Dr. Ijeoma Opara: Partnering with a Community (Health & Veritas Ep. 22)

On the Health & Veritas podcast, Yale physician-professors Howard Forman and Harlan Krumholz talk about the latest news and ideas in healthcare and seek out the truth amid the noise. In the latest episode, they’re joined by Dr. Ijeoma Opara of the Yale School of Public Health to talk about the impact of persistent violence on mental health among urban youth and the power of community-based participatory research.

SASH: The Substance Abuse and Sexual Health Lab

Howard P. Forman
Professor of Radiology and Biomedical Imaging, Economics, Public Health, and Management; Co-founder, Pozen-Commonwealth Fund Fellowship in Health Equity Leadership, MD/MBA Program, and MBA for Executives Program
Harlan M. Krumholz
Harold H. Hines, Jr. Professor of Medicine and Director of the Yale Center for Outcomes Research and Evaluation
Ijeoma Opara
Assistant Professor of Public Health

February 24, 2022

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Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. This week we will be speaking with Yale School of Public Health professor Ijeoma Opara, hearing about her work to incorporate cultural strengths into prevention programs for urban minority youth. But first, we like to check in on current health news. Harlan, what has caught your attention this week in healthcare?

Harlan Krumholz: Well, thanks, Howie. This week, the community in academia and in global health was stunned by the news of Paul Farmer’s passing. Paul Farmer, well known to many, American medical, anthropologist, and physician. But really so much more. He is chair of the Department of Global Health and Social Medicine at Harvard, the co-founder and chief strategist of Partners In Health, an international nonprofit organization that since 1987 has provided healthcare services and undertaken research and advocacy on behalf of those who are sick and living in poverty throughout the world, and has been part of administration efforts, government efforts, nonprofit efforts, obviously deeply invested in the work in Haiti. I wanted to just take a minute today to reflect on Paul, and I thought the best way to do that was just to read some of the quotes from Paul.

He inspired so many. His work will go on, but what a loss. He was in Rwanda to receive an award and died in his sleep. It’s just so unfortunate. Okay. Here’s some quotes. “The idea that some lives matter less is the root of all that’s wrong in the world.” That so exemplified, I think, how I approach things. Here’s some more. “If I’m hungry, that’s a material problem. If someone else is hungry, that’s a spiritual problem.” Here’s another quote: “It’s very expensive to give bad medical care to poor people in a rich country.” “With rare exceptions, all of your most important achievements on this planet will come from working with others—or, in a word, partnership.” Another one: “Managing inequality almost never includes higher standards of care for those whose agency has been constrained, whether by poverty or by prison bars.” Anyone who’s listening, you can go on online and see a lot of what he’s written.

He wrote a book called Pathologies of Power: Health, Human Rights, and the New War on the Poor and really invested himself in these ideas. He said, “In this increasingly interconnected world, we must understand that what happens to poor people is never divorced from actions of the powerful. Certainly, people who define themselves as poor may control their own destinies to some extent. But control of lives is related to control of land, systems of production, and the formal political and legal structures in which lives are enmeshed. With time, both wealth and control have become increasingly concentrated in the hands of a few. The opposite trend is desired by those working for social justice.”

Finally, “Do we see [human disparity] as a human predicament—an inescapable result of frailty of our existence? That would be correct had these sufferings been really inescapable, but they are far from that. Preventable diseases can indeed be prevented, curable ailments can certainly be cured, and controllable maladies call out for control. Rather than lamenting the adversity of nature, we have to look for a better comprehension of the social causes of horror and also of our tolerance of societal abominations.” Part of this episode, I think, we should dedicate to Paul. We have a remarkable guest coming to us next who’s been working deeply with communities and helping those who are disenfranchised and trying to figure out how to strengthen their position and improve their health. I think it’s a good day maybe for us, I would like to have us dedicate that. I wanted to just take anyway a few moments to talk about him. How about you, Howie? What’s on your mind this week?

Howard Forman: Yeah. First, I just want to say I never met Paul Farmer, but I don’t think there’s anybody in medicine who has influenced my students more than Paul Farmer. I can’t even begin to tell you the list of students who either went into medicine or did what they did starting nonprofits, working on health equity because of Paul Farmer. One of my students yesterday when I sent him a text saying that I’m very sorry. He was very close with Paul Farmer, just visited with him a few months ago. He said, “I cried all morning.” He said, “I was having a hard time not crying in the operating room.” This is a man who touched many lives, including the development of young talent. I think his legacy will continue through them. I’ll pivot to talk about what I wanted to talk about this week, which is I was teaching about externalities this week, and I could give you the formal quote of externalities.

I think I’ll skip over that and just say externality is when some positive or negative effect is felt by someone who’s not party to a transaction. For instance, you might decide to consume cigarettes and you suffer the harm for smoking those cigarettes. But others also suffer from the secondhand smoke, and they were never part of the deal. That’s a negative externality. Well, antibiotic resistance is another example of a negative externality that occurs from the overuse or overprescription of antibiotics. Last week, a report came out in the CDC’s Morbidity and Mortality Weekly Report which highlights that in the Medicare population about 41% of all antibiotic prescriptions are written by 10% of the prescribers. There’s numerous studies that have now demonstrated that some physicians do tend to overprescribe. It’s true also that patients frequently go to doctors looking for a prescription, looking for an antibiotic, and physicians may feel compelled to oblige. But there are real costs to society. In the United States alone, 35,000 people die each year from antibiotic-resistant organisms, and 2.8 million people suffer from one of these infections.

We all have a stake in reducing the development of antibiotic resistance even though individually, we may want to be treated for a mild illness sooner rather than later. We may think that’s in our personal best interest. There are guidelines in stewardship considerations that can help us reduce overprescription. I want to just bring this back to the pandemic because there is again a need for some collectivism over individualism, but it’s a lot easier said than done. I hope that the “public” in “public health” comes around to understanding that we are all in this together, and we all benefit from working together on these issues.

Harlan Krumholz: Great. Couldn’t agree more.

Howard Forman: All right, here we go. Excited to introduce my colleague, Dr. Ijeoma Opara. She is an assistant professor at the Yale School of Public Health in the Department of Social and Behavioral Sciences. Her research interests focus on HIV/AIDS and STI prevention, substance abuse prevention in urban youth, and health disparities among girls of color. She has received many awards for her work in prevention research from the American Public Health Association, the National Council on Family Relations, and AcademyHealth. She also founded the Substance Abuse and Sexual Health Lab, SASH, which uses community-based research to develop racial and gender specific health solutions. Dr. Opara adopts a strength-based approach in her research, leveraging social support and cultural elements like racial ethnic pride to help tackle health disparities and empower Black urban youth. Currently, she’s pursuing a five-year community-based study on how neighborhoods shape substance use and mental health among urban youth. So delighted to have you here and so happy that you’ve joined us at Yale in this last year.

Ijeoma Opara: Thank you. That was a beautiful bio.

Harlan Krumholz: Oh my God, you’re too nice to him. I think it was stiff, honestly. It doesn’t really do you justice. Let me just say, one of the great joys for me of being on this podcast is I get to meet friends and colleagues. Look, all it takes is to look at the titles of some of your pieces to realize how you’re trying to tell the truth and get it real. Where like this paper, it starts with the parents of qualitative study on protective factors on drug use. Another one that I saw that really I thought was important had to do with the framework around social media and eating disorders. I wanted to talk to you just for a little bit about your approach, because clearly what you’re doing is to get into the discussions with people who are affected and trying to bring their voices up, amplify what they’re saying, and help us as researchers learn from them, not to tell them what to do, not to say, “We’ve got advanced degrees, and we’re going to try to provide solutions,” but to learn.

The one I wanted to start with was a paper you wrote that said, “‘Bullets Have No Names’: A Qualitative Exploration of Community Trauma Among Black and Latinx Youth.” One of the things that you did in this paper was to really bring forth quotes. Today’s the day of quotes, and I want to bring up some of the quotes that you brought up. Let me just do one and then just get your reaction, tell us a little bit about how you ended up doing this, what it was. The quote was from someone that you interviewed in the study, which I really love that in these qualitative methods how we can hear people. This person said, “And then you have to sit there and worry about sitting in the house and your kids, your siblings, your family, are outside. You have to worry about, ‘OK, my kid might get shot. Bullets have no one’s name on them. Bullets can hit anybody.’” I wonder if you could just reflect on this study, this method, what you learned and where it’s leading you. I’m just so excited to read your stuff.

Ijeoma Opara: Yeah. Thank you so much for your kind word. I really appreciate it. Thank you for bringing up that article. I haven’t talked about that study in a while, so I’m really excited to even dive in on it. That study was actually conducted in Paterson, New Jersey, where I do a majority of my community-based participatory research, in that community. It was a part of a larger grant that I trained under through the Substance Abuse and Mental Health Services Administration, or SAMHSA. One of the reasons why we did that study was we were trying to figure out like, what are some resources that youth need in their community to feel successful? This discussion about trauma, about violence, about crime within their communities emerge without us even having to really probe or ask these questions, right?

That’s one example. It’s one of the reasons why I love qualitative work because it not only gives youth and young adults a voice to express their concerns, but oftentimes no one’s asking them these questions. No one’s giving them a space to really talk about the issues that they’re facing and how they feel about it. A lot of times when you just open the room and just ask general questions, you would get so much insight on it. With that quote, that quote really inspired me to title the paper and to highlight “Bullets Have No Names” because I wanted to show the world that this is what teenagers, people under 21 are having to deal with and grapple with. When I did this study, when I actually did the interviews, I had a real emotional reaction to it that my colleagues didn’t necessarily have.

Just to add, I was the only Black person a part of this study team. I was the person on the team that lived in an urban community. I grew up in Jersey City, which was a primarily urban, or was—now it’s changed. That’s a whole different story. Where I grew up, it was a predominantly Black and Hispanic community. I identified a lot with the stories of youth from this community. Oftentimes, whenever we do focus groups as a group, and I continue to do this with my lab, is that we process the information. And I notice that my reaction to the stories of youth related to violence and gun violence and the things that they were worrying about were very different than the reactions of my White counterparts in the room. You know, they thought it was exciting! Like, “This is so cool, and they’re opening up to us.”

For me, it was like, I can’t believe that youth are actually going through this, and they’re not gaining any resources to deal with the trauma that they’re facing on a day-to-day basis. It’s normalized for them to have to deal with worrying about if their mother or their father or their brother or their sister is going to get shot. That shouldn’t be normal. This is not something that we should be excited to hear about. We should be sad and trying to figure out ways that we could actually allow them to have a childhood where they don’t have to worry about these things at such a young age. When I hear those stories and I hear those quotes, I first thank them for even sharing them with me and trusting me to highlight their voices. But then as a researcher, I do tend to feel a little bit disappointed that this is what they’re going through.

Harlan Krumholz: No, I think it speaks to the importance of having someone on the team who can bring that perspective, let alone lead the effort like you did. Let me just one quick follow-up on it because what it made me think as I read it was the toxicity of the environment that many of these people are living in. It’s emblematic of some of the effects of structural racism in our society too because you can provide these kids even opportunities, but the stress, the allostatic load, the distraction of just having to worry about safety, let alone the parents and others in there. The grind that it must do to health, the resistance to intellectual cognitive development in young kids. It made me so sad to think.

It’s not that I don’t know it, but this paper’s so powerful. I really recommend listeners to take a look at this paper. It’s just such a powerful expression. Was that also part of what you’re thinking when you see the toxicity of the environment? It’s almost like we think about pollution, we think about air quality, but this is about something else going on in the ecosystem that’s really having a major effect on people’s lives and health.

Ijeoma Opara: Yeah, absolutely. This paper, honestly, was the foundation of the grant that I’m actually funded for now to look at neighborhoods’ impact on substance use and mental health, because it was through this study that made me realize the environment has a huge impact on not just physical health issues like asthma, like most people typically associate asthma with pollution and things like that, but also mentally too. Why is it that youth of color who live in this community have to be exposed to violence on a day-to-day basis? How come everybody in the room who knows at least one person who died from gun violence and why aren’t there resources for them that deal with grieving or bereavement groups or things like that? How come they... These are things that they never even heard of.

And the youth acknowledged, they know that this is something that’s unique to their community. They know that if they step outside and go to a predominantly White community, which is not very far from Paterson—Paterson’s actually surrounded by suburban, predominantly White communities. They know if they step outside and go to those communities, they know that there’s a huge difference. They see it just by having access to trees and parks and clean roads and streets. They know that this is unique to their community, and they often end up feeling hopeless and feeling like, “The only way for me to survive is to leave.” Right? My goal as a researcher is, of course, to acknowledge environmental racism and structural racism and how that impacts where youth of color often live and what resources they have and the type of things that exposed to.

I also want to encourage youth of color living in these communities to identify strengths within their community and to be able to bring in more positive resources in that community. It contributes to this feeling of being inferior, of feeling hopeless and feeling like I live in a community that nobody cares about. You don’t have necessarily the motivation to want to improve that community. You just want to leave. If you continue living and seeing your community as worthless and hopeless, nothing gets changed and then it contributes to your self-esteem, your confidence. It’s a big part of the work that I’m doing now within neighborhoods in Paterson. I want to be able to use my work to bring in to communities like New Haven and other predominantly minority communities so that I could be able to work towards this issue of environmental justice. Environmental justice actually wasn’t even something that I even really had a passion for until I started doing this work and realizing this is needed. This is all a result of systemic racism, and we need to address it. It’s a public health issue.

Howard Forman: That’s a good segue to my question, which is I think a lot about people’s careers. When I look at your path, which I haven’t discussed yet, in my mind I would think, “Oh, my God, this is the most intentional path possible.” After your undergraduate degree, you did a public health degree, then you did a master of social work, you actually practiced social work before you went back and got a PhD and now you’re doing what we call community-based participatory research, which quite frankly, I learned from Harlan about 20 years ago. It’s on the edge of my knowledge base, but I’m familiar with it. I’d love to hear about what that path was like for you and how it prepared you to do the type of work you’re doing now, because there are very few people in this country that have your experience in all those spheres.

Ijeoma Opara: Yeah. Thank you so much for sharing that. It’s funny to me. I’m a very spiritual person. I really do believe that God put me on this path because I’ll be honest with you, when I was an undergraduate student, if you would’ve told me you’re going to be a Yale professor and you’re going to be doing community-based participatory research. I’d be like, “No, I’m not.” I would think you’re lying! I think that my path was set because I was in this place where I knew that I wanted to be an advocate. I knew that I wanted to fight for people that looked like me and inspire the next generation. That was something that I always knew as a child. I just didn’t know how to do it.

After undergrad, I actually wanted to go to law school. I applied to law school with the LSATs, and I specifically wanted to focus on public health law, because health disparities was something that was really important to me, especially since my mom passed away at a young age. She had diabetes and she passed away when I was 16 years old. I knew that health disparities was something I wanted to enter, but I ended up not getting into the law schools that I wanted to get into. I just decided to just change my path and focus more on public health, as I felt like, okay, maybe if I could get an MPH that would give me the support that I need to do this work. During my MPH, my father passed away. My first year in my MPH, he passed away from a heart attack.

It also strengthened me to be like, I really want to engage more in this work because I feel like both of my parents, they died at young ages. My mom was 46. My dad was 57. I felt these were ages that they should have been living their lives. They should have been thriving, but they weren’t. As I got older, I realized that that in itself is a form of racism that impacts people like my parents, Nigerians who are immigrants, and they didn’t necessarily know how to navigate the system of healthcare to really encourage a more healthy-living lifestyle. They didn’t even know where to go to. That’s a whole nother conversation. Maybe you guys could invite me; we could have a conversation about that. After I did my MPH, I got an internship at Johns Hopkins School of Medicine.

That was actually my first experience in doing community-based participatory research. The PI that I worked under as a student, Dr. Arlene Butz. She was actually working on a community-based study focusing on asthma in a city, Baltimore. It was then that I saw for myself and my own two eyes to see PIs actually be in the room with community residents and community residents telling them, “We don’t want you to do this. This is what we want you to do. We want you to do this. We want you to do that. We don’t even really trust you all like that.” Just having these really hardcore conversations and having PI say, “You know what? We’re going to do that. We’re going to change up things so that we could work on not only building trust but building something that the community wants.”

Howard Forman: And by “PI” you mean principal investigator, the person who’s leading in this study.

Ijeoma Opara: I was like, I want to do this because as an MPH student, I actually have an MPH in epidemiology. I felt like with my epidemiology degree, I didn’t want to sit behind a desk and calculate and do data analysis all day. I wanted to actually work with people, especially children and families, and figure out how can I work with communities—

Harlan Krumholz: Well, let me ask you this because I’m really interested in what advice you got along the way.

Ijeoma Opara: Okay.

Harlan Krumholz: The traditional way is the epidemiology way. When you get out into communities, it’s harder, it’s messier. The most prestigious journals aren’t open to these papers. BMJ, JAMA, New England Journal. They basically say, “If you’ve got this kind of research, don’t send it our way.” But I’m looking at your stuff, and I’m going like, “This is groundbreaking.” It’s so important, but yet everybody wants to see a large N. They don’t understand qualitative research about getting to saturation and the thematic approach. What’s the reception for your work? Let alone the fact that you’re working on the edge of race and disparities and injustice. While everybody wants to say that they’re all in on that, when it comes to publishing this kind of work, there can be resistance. What’s your experience so far in trying to get this stuff through? Because I’m reading it and I’m seeing you’re on peripheral journals. You’re not on journals that people would say, “That’s Broadway.” I think that’s a problem with the journals, not with the research.

Ijeoma Opara: Absolutely. Is a problem with the journals. Just through my career, I became a social worker. I understood how to do community-engaged work, which is different than community-based research but knew the importance of listening to communities and my training. Luckily for me, when I did my PhD, I was trained in a lab that focused solely on CBPR work, but I also had co-mentors. This is why I believe in the beauty of having a team of mentors from different disciplines, because they’re able to provide me with things that I can’t necessarily get from one mentor. With one of my mentors, one of the things that as a full professor, he didn’t really care too much about publishing multiple times. He was just like, “Just do whatever you want.” As long as you’re doing stuff in the community, he was okay with that. Right? That was one mentor I had. I had another co-mentor who was CBPR but not too into it. She focused a lot on collecting large datasets.

Harlan Krumholz: Just for people listening because the CBPR, maybe let’s break it down for people. What is CBPR? What is the difference about this research? Just because still for now, lots of people are like, “CBPR, what is that?” Can you just give a little—

Ijeoma Opara: Sure. Yeah. Community-based participatory research is, it’s a form of research that allows equitable partnerships between researchers and community members. Actually having community members be on your team in various positions or various ways to be able to guide the study design and the work that you’ll be doing with this community. Also, being flexible enough to change the direction of this work, that’s going to have a direct impact on the community. It could look different for different people. You could have community members be your co-PIs depending on the grant that you’re writing. Just really having this equitable partnership with universities and—

Harlan Krumholz: Here, I’m going to ask you real quick. You mean researchers didn’t talk to the people that they were trying to help? You mean there’s research projects where they don’t actually talk to the communities that they’re trying to study? Is that right?

Ijeoma Opara: Absolutely. Those are actually seen as more prestigious and more rigorous than the work that we’re doing in CBPR.

Harlan Krumholz: Right.

Ijeoma Opara: I will—

Harlan Krumholz: No, I’m just saying it like that, tongue in cheek. I’m just saying that this is a real inversion of the usual power pyramid where you basically walk in and say, “I’m a researcher out of my way. I just want to study.” Versus, “Hey, let’s talk and partner.” Right?

Ijeoma Opara: Yeah, exactly. We’ll go back to your question about advice that I’ve gotten and what motivates me to do this work, because I’m really passionate about this work. My qualitative work, I do mixed methods. I do qualitative but also quantitative. My qualitative work is usually the hardest to publish. It takes me the longest to do, it takes me the longest to publish, to get through journals and have to go back and forth with reviewers that obviously don’t know how to do qualitative research or are not well versed in it. It’s the work that I typically have to defend the most when it comes to journals, but it’s work that’s important to me. It’s typically the work that when I publish it’s usually the most popular, is usually the one that people will reach out to me and say, “Oh my goodness, I just read the findings of your article, and I want to talk to you more about it. Can we invite you to a class or invite you to a seminar?”

It’s the work that’s really important. It’s unfortunate that it’s often devalued by these big journals and so forth. While I’m aware of that dynamic, I’m also an academic and I tend to tell the stories of youth using multiple methods. Not just qualitative work; I usually also use quantitative measures as well. We’re able to collect large samples. I think that’s also a misconception, that you can’t collect large samples for statistical analysis when you focus on one community. You can have a large sample size, rather, and be able to do quantitative work. I do a mixture of both, and I think that’s what has helped and propelled me to be where I am. To be honest with you, I was actually, when I got funded for my grant through National Institutes of Health, when I applied for it, I swore I wasn’t going to get it. I was like, “NIH doesn’t want to hear about my community-based work in Paterson. They don’t even care about it.” Not only did I get the grant, I got one of the best scores for the grant. I was grateful that I think that we’re moving—

Harlan Krumholz: We can be hopeful.

Ijeoma Opara: Yeah. I’m sorry. I am hopeful. I think what helps is having that mix of data to show I’m doing qualitative work but also quantitative work as well.

Howard Forman: Can you give us a quick sense, I watched the video that you posted from one of your interactions with a group of young women. I’m just curious. Do you see the seeds of success starting to percolate out from the work that you’re doing that others aren’t doing? Can you give us hope about not just the research, but maybe how we might be positively impacting these communities?

Ijeoma Opara: Yeah. No, definitely. By talking to youth, one of the things I realize is that youth are not only appreciative of being involved in the research design, but youth want to hear from other youth, right? A lot of the... And this is a big point of why I do community-based work and why I do strength-based work and race-/gender-specific work is that obviously “one size fits all” approaches to things as complex as substance use or mental health or HIV prevention just won’t work. While we have a lot of evidence-based interventions that I respect, we have to understand these problems are very complex. An intervention or curriculum that’s done in schools is not enough to end an epidemic as complex as substance use or the mental health epidemic that we’re seeing now where we’re seeing young people dying by suicide almost weekly. This is something that needs to be addressed specifically. We have to have those uncomfortable conversations around racism and sexism and classism and all the -isms that are impacting youth and young adults individually that aren’t being addressed because they’re not being talked about.

One of the things that I do in my work is I am actually working on developing peer coaching models. Training youth who can be not only models but facilitators of interventions that could be done with their peers, because not only is that more beneficial, it’s also sustainable too. It’s something that could actually happen for the next couple of months or years, and it becomes a culture within that community or within that school to be able to go to trusted resources who look like you, who are more accessible. To be able to receive quality and important information. That’s something that I’ve learned from youth for years that I finally have the opportunity to be able to develop or work on developing these interventions.

Harlan Krumholz: Well, let me thank you for the time you took. Howie said you’re amazing, but I’d say he understated it by a lot. You are really amazing.

Ijeoma Opara: I appreciate you. Thank you.

Harlan Krumholz: Also, I’m going to give you a call, because I want to work with you. I’ll be your assistant or something. I really think I want to follow up with you because—

Ijeoma Opara: I do need an assistant.

Harlan Krumholz: —I’m inspired by what you’re doing. I want to figure out, then I’ve got, anyway, some ideas. Let me just say, really appreciate you joining us and look forward to seeing all the great things you do in the future. You’ve taught me a lot about how to write a snappy title for my papers, and I’m going to try to improve my titles too as a result.

Ijeoma Opara: Wonderful.

Howard Forman: With your consent, we will have you back. We’d love to have you back.

Ijeoma Opara: Absolutely. I would love to.

Howard Forman: Thank you so much.

Ijeoma Opara: This was fun. Thank you so much for giving me the platform. I appreciate it.

Howard Forman: Harlan, what’s something that inspires you or keeps you up at night?

Harlan Krumholz: Well, Howie, I think this week I’d like to maybe just reflect for a moment on something that’s keeping me up that I’ve been pondering a bit. That’s the regulation of what’s being called “software as a medical device” and what we’re going to do about the proliferation of tools that are appearing online and in different places and in medical records that are seemingly available to help guide physicians and patients to better decision making, but whose regulation is quite questionable, leading to the issue of what can you trust. Recently, there was a published study that determined that Epic Systems Corporation’s sepsis model…Epic is one of the very common medical record systems that exist in many hospitals. They had put together what they call a sepsis model. Sepsis is a medical condition where you have a rampant infection that’s life-threatening.

What you want to be able to know is when people come into the emergency department, for example, to be able to make the diagnosis rapidly, because if we can administer antibiotics quickly, then maybe we have a chance of turning it around. Every minute counts when people are desperately ill like that. They had put together a model, a software, it was a calculation that was intended to help doctors make decisions and inform them about people’s risk. When this was subjected to rigorous study by an independent academic group, they saw that, in fact, this software performed poorly at identifying patients at risk for sepsis. That actually compared with standard workflows within the emergency department. It could lead to a false reassurance that people didn’t have sepsis and then ultimately to delays in treatment and even effect ultimately outcomes.

Epic said that they had internally validated this in 2015, but where’s the oversight? If this were a new drug, it would undergo very rigorous review. There would be lots of data; people would examine it and try to decide what do. Devices, as you and I know, it’s a totally different topic, but I feel that devices themselves aren’t subject to the same rigorous evaluation that drugs are, and that’s causing a problem right now. We can spend time on that at a different episode. Software’s being put into this category and is often getting a pass. There’s other software, by the way, that’s on the web, that’s supposed to help people make decisions about their health. That is also totally getting a pass.

Actually, we put together a piece, a group of us, that’s going to appear in the BMJ with some recommendations for what we think should be in federal legislation. There’s a big law that’s been put together called Cures 2.0. There was Cures 1.0 that was put together at the end of the Obama administration which is intended to try to guide regulatory approaches. Many of us think that it’s time for the FDA to really take a very close look at how these software programs are proliferating and to what extent they need to be regulated. This is something on my mind a lot. I think it’s a problem to solve, but it’s something that could cause problems and even danger if we don’t get ahead of it. Anyway, that’s on my mind. How about you? What’s on your mind this week?

Howard Forman: You and I were both on a private email thread about the challenges of getting the population vaccinated in Ghana and a bunch of other countries, but Ghana was specifically mentioned. I learned a lot from our colleagues about those low vaccination rates, the vast efforts, misinformation specifically in Ghana, but also in other sub-Saharan African nations and the willingness of people to use religion and lies to scare people from getting vaccinated. It was really heartened just randomly looking into this.

I was heartened to read about a recent effort by Sister Lucy Hometowu, who’s the superior general of the Sisters of Mary Mother of the Church in Ghana, to fight against misinformation. It turns out she’s also an OB-GYN and physician. Together with similar folks locally and in other sub-Saharan African nations, has convinced thousands to get vaccinated. It seems to me and I think it has seemed to most of us from the beginning that the more that local efforts can be driven by local individuals, the more likely they are of success. I am unlikely to convert a “Ruby Red Republican from the deep South” from being vaccine-hesitant to getting vaccinated, but local churches and other trusted folks can do it. I remain hopeful that these efforts will spread and that they will grow.

Harlan Krumholz: Yeah. I think that, of course, consistent with the kind of things Paul Farmer was trying to do, so back to the beginning about the dedication in this podcast, I think that’s a great topic for him. I also think when we heard Professor Opara talk about her work in the community, the importance of having people on the teams who are from the community, who understand the community can relate to the community.

Howard Forman: Exactly.

Harlan Krumholz: I think there’s a really great point, Howie, that is relevant to the pandemic, but relevant to anything we want to do in population health. It’s “Are we really relating and working together?” and back to Paul Farmer’s quote about partnership. Are we really trying to forge partnership or trying to get people to do what we want them to do without taking the time to listen and understand where they’re coming from?

Howard Forman: Right. I couldn’t agree more.

Harlan Krumholz: You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: How did we do? To give us your feedback or to keep the conversation going, you can find us on Twitter.

Harlan Krumholz: I’m @H-M-K-Y-A-L-E, that’s @hmkyale.

Howard Forman: And I’m @thehowie, that’s @T-H-E-H-O-W-I-E.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Sherrie Wang, and our producer, Miranda Shafer. Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan. Talk to you soon.

Department: Faculty Viewpoints

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