Elizabeth Bradley: Leading Vassar through COVID-19

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. So Harlan, we're about to have a conversation with Elizabeth Bradley, the 11th president of Vassar College and our friend and colleague who's been a leader in global health. But before we get to that, what's something in health news that's got your attention this week?

Harlan Krumholz: Something that caught my attention this week was an article that was published in JAMA Network Open on the topic of surgeon proficiency and its effect on patient outcomes. Now, this is something that's interested me for a long time. What we would like to happen is for surgeons to be like pilots. That is, you assume a certain level of competency. You don't have to vet them. You don't have to ask people, “Which flight should I take? Who are the pilots? Let me see what their record is. How many flights have they taken? How did they do on the simulator?” We assume the industry takes care of this. So when we get on a plane, we've got a team, not just a surgeon, but a team that can actually get us to where we're going, go safely, and we don't even have the cognitive load of having to worry about this. But in healthcare, what's a normal thing that happens? I need a procedure. Then somebody says who's good. And of course, nobody knows for sure. And then there's this big question of how much variability is there?

So in this paper that was published out of the University of Michigan, a really good academic center, they look particularly at surgeons who were reattaching digits. Now I know this sounds gruesome. Maybe we're on the cusp of Halloween, so this may be appropriate. But you know, unfortunately from time to time someone sustains an injury and actually a digit gets separated from their body, and the truth is, good surgeons can reattach them. But what they did was they looked at all the digits that had been reattached over about a decade. And they looked closely at the surgeons and came up with a novel score of their proficiency. And they looked at sort of the first half of the decade, and then they said, “Now, based on what we know of how good they are, does that actually hang true for the next half, for the ones that they did next?” And they could see that there were marked differences in the success of the surgeons and marked differences among all the surgeons. And that was highly correlated. That is, the surgeons who were good in the beginning were good in the end. And so it made a difference who your surgeon was. And I found this very disturbing because I've been pushing the idea of team-based care, the notion that the results are really the basis of how everyone works together. And in this study, disturbingly, it made a big difference. The success rates were very different between the better surgeons and the surgeons that were not as good.

Howard Forman: It is a challenge when you think about commoditization in medicine. On the one hand, we would love to think that we're sufficiently equal among each other, that everything we do is high-quality, and it shouldn't matter who you go to. On the other hand, we know factually that's not the case. And you've just given another example of that.

Harlan Krumholz: This is building on a theme of studies that came out of the University of Michigan, just to say, there was another set of studies that were done earlier, where they actually filmed people doing bariatric surgery, and they could see the difference between people who had very smooth movements, versus people who had jerky movements and actually got worse outcomes. And again, if we're going to start to realize that, then we need to feel like, how can we get everybody so there's a narrow range of top performance, not a big range where it just happens to be who you got may importantly determine how you do. That's just unacceptable.

How about you? What did you see this week?

Howard Forman: Yeah. I've been thinking a lot about global vaccine equity over time. And today, I saw in the news, which gave me a little comfort, that the Biden administration is allowing Moderna to basically take 20 million doses that were due to be delivered to the United States earlier and deliver them to Africa and deliver them to areas that are vastly under-vaccinated. And they're able to do that because quite frankly, we're not vaccinating enough in this country. And so there are leftover doses.

But the reason why it gave me comfort is that too many people have been saying to me that, “Well, if we don't use them, they're just being wasted. They're being discarded.” And that never made sense to me because the manufacturers can direct vaccines to where the need is at any given moment in time. And the only way they should be discarded is if we're over-ordering them to the point of care. And this is a good example that we're not doing that, that there are doses available. And if we're not using them fast enough in the United States, we can release some of those to other countries that need them more acutely.

Harlan Krumholz: And speaking of global health, we have one of the world's great global health experts just about to join us.

Howard Forman: Yes.

Harlan Krumholz: Howie, I'm excited today because we are having one of my most favorite people in the world join us for a session. Well, it happens to be Betsy Bradley, Elizabeth Bradley, the 11th president of Vassar and a spectacular researcher, policymaker, advocate, and now president. Hospital administrator. I mean, she has done everything over the course of her career, including leading Branford College while she was at Yale and having a dramatic influence on the course of my own research and the kind of impact that I was able to have in cardiovascular disease. I couldn't have done a fraction of what I was able to accomplish without collaborating with Betsy. So we're very fortunate to have her. She's steered the institution through some very challenging times throughout COVID. So this is a chance for us to talk to her and get some of her perspectives on where we've been and where we're going.

Howard Forman: Yeah, no, this is really exciting to have you here, Betsy. I've known Betsy for the same 25 years since she finished the PhD. I think we both came on the faculty at the same time. It's an honor and a privilege to have her here. We also share students at this point, and I've gotten used to the fact that we're supposed to refer to her as “President Bradley” from here on. So President Bradley, it's great to have you here. And I think my first question for you is, tell us what it's been like leading a major liberal arts college during a time of pandemic as a global health expert.

Elizabeth Bradley: Thanks, Howie. But before I address that, I have to really just thank Howie and Harlan, those are really kind words that you said, but I just need to tell the truth about this. I would be nowhere without the two of these people. So many times I can remember sitting down with Harlan and him preparing me for a interview to get a grant. And he just basically taught me how to present.

Harlan Krumholz: Oh, come on.

Elizabeth Bradley: And I think of some of those pearls of wisdoms my whole time. And Howie, Howie got Vassar through this pandemic with me. I invited Howie at least three times up to campus. And now our faculty keeps saying, "Can't we start a medical school so we can employ Howie?" But we haven't been able to do that.

So, getting through the pandemic, well, first of all, it has been a 24/7 job. It's really just been a way of life. And I think so many of us in the public health and medical field feel this way. You're just never not thinking about COVID. And when you're responsible for a liberal arts college, where you have 2,500 students living on the campus, 300, 350 faculty coming and going, another 1,200, 1,400 employees, any potential for outbreak is just very chilling and very scary. So what it was like to get through it is just the biggest stretch I've ever had to do in my life. And I do feel like I have, as Harlan said, done a lot of different things across a lot of different countries, but when ultimately you're responsible for people's lives from a systems point of view, yeah, it was really a big stretch—but also thrilling, and I guess, I don't know, one of the most thrilling things is to see how the culture shifted during this time. We were very focused on having everybody here. As you said, it's a residential program, being face-to-face was important. And we have been that from the beginning.

Harlan Krumholz: Well, I think there can't have been anyone who was more qualified than you to lead at a time like this. I mean, and this is speaking truth, with your global health background, with your deep roots in public health and your education around administration, what do you think that you were able to bring to this? And do you think that background helped a lot? I mean, how did you think about it?

Elizabeth Bradley: I mean, my background really did help a ton. I'll start with the background in public health. I mean, just like both of you, I could read the scientific literature. I could challenge some of the papers being written to say, “Wait, wait, wait. Is that right?” And I could sort of use my own methodologic background to pitch different ideas that might work, et cetera. So comfort with the scientific literature was a big thing that helped.

I think also my board was tremendously supportive of us because they knew I had a public health background. That doesn't necessarily mean anybody in public health knew more what to do than anybody else, because none of us have been through a pandemic like this before, but I think I got more sort of confidence. And then I got put on Cuomo's reopening committee for New York State because of my background. And so I was intimately involved in writing the guidelines for higher ed coming back. And that helped a lot too. I'd get early information and then would be relied upon about, “Okay, how could we actually bring higher ed back?”

The management side has been incredibly important too. And I must say, I never thought I'd be a hospital administrator again, but there were times that I would walk in in the morning and I'd say, “Oh my gosh, this is exactly like being a hospital administrator. We need a bed management program. We transfer people to different parts of the college.” And really, all of that came back. The greatest wisdom I got from management and so much of this work was with you, Harlan and Howie, was at the end of the day, you're championing a vision, an idea, which is at the top, you got the big vision, but you're getting nowhere unless you have the front line completely sold. And in fact, get the momentum going at the front line. So we worked a lot on how to do that.

Howard Forman: Yeah, I will say, you've taught me a lot about leadership over the last few decades. And you have been a true leader during this time because it does require bringing together all the different stakeholders, both in the community, within the college, the students, the staff, the faculty. I experienced a little of this speaking to your various groups.

But I'm curious to know, what attributes do you think you drew upon the most from your personal experience that helped you be so successful, because quite frankly, as an outsider, you were extremely successful at having agreement among all these groups and a singular focus?

Harlan Krumholz: And the parents. Don't forget the parents. I'm sure you were getting tons of calls.

Elizabeth Bradley: Oh, my gosh.

Howard Forman: Oh, my God.

Elizabeth Bradley: Tons.

Howard Forman: Including our colleagues.

Elizabeth Bradley: Tons.

Howard Forman: Including colleagues.

Elizabeth Bradley: Exactly. People that all three of us know very well. Yeah. I don't know about the attributes, Howie, but I do know about some of the sort of strategies that we use. And I will say, one of the most important was setting our values at the very beginning. I remember sitting in this office with our whole senior team and we were flailing, like everybody was, “What are we going to do? What are we going to do?” And we said, “Okay, job one, we have to set our values. And after that, we'll know what to do better.” And so we set them from the beginning, and I put them on a big sticky on my wall in the office, et cetera. And then later on Zoom, but the first one is to protect our most vulnerable, no matter what. We had to create a system that our most vulnerable people, we were not going to have any deaths. We were not going to have any train wrecks. We were going to protect them. And that was financially vulnerable people too. So that led immediately to, we will not have layoffs, no matter what.

And our second value, which is very Vassar, was equity. We were going to try to implement things in an equitable whole of college. So if we had to take cuts, everybody was going to do it, from the chair of economics, which is sort of like the cardiac surgeon to another field that's less well-paid, et cetera.

And our third value was our mission. We wanted to continue to give the highest-quality liberal arts education you could in an inclusive setting. So that means you've got to be on campus. Setting those values at the beginning and keep talking about them every time I was in front of the faculty or any of the employees was super important.

The other thing that we did is, we created a group called Vassar Together, made up of our union staff, our administrators, our students, and our faculty who was in charge of taking what the senior team said was the vision and was the general framework and telling us how to implement it. Like, what does that mean that we're going to have a campus that everyone's got to stay on the campus, like an island, like the New Zealand of higher ed? How are we going to do that? I didn't figure that out. We gave it to the front line and said, “Okay, we got to keep the students on campus. How are we going to do that?” And they came up with really great social norms and ways to support people doing that. They were non-carceral, non-punitive. And I probably wouldn't have thought of all those things, but they did.

I guess the second thing is trusting that you just have to set the basic bar and then trusting people that they will come up with better ideas.

The last, and this is an attribute, we just communicated constantly. Every two weeks, we had an all-college forum on Zoom, and really, most of the college came, webinar. An hour. I would give 20 minutes of comments and then say, “What are your questions?” And it was just exhausting, because you get kind of repetitive, but I learned so much through those, what people asked me, I'd be like, “Okay, we got to really think about that now.” That's a priority. So I guess those are some of the ways that we got through it.

Howard Forman: I had a tiny taste to that when I spoke to your faculty and staff, and I will say, you are remarkably transparent. You would say to me in advance, “Here are the types of questions they might ask you. And as long as you're comfortable, answer anything you can.” It was never like, “Tell them only the good stuff.” It was really powerful. So I appreciate that.

Harlan Krumholz: So what's it like now? I mean, do you feel you're still in it, or have you now reached a point of equilibrium about how people act? What do you see is happening in this moment? And what do you think is going to be in January? I mean, if the variants and so forth don't change, but we're sort of like where we are now.

Elizabeth Bradley: Well, the truth is, I've been surprised at how hard this year is compared to last year. Last year, you could rev people up to be urgent, like, “We are in a pandemic, people. Get on your mask.” You could sort of get people to take it really seriously. This year, I kind of want to calm people down. We are a hundred percent vaccinated. We are just testing all our students because it was past... We've been away for a week, and I think we've tested thousands, really. And we're getting maybe five, six cases. I mean, we are just really okay. But to have people take a breath and stop being so scared, that's actually a fear I have, is how are we going to revert to the normal risks of normal life and not be sort of overreacting? And often when we overreact, there are unintended consequences.

Like I'm thinking of this one debate we had this morning about when we have a lecturer come to campus, if they're six feet away and vaccinated, and they're giving a lecture to 200 people, all vaccinated and all in masks, can that lecturer reduce their mask? Can they take it off? And I mean, of course they can from a public health standpoint, but the faculty, the students, people go, “Errrr, I don't know!” We're so used to constantly having a mask. So how to calibrate risk tolerance, it's much harder this year than last year, much more subtle, I think.

I do think that going forward in the spring, and this will be our biggest challenge, how do we get back to not having a mask inside? I mean, that's what we're really working on. How do we do that in a safe way? We just can't keep masking on the inside. It changes people's mental health. It changes how we socialize. It changes how we learn, particularly languages. I mean, you both know this. So that's what we're really kind of shooting for. We're getting everybody boosters soon. I think we're going to get there. That's my dream.

But you're the physicians. You tell me!

Howard Forman: Yeah, look, I think it's challenging. And I will say our School of Public Health has taken a position to wear masks when you're lecturing. The rest of Yale University makes it optional. And for me personally, I've decided to just test on Mondays and Wednesdays so I can take the mask off Tuesdays and Thursdays without feeling like I'm in conflict, but there's no perfect way to do this. It's all about mitigation and all about trying to balance the interests of everybody. So I agree with you, it's not easy. And it's great to hear that you're working toward trying to remove masks in most situations going forward. I'm curious, because you said you have a hundred percent vaccination on campus. That's an enormous accomplishment, and very few places have gotten to that. Can you speak a little bit about how difficult that might've been, or why it was so successful?

Elizabeth Bradley: Yeah. Yeah. It was really hard among the employees because we have four unions and although the unions cooperated and we cooperated with them very well, it took time for us to go through the science a lot, to really sit down again and again and say, “This is really where we have to get to.” So we didn't have the agreement from all four unions until about three days before school started. And then we gave some bleed-in time. So that took a while.

We do have medical and religious exemptions, very, very small, like less than 2% of the population has a religious or medical exemption. Everybody else is vaccinated. I think for the students, it was easy. Really, they just all wanted to be vaccinated. The employees, it was harder. And again, I think it was the relationship with the unions.

Also, and this ties to just another point I'm hoping to pull out of last year and keep with Vassar forever, we really worked at this “whole of campus” of response, and the moral underpinning of it was this motto and, Howie, you probably heard it when you were here, but “we” precedes “me,” which is not that easy for 18- to 22-year-olds to think about, that the community is more important than what I want. And when we were pitching the vaccination, that's what we were saying, like, “You might not want to be vaccinated, but this community can work a lot better together if you're vaccinated.” That's a value we have, “we” precedes “me.” And people bought into that, and it's small enough and close enough physically that we could actually make that work. And I hope it'll stick because I think the more people recognize and accept their interdependence, the healthier we'll be over the long term.

Harlan Krumholz: So you have deep experience in strategy in the United States and across the world, of course, having worked with Tedros [Adhanom, director general of the World Health Organization] very closely in Ethiopia, and you see what's going on in the country. If you were in a political position in this country right now, and you're giving advice to the administration about how to bridge this hesitancy and the fact that our nation is fragmenting into more of “me” than “we,” what are your thoughts about what we should be doing or how we should be doing things differently?

Elizabeth Bradley: Tough question. I really do not have the answers, but I'll give it my best guess. I mean, you asked what I would do. So what I would do is take advantage of what Americans are really good at. We're super good at innovation, and we're super good at local activism, local movements. And even when we look at the top-performing areas of the country, it's usually a county or a hospital. So I think we have to work locally at this as well. And what we haven't done enough is create a latticework of local leadership, and that can be from any sector, medicine, religion, social services that start to work with their own constituents about, okay, vaccination and scientific literacy.

I think if we constantly try to do it from the top down, even at the state level, it's too high. I think the investments have to be made very locally. And when I think of what has happened at Vassar, and again, we're still in the middle of it, so I don't have so much hubris. Like, I want to stay humble here. I think the fact it's really a local institution has helped us a lot. So we've got, I don't know, 3,000, 4,000 people we have to take care of. So if the country is split into aliquots of 5,000 people with some leadership, I think we have, really, potential with that, but top-down things I don't think we do as well.

Harlan Krumholz: Yeah. I'll just say one quick thing about that. I felt that from the beginning, that it's the in-group, not out of group where the influence comes from, and even with the issues in Florida, the federal government just can't come in as strong-armed people. What it needs to do is to tell people, “When you're ready, we're ready. We will help you at any time. We'll make sure anyone who wants a vaccine can get it. You guys have to work this out locally because it just is too hard on the federal level.” I know there's counters to that, which is, there's a responsibility federally, but it just, in some ways that push created an even stronger resistance.

Elizabeth Bradley: And I think what you just said is exactly right. The federal framework has to be enabling, has to set the framework, the governance structure so it's there if you are ready, but at the end of the day, we are a local people. We are individualistic and independent and that benefits us because people will move when they want to move, but we have to step back and I think rely on those more local structures.

Howard Forman: I know we don't have much more time. So I want to ask one last question and that is, everybody you talk to say, “There are some silver linings from this pandemic and lessons to be learned that can help inform the future.” I'm curious to know, are there any one or two things that you think about that Vassar gained that will help propel them into the next decade and so?

Elizabeth Bradley: We learned a lot, honestly. First of all, I think starting with “we” precedes “me,” that's kind of in our blood now. We're going to keep that and do our best going forward. And what better thing to grow up with when you're 18 to 22 and hopefully replicate when you graduate and go into the larger globe of what one wants to do. So that's key.

Technologically, it's like we went forward 10 years. Every faculty member knows how to teach online. We know how to have meetings online. I mean, our classrooms are now equipped technologically. We're just so far ahead of where we would have been.

The last thing we really learned is how to be in community with Poughkeepsie and our Dutchess County, because I worked really closely with our public health agencies here, and our faculty did too. And I think going forward, a lot of those pathways between the college and our larger community are much better worn now. And I hope we'll continue to benefit from each other's assets and understandings.

Harlan Krumholz: Yeah. I just want to thank you for taking the time. Great work. No surprise, but really great work.

Elizabeth Bradley: It's so nice to talk to both of you. And you are invited to Poughkeepsie anytime. Hour and a half from New Haven, right up the train line. And we'll treat you well up here. So thank you so much, Howie and Harlan.

Harlan Krumholz: Thank you so much, President Bradley.

Howard Forman: Thank you, President Bradley.

Elizabeth Bradley: Take care.

Howard Forman: Take care.

Harlan, what's one thing that inspires you or keeps you up at night?

Harlan Krumholz: This is kind of something that's keeping me up at night. You know I love NIH, and I think Francis Collins walks on water, Tony Fauci, same thing, but there's this weird thing going on, where the NIH sent a letter to members of the House Committee on Energy and Commerce that talked about a grant that they had given to an organization called EcoHealth Alliance, a New York City–based nonprofit that works with laboratories around the world. And it turned out that this organization had been working with that lab in Wuhan and, in fact, was working on bat coronavirus. In fact, we're working with putting a gene into mice that has this ACE2 receptor. That's the receptor that we all carry, humans carry, that the coronavirus links into. In fact, did some work where they found that with some manipulation, actually that the virus became more aggressive and more pathogenic.

And for a while there was a lot of uncertainty about these grants and what were they, what are they doing with China? What's this Eco Alliance, and now they're coming out with this letter saying, on one hand, there's no way this has anything to do with the pandemic. On the other hand, we want to disclose that Eco Alliance was behind in reporting what was going on with the grant. We would have had a higher level of scrutiny if we knew that one of the experiments was leading to a situation where the virus had become more pathogenic. And I just find it all confusing. I'm not making any conclusion about it, but it just seems like it took a while for this to get out.

And then a guy, a Stanford microbiologist, David Relman, you may know him. He's a very well-regarded scientist. His father was a New England Journal of Medicine editor. And he was asked about this and he said, given all the sensitivity about this work, it's difficult to understand why NIH and EcoHealth have still not explained a number of the irregularities with the reporting of the grant. And he goes on to say, “It's another chapter in a sad tale of inadequate oversight, disregard of risk, an insensitivity to the importance of transparency.” And I'm looking at this, and I know Relman, and I'm thinking about how all this fits together, and yeah, this is something on my mind. I think there will be more to come on this. I think it's not done yet. And it is a question of, is this just a true-true, an unrelated, but it just seems weird that the US was funding research in that Wuhan lab around that coronavirus and ACE2 receptors. I don't know.

Howard Forman: Yeah. It really reminds me just how important transparency is and how important journalists are for digging into areas that may be opaque to the rest of us. The topic I wanted to talk about this week is somewhat related to that in the sense that our colleague and friend Eric Topol from the Scripps Institute tweeted out yesterday about a paper that sort of summarize the evidence in ivermectin, but looking at it through a lens of bias and fraud trying to minim—, when you're looking at a meta-analysis of the evidence in ivermectin starting to minimize those papers that have a significant amount of bias built into them. And obviously excluding those papers that have now been found to be fraudulent. And it just changes completely our apparent equivocation about ivermectin to basically showing that there's no compelling evidence that shows that it works.

And his point and other people's points, and you have said this to me many times, is we just need to document every clinical trial. Like it is no longer acceptable to have some clinical trials moving on to publication and some clinical trials, perhaps with negative results, not moving on to publication because when you do these types of meta-analysis, it will bias the ultimate results from them. So again, in that theme that you've talked about, transparency, in my opinion is only a good thing. And more interrogation of that data is always a better thing.

Harlan Krumholz: Oh, this is more than transparency, in my view. I mean, this is really scientific misconduct. I mean, people running experiments on human beings and not sharing the results, it ends up corrupting the entire medical literature. It leads you to concerns that many of the trials, particularly ones that didn't go the way the investigator wanted, never see light of day. And so when people combine them and then say, like, “This is the world's literature on this topic,” and yet a large amount of evidence is missing, missing, hidden away, no one can find it or see it, the truth is you can't draw any reasonable inferences from the data.

And as you said, I've written about this a lot. I've talked about it in many venues and believe that this is something that we should take very seriously. If you do not publish your results, you should not be eligible to get federal grants. You should be suspended within your institution if you conducted experiments on human beings, for which you registered studies, and you did not share what you found. And yet institutions do not take this seriously enough.

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: I'm at @hmkyale, H-M-K-Y-A-L-E.

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 to our producer, Blake Eskin of Noun and Verb Rodeo. Talk to you soon, Howie.

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