Dr. Saad Omer: Lessons Learned about Vaccine Hesitancy

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, and we’re trying to get closer to the truth about health and healthcare. Harlan, what’s caught your attention this week in healthcare?

Harlan Krumholz: It’s this thing that’s going on at the Olympics with Kamila Valieva and the question of her doping, that she had been taking medication or that there was medication found in December in her blood, this drug called TMZ, and the question of her eligibility. But what I’m concerned about in this whole story is that this is all swirling around an enormously gifted 15-year-old. And just for people listening, I mean, people have probably heard a lot about this, but this is a drug that’s not even available in the United States. It’s used in France and maybe some other countries. And the theory behind the drug is that it flips the metabolism from focusing on fatty acids. That’s really what the heart depends on towards glucose. And the advantage is that fatty acid metabolism is more reliant on the use of oxygen.

And so for areas of the heart and people who are having decreased blood flow and are therefore delivering less oxygen to the muscle, that giving them a medication that sort of puts that cardiac muscle in a position where it’s using glucose more as a fuel source, provides some relief, because now it’s a little less reliant on fatty acids, a little less efficient, but that’s the theory. I can tell you that there’ve been drugs over the years that have tried to do this. And there’s still a lot of questions about whether they produce the effects that people think they should. And that’s one of the reasons it’s not even available in the United States. The evidence has never really accumulated about that. There was another drug, Ranolazine, that is available in the United States. It actually was also an inhibitor of the fatty acid metabolism, but ultimately they actually sort of thought that wasn’t the mechanism of its action and thought it was something else the drug did. So even the medical community’s not really sure about what this med does.

The idea is that if it makes cardiac muscle more efficient, maybe it can make skeletal muscle, the muscles that people are using to make those magnificent jumps and to do those amazing twirls on the ice, for example, could maybe make them, the skeletal muscle is different than the cardiac muscle, but that’s the idea, but I’ve never seen even a single study that has convincingly shown that this increases performance, but it’s hard to believe that that someone as gifted really needs something. So here’s the situation where she’s got that. Then the news came out yesterday that maybe there are two more meds that are involved; there’s all sorts of commotion around it.

But the big point I wanted to make, Howie, about health was, should the Olympics be allowing 15-year-olds to compete? Because this 15-year-old is now put in this terrible position around doping, but even with regard to the training schedules and what is required to become the very best in the world, I mean, is this person really in a position where they can make choices for themselves, and decisions? I mean, this individual is a minor. And so I have concerns about the health of any child who’s being put in a position to be the very best in the world and what it’s requiring, what it’s costing them, and what risks are being incurred. I’ll say I was quoted in the Washington Post about it. And I said, “If this turns out to be true, what a tragedy that someone who is so gifted, working so hard and performing at such a high level would be tainted by a medication where it’s not clear that it makes any difference.” And she may not have even known she was given the medication. I think this should cause a lot of reflection, not just about her but about a system where a 15-year-old is put in this position. And anyway, that was the story that grabbed my attention in medicine this week, because it had to do with the use of the medications and the doping. So, Howie, what’s been on your mind in medicine this week?

Howard Forman: So, it’s a COVID topic again, and it’s just reminding me that no matter how much we learn, we still have a lot more to learn. And every country in the world has been a laboratory for COVID policy. We’re watching each country do things a little bit differently, hoping to learn from each, and now I think my eyes and a lot of eyes are now squarely on Hong Kong, which is a very unusual setup where a large part of the population is vaccinated, but it’s disproportionally younger individuals. Only 26% of those over 80 are vaccinated. And the next younger group, the 70- to 80-year-olds, are only a little bit more. And yet 40- to 49-year-olds are 90% fully vaccinated at this point. And the country has very little native immunity at this point. They have not had large outbreaks. They’ve been part of this sort of zero COVID movement. And zero COVID has failed. There is no country that is going to maintain zero COVID. And so the outbreak in Hong Kong, which today hit a new record, only four thousand cases, but still a new record, is stressing and straining the system. And unfortunately, those who are most at risk, those who are elderly and most at risk are actually the least vaccinated. And very likely we’re going to see a lot of deaths there. There’s already strain on the hospital system. And it’s just one more example that every country has attempted to look like they were the perfect example of COVID policy. And there is no perfect COVID policy; there’s just best efforts.

Harlan Krumholz: Well, and we know what we’re going to see there. Omicron spreads rapidly, even among those who are vaccinated. There may be some protection, but it’s not great. It mitigates the risk of the complications, but China—we’ll see what happens. I mean, there may be waning immunity from—even those who are vaccinated, Omicron gets through anyway among people who are just even well vaccinated. And I think that whole strategy is going to start to crumble as it spreads throughout China. And we’ll need to watch carefully. I think we should take care to learn what we can, help them as we can. But yeah, that zero COVID policy is likely to start crumbling in the face of Omicron, I would bet.

Howard Forman: So Harlan, I’m really pleased today to have Saad Omer, who’s the director of the Yale Institute for Global Health, which is an exciting, relatively new collaboration of the nursing school, the School of Public Health, and the School of Medicine at Yale, and really is a core entity within Yale University as a whole. He’s an associate dean in the School of Medicine, a professor of medicine as well of infectious disease. And he’s the Susan Dwight Bliss Professor of Epidemiology of Microbial Diseases in the School of Public Health. He is an absolute expert in vaccinology and virology, and well before the pandemic he was one of those people who was talking about vaccine hesitancy and how do we reverse the vaccine hesitancy that has been developing in the era of social media? So it’s just a pleasure to have you, Saad. Thank you very much for joining us today.

Harlan Krumholz: He is actually an expert in COVID. I mean, we have so many pretend experts who became experts—actually, you and I are two of them—but actually this is a guy who actually knows what he’s talking about. But Saad, I just wondered if maybe, for me and for those listening, you can just tell us a little bit about your journey. I mean, how did you end up doing this, and what was the path that you took?

Saad Omer: Well, there were a series of fortunate events in my case. I was a medical student in Pakistan. When I got into what is now called global health, it was just called public health, but it wasn’t just public health. We were doing clinical medicine there in certain underprivileged communities. And part of the work there, part of the curriculum was to essentially work in underprivileged communities and provide primary care as part of your training. A lot of the training was in a tertiary care hospital, the best in that country, but a lot of it included engagement with communities. On top of that, I got interested in the population health aspects of it and found myself setting up a field site at the age of 19 as a medical student in a remote part of Pakistan, a relatively remote part of Pakistan, which was close to what was called a “kidnapping for ransom capital” for Pakistan. I had to fly in from Karachi, where I was based.

Harlan Krumholz: Your parents must have been thrilled. Were they happy when you decided to do that?

Saad Omer: I give credit to my parents. My dad was perpetually chill about things. My mom would worry about these things, and she was pretty okay with that. So I spent my first break in med school doing this kind of stuff, setting up a field site or one of the initial breaks. And then, while the med school was going on, during the weekends, if I had a weekend free, I would fly in this old what called F27 plane, which was a Dutch plane, to this remote airport. My team would pick me up in these Toyota Hilux open cab trucks. I would make sure that I had stubble to blend in. So I would do that on a Friday evening and come back on a Sunday night and spend weekends there after spending a few months initially setting up these field sites.

So that’s how my journey started. One of my initial projects was in the central prison in Karachi, on voluntary counseling and testing for HIV. HIV was relatively new in that part of the world. And what I discovered, taking sexual history of convicts, is that all the Casanovas in Karachi were imprisoned at that time because they had some colorful and pretty interesting sexual histories. Having said that, then I found myself at Johns Hopkins, where because I had done a lot of work, I was offered a bottom-of-the-ladder faculty position. And I read the rules and have figured out that I can actually, after spending a couple of years there, I can be a full-time faculty, which I needed to be because of my visa.

Harlan Krumholz: Were you in public health, or where were you looking?

Saad Omer: In the [Johns Hopkins] School of Public Health. I was a faculty member because I already had a medical degree, and was doing research around vaccination, because that’s where the job was. So I found that thing, someone found me with my specific skills, and I found myself there. And I read the rules. And when I asked every single person at Hopkins, including my wonderful mentor, Neal Halsey, one of my main mentors. Neal Halsey was a peds ID [pediatric infectious diseases] guy who’s now a professor emeritus, and this is early 2000, right before 9/11. So I worked there for a couple of years, and then I realized that I needed to do a doctoral degree, a master’s and a PhD. And everyone I talked to told me, “You can’t be a full-time faculty and a student in this department.” But I actually read the rules, and it turns out I could be. So it’s been a fun, interesting journey. Then I found myself at Emory as a tenure track position where I went from assistant professor to associate to full to endowed professor and then got recruited to Yale as the inaugural director of the Institute for Global Health.

Harlan Krumholz: And how did we get you, by the way? I mean, what was it that we said that said, “Yeah, I’m going to make a move.” Because you were so well established at Emory and so successful.

Saad Omer: Well, the thing is, a couple of things. I fortunately had options for leadership positions, but the reason why I came to Yale was the fact that it’s a university with multiple loci of excellence. Doesn’t just have a good med school, just doesn’t have... it’s not, that only has a good school of public health, et cetera. It has a strong school of management, strong school of nursing, strong school of engineering, et cetera, and then a strong economics department. So what I found was that what Yale brings to the table is, it’s the breadth of excellence, and Howie knows, and perhaps you know as well. But with Howie, we worked on a few things that had six, seven centers and schools at Yale that were included in these projects. So that was the attractive part. The other thing is, you find, you know, I love setting up things, and it’s rare that a 300-year-old university says, “Come set up a new institute in the area that you are passionate about.” So that was the other thing.

Howard Forman: Can you tell us about when you first recognized that vaccine hesitancy or vaccine confidence, depending on how you want to frame it, was going to become a central issue? I mean, some of your early work, way before the pandemic, was just about how to get women and children vaccinated, but when did you realize how important this issue was?

Saad Omer: You’re right. Absolutely. My very early work was in terms of vaccine trials. I continue to do that. I do vaccine epidemiology and safety, et cetera. But when I started working, it was the early years of what the impact of this gentleman, this physician, who’s not a licensed physician anymore—he was kicked out by the General Medical Council—Andrew Wakefield, who published this paper in The Lancet that created the myth that there was an association between autism and the measles, mumps, and rubella vaccine. And then there was this scare about this mercury compound thimerosal and vaccines and autism. So I was at that point. And as I started seeing very earlier on that often it’s not the vaccines that save lives, it’s the vaccination that saves life. And I heard that for the first time from Walt Orenstein, who’s a former director of the national immunization program who actually came to Hopkins for a collaborative project. And I ended up working a lot with him when I went to Emory, where he was based.

And so that’s where it started. In fact, my PhD ended up being the epidemiology of pertussis, pertussis vaccine refusal, and the impact of laws, of mandates on pertussis vaccination. So fairly early on—not the first thing I did but fairly early on—I started focusing on vaccine hesitancy because that was pretty obvious that that was becoming a bottleneck, not the technologies that we were coming up with.

Howard Forman: Very early on, you and I had this conversation, I remember exactly when it was, it was July of 2020. We didn’t even have a vaccine yet. You and I first had this conversation about the obstacle of vaccine hesitancy and what would happen once we had a COVID-19 vaccine, either what could we have done differently or put a different way, what can we still do now that’s going to help us to get more widespread adoption of this vaccine and to make sure we don’t backslide on childhood vaccinations.

Saad Omer: That’s a really good point. So I think it is worth revisiting what we could have done because this will impact what we should do next—for the next pandemic and for this one as well. And some of this is, as you know, that contemporaneously, some of us had been pushing, but there are a couple of things I’ll come back to that is hindsight, but we should learn from hindsight as well. And so the first thing is, we didn’t plan. We did not have a national immunization delivery plan. People did not realize how unprecedented the scope of delivery was for this vaccine, both domestically and internationally. We had never vaccinated the whole population in a single year. We do cover the full birth cohort in this country and fairly well, we cover teen cohorts, et cetera, but we don’t vaccinate the whole population in a single year.

So the national plan did not come until late 2020 and early 2021. The second thing was—a lot of us had been pushing for money in the appropriations with Operation Warp Speed for vaccine acceptance—that you can’t assume that vaccines will be accepted. The other thing was, a specific vaccine hesitancy and acceptance plan, and we had several discussions, Howie, if you remember, and I’m sure you do, because you’re equally passionate about this. From July through fall, et cetera, that, what can be the specific things? And so I wouldn’t go into the details of that, but that, we needed that plan. The other thing we could have done is, so here’s the hindsight comes in. I think the federal communications should have been proactively from Atlanta from the outset. That I didn’t point to [at the time]. I am a big believer in the whole of government response, but if the career people, and not just the people in the White House, are at the forefront, the image of a former consultant coordinating scientist, in retrospect, didn’t make it a national issue, it made it a federal issue led by a compassionate administration.

And I think that is something I would do differently going back. And the second thing is, we tried to “town hall” our way out of the hesitancy interventions. And the reason I’m saying is, it’s a good way of doing this. This is part of the solution, but these were not town halls happening in church basements, where people are there for other stuff. People who show up on online town halls are already part of the group that wants to hear about a specific topic. And we were not reaching the people who were already part of that. So these are a few things we could have done differently at the macro level, but I’ll pause here.

Harlan Krumholz: I wanted to ask you about an issue that I find difficult, which is an environment where so many of us are concerned about vaccine hesitancy, but sometimes it gets to the point where we can’t even talk about the side effects of the vaccine, so that we can’t have an honest conversation in the country about this balance, because people are afraid if we say anything that acknowledges that the vaccines have any potential side effects. And we know there’s no such thing as the perfect vaccine. I mean, I don’t know that there’s been a vaccine that’s as dominantly beneficial in terms of lives saved. I mean, obviously there are wide range of vaccines that have made a huge difference, but this, given its global nature, was a miracle to come out this fast and the risk benefit is so far on the benefit side. But there is a chilling effect to being able to even investigate, talk about, voice any of these issues.

And I wonder, in your research on this, I mean, is there a path forward, or is it that if you introduce any doubt that it just is amplified? And again, in this social media world, there are people who are just anti-vax and they’ll seize on any information to try to turn back the public health efforts. And I don’t quite know how to walk this, because I do think we as scientists need to illuminate where there might be issues, even though they’re rare and unusual, and yet there’s a prevailing wind that says that that could jeopardize the entire enterprise if we do. What are your thoughts about that?

Saad Omer: So we should, absolutely. It’s not even a close call. We should absolutely be not just candid but proactive in studying and sharing any side effects, for two reasons. First of all, it’s the right thing to do. We should go after vaccine safety hypotheses with the same vigor and intellectual rigor as we go after vaccine efficacy hypothesis, that’s absolutely. My first leadership position was at Hopkins, and I was the associate director of the Johns Hopkins Institute for Vaccine Safety. And we never stopped, within thimerosal, within all of that stuff, we never stopped studying vaccine safety, and we should study it and impact policy, et cetera. And I currently serve on the WHO’s Global Advisory Committee [on] Vaccine Safety. The other thing, the other reason is, it’s highly shortsighted to think that we can paper over some side effects and falsely reassure people and still maintain or earn people’s trust. It almost invariably backfires if you try to act smart in this area.

So for both reasons, for ethical reasons but for also practical, pragmatic communications-related reasons, you never give false reassurances. You tell people what the uncertainty is. You tell them what we know from previous vaccines, but you never hide behind a communications excuse for this. So those of us, and I’m sure you’re in that camp as well, who care about the whole patient, the whole population, care about the efficacy as well as safety of products, including not just drugs but vaccines as well.

Howard Forman: I’m curious to know what you think about for childhood vaccinations in the next decade. Are there things that we can do now to sort of minimize the harm that seems to be occurring from hesitancy?

Saad Omer: That’s a really good question. And there are two things that are happening. One was early science. In March 2020, as lockdowns roll through, and I was sort of talking to collaborators around the world, et cetera. One of the most fragile things in a health system is vaccination system, because you need to continue to sort of deliver vaccines to children, the childhood vaccination system. And in the Ebola outbreak, we knew that more children died of measles than Ebola itself, because of the disruptions. So that was one disruption. And I’ve been calling for a national catch-up strategy. We can’t just increase the coverage in the next cohort. We need to go back and catch up. And we need to do it as a campaign, et cetera. So these susceptibles are accumulating as schools open up, as masks become less frequent in a lot of places for various reasons, these diseases can be the next threat. So that’s number one.

The second thing you were alluding to, the impact on hesitancy. So that’s a tricky one. I think on a state-by-state level, listen to the state public health leaders. And sometimes pushing too hard on some of the more direct measures like mandates. I’m a big believer in mandates. I think there should be a Goldilocks approach to it: not too hard, not too soft. And they should never be used for vindictive reasons to punish someone. But Band-Aids have their own place, et cetera. But then you have to see what is the spillover effect on childhood vaccination, and take the full chessboard approach to mitigate that impact. The other thing is, don’t bring in childhood vaccination when you’re moralizing about a certain part of the population. It’s really difficult when there is a group of politicians who are pushing against vaccination, but as public health people, we need to have the majority to see that look, even if they’re wrong now, we can have a majority of people continue to support vaccines, irrespective of opposition from a specific political section of our society.

But we don’t need a simple majority. We need 90%, 80% people not just supporting but taking their kids to vaccination centers. So we may win the rhetorical battle, but we may lose the public health war if we do not cauterize, we do not separate childhood vaccinations from the political discussions that are happening. It’s a highly unsatisfying answer. I’m as frustrated as anyone else, but that’s part of it. The second thing is, in terms of mitigating the emergence of hesitancy for childhood vaccination, invest in local public health. And make sure that they continue to have the resources and engagement and those pragmatic conversations. Invest in training healthcare providers, because we know across—so I have worked on trials in hesitancy and all of that stuff around the world. One thing that is consistent when it comes to vaccines, the most trusted source of vaccine information is the healthcare provider.

The second and third sources vary all the time between space and time. And so we are not investing in training healthcare providers in evidence-based vaccine communications. Not the evidence of vaccines in terms of the mRNA vaccine technology, et cetera, no, no, evidence from communication science. So these are the things that will help isolate the impact or help reduce the impact of the cacophony of a public debate that is happening around vaccines and aspects of vaccines around COVID and help save the childhood immunization program.

Howard Forman: I want to just pick up on something Harlan said at the beginning as we thank you for joining us today. And that is, it is such a pleasure and an honor to have experts like you on our campus. A lot of the role of public health is about communications and amplification, but you can do neither of it if you don’t have the experts who are doing the research and understanding the topics. And you are an amazing colleague. You are an amazing contributor to the public discourse. And I just, for one, want to say how much I appreciate you and thank you again for joining us.

Harlan Krumholz: Yeah. Thanks so much, Saad.

Saad Omer: It’s my pleasure. And thank you. The two of you, who are leaders in medicine and public health to take on this task of producing a podcast that goes through things with nuance, et cetera, and thanks for your years of contributions to Yale and the field. Appreciate it.

Harlan Krumholz: Thank you.

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

Harlan Krumholz: Well, we were talking about global health and vaccinations today, and I wanted to say that one of our valued friends and colleagues, Gregg Gonsalves, has been working with others to try to advocate for the United States to play a stronger role internationally in trying to fight the pandemic. And I guess you asked me what inspires me, and I’ll say Gregg is a remarkable individual. He’s not only a very good scientist and a wonderful teacher, but he’s an activist. He’s someone who tries to take the ideas into action and to see them manifest as benefit for others. He was putting together a letter to the administration this week, for example, that was seeking signatures. And I thought it was really well stated. It wasn’t confrontational. It was making the case that we have a responsibility to help deliver vaccines to low- and middle-income countries, that our prior efforts have largely failed to really produce the kind of availability, accessibility, and ultimately the vaccination of large numbers of people in those countries. And that the toll of that failure will be immense.

And that we need to step up and we can’t fix what’s happened, but that it’s really a time to try to see what we can do to make things better going forward. And this has to do with a real commitment to doubling down on strategy. Now there have been some efforts to share vaccines and so forth, but there needs to be more, and we need to share vaccine technology. We need to provide vaccines and help with distribution and expand production and sharing of the COVID therapeutics as well. So anyway, I just wanted to say that I see him as someone who’s constantly trying to play a role positively and constructively to make a difference. We know Gregg can sometimes get frustrated with the policies that are around. And I can think in many cases, it’s well founded. So anyway, I just wanted to call out Gregg’s work. How about you, Howie? What’s inspired you or kept you up at night this week?

Howard Forman: Yeah. So I’ll keep this short. I’ve tried to be optimistic on this end over the last few weeks, but I’m really frustrated watching the hypocrisy as we enter sort of the primary season for our midterm elections. And the more and more I see, and it does occur on both sides, but I’m just seeing so much hypocrisy around things within healthcare and outside of healthcare, whether it has to do with deficits, whether it has to do with our role in the world with regard to Ukraine and other nations, or whether it has to do with masking and vaccines. And it’s hard to believe that just 14 or 15 months ago, the vaccine development and the vaccine program was one of the things that President Trump was most proud of. And now it is seemingly such a divisive issue. I think that with gerrymandering and with other movements toward greater partisanship, this doesn’t get better anytime soon. But I do hope there are people in the middle, people who are moderate, who are willing to continue to do the hard work to bring people together and not divide us.

Harlan Krumholz: Yeah. The partisanship is just so intense around anything. We’re seeing, I think, sometimes an absence of principled leadership, but more about partisan advantage. We barely got an FDA commissioner this week. The Congress just can’t seem to come together.

Howard Forman: Exactly right.

Harlan Krumholz: There are a few things that they’re doing in a bipartisan nature that gave me a little bit of hope this week, but yeah, there’s a lot of division, for sure. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

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

Harlan Krumholz: And how about one positive thing, Howie? Since you sort of ended on something that’s got you down.

Howard Forman: One positive thing is that we are absolutely seeing lows in cases, hospitalizations, deaths that we haven’t seen since before Omicron right now. We have therapeutics that are coming on board and becoming more accessible. We have vaccines that have been proven to work during this time. And we’re heading into a period right now where states are arguably prematurely, but maybe not, starting to relax a lot of the nonpharmaceutical interventions, including masking. And I think that we have a good few months ahead, and I think we’re better prepared than we’ve ever been for the future. So I’m optimistic about that right now.

Harlan Krumholz: All right. I like that. That’s good. So I’m at H-M-K-Y-A-L-E. On Twitter, hmkyale.

Howard Forman: And I’m @theHowie, that’s at 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 to our producer, Miranda Shafer. Talk to you soon, Howie.

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