor health outcomes and death in these communities, but it is also important for maximizing resources, creating community resiliency, and ensuring sustainable neighborhood capacity to address the virus. Through these mechanisms it will also be easier to adapt and implement the two most direct ways to combat COVID-19 disparities: stable invoice and back-to-work formulas, and policies and procedures for safely opening schools.
Secondly, I know that the majority of my colleagues in academic medicine or in private practice want to do the right thing, but because of lack of training, they don’t have a good understanding of the cultural environment that our patients come from. This directly impacts their health. To better serve these patients, it’s critical for providers to undergo implicit bias training—and to continue to do it; it’s not just a one-time training. We need ongoing dialogues and discussions about this, and we need to be continually asking: what health equity challenges do our patients face, and how are we, as a department, as a school of medicine, as an organization, et cetera, addressing these challenges?
Indiana consistently ranks very low on nationwide measures of health, with high rates of the conditions correlated with poor COVID outcomes —
cardiovascular problems, kidney disease, diabetes, etc. How do you view your role in improving Hoosiers’ health?
Indiana ranks in the bottom five states in terms of the amount of money and resources directed to public health. Our state department of health, and health departments across the state, need more resources. One of the areas I consider my responsibility in my academic and public health work-products is to help Indianapolis secure additional public or private resources. Marion County has been fortunate to have philanthropic supporters—the Lilly Endowment, the Fairbanks Foundation, United Way, CICF and several others. The Chamber of Commerce with the City of Indianapolis has also gotten business together to help support smaller businesses and give mini-grants to the ones who didn’t receive money from the stimulus package. So, these groups have really come through.
My role in this is to give scientific advice and guidance, to highlight the challenges and barriers that many people face, and to do advocacy and community education on their behalf. Educating people about poverty and how to address it is critical for me, as is continuing to work on making more resources available for people who need them—not just available, but visible and easy to access.
In your view, what is the way out of this pandemic (if there is one)?
There is a way. We have the tools, and we have the information; we just need people to do the right thing. If all members of our community could fulfill the responsibility of wearing a mask in public, social distancing, and practicing good hygiene—all health care directives that are recommended by the City of Indianapolis—we could easily control this infection within, I believe, eight weeks. But some people lack the education or awareness to follow these directives, and others intentionally don’t respect the recommendations. Unfortunately, they are putting themselves and others at risk. I really want to get back to normal—or whatever our new “normal” is—but a number of people in our community are preventing that from happening. So, they can continue flaunting their disdain for our recommendations, but that has consequences for the community, and it will take us much longer to get the infection rate to safe and manageable levels and hopefully avoid unnecessary deaths.
The views expressed in this content represent the perspective and opinions of the author and may or may not represent the position of Indiana University School of Medicine.
Hannah Calkins is the communications manager for the Department of Medicine.