Joshua Sharfstein: Policy and Health

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

Howard Forman: I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. Our guest today is Dr. Josh Sharfstein, but first we’re always going to check in on current or hot topics in health and healthcare. What do you got for us, Harlan?

Harlan Krumholz: Well, it’s summertime, Howie, and I’m pondering the COVID pandemic. I think we can talk about—

Howard Forman: Oh, I’m grateful that you’re going to do that, because I have to say, my father has asked me about that. I didn’t want to bully you into doing it, but I’m thankful.

Harlan Krumholz: No, no. I’m only here for your father, honestly. That’s the reason I’m here. It’s a little puzzling still, this pandemic thing. First of all, of course we’re dealing with all sorts of different things. As you’ve talked about with flu, and there’s just lots of viral illnesses going around, but COVID is rearing its ugly head. If you look at the CDC stats that they just posted this week, test positivity is 11%. Of course, that depends on who gets tested, but if we look at emergency department visits for COVID-related illness, it’s up. Hospitalizations is starting to nudge up. Deaths, yeah, a little bit nudging. It’s really not peaking, which is the interesting thing. I’m sure you’ve had the same experience I’ve had. Talked to a lot of people who’ve had COVID testing positive, not sure what they should do because should they really isolate or not.

One person, healthy individual, young, reported to me that he had a bad case of COVID and developed myocarditis associated with it. Hadn’t heard that in a while. Said that he lost smell for a while until he started Paxlovid. Whether that was related, hard to know. But we haven’t heard about the loss of smell for a while, and maybe we’re now in a variant and in a time where some of this is going back. I mean, the interesting thing is it’s very hard to talk about the pandemic reflecting on past experience because it’s in such rapid evolution that almost every wave is a separate illness unto itself. So of course in the beginning when people were lining up for ventilators in New York City, I mean, that was a very different disease, a lower respiratory disease than what followed it subsequently with Omicron, with more upper respiratory, to where we get now with the FLiRT variants and so forth.

I always look to the wastewater as a real barometer to the extent to which our society is being infected by COVID. I say that because the tests, people are intermittently testing now. There’s not a real good surveillance system. Whether people show up in the ED depends on emergency department, depends on the severity of the illness. So it could be that lots more people are being infected, but it’s just not as severe now. Well, if you look at the wastewater activity across the country, it is going back up, and it looks like a pretty big inflection point that may get us to close to where we’ve been with some of the other peaks. Nothing like January 2022, but since that time, if you look at the other peaks, I expect this peak may approach it. The West Coast has got pretty high rates. We’re on this East Coast Corridor experiencing kind of high rates, New Orleans, Florida, St. Louis, a lot of places are seeing this.

So anyway, I think there’s a bunch of questions that are coming up, which what is this going to be? What’s the impact? What should people do? Is Paxlovid still effective? Seems like it is. How about should people be getting boosters? Hard to tell right now. There is still going to be a push in the fall for boosters. Whether the boosters that we’ve got available are good matches with the variant that will be circulating at that time is uncertain. I think there’s some degree of optimism that they will be, but it’s unknown. I just want to say to people, sometimes you hear this word “FLiRT variants,” which may seem kind of funny to call the virus a FLiRT variant. Just to say what that is, because if people don’t know, it’s describing a family of variants with particular kind of mutations. You may hear the word sometimes people are calling KP and then some numbers after it, or JN with some numbers after it.

It was this JN.1, these are just nomenclature they’re using, which has been dominant in the U.S. for the past couple months, and that family. What is that family? What happens is that within the spike, this virus has got a spike protein and that’s when the vaccine is doing an anti-spike helping us to fight that. The virus is mutating that spike all the time. When there are specific mutations in particular positions of that spike, that protein within the virus, it’s helping it to evade antibodies that have learned to attack the virus when the spike looked slightly different. So even very slight mutations in the spike can help the virus to evade the attack from antibodies and also by extension the vaccine, because the vaccine’s helping the body produce anti-spike antibodies.

If the virus shifts so that our anti-spike antibodies are not tuned to the way the spike currently looks or is, honestly, configured in three-dimensional space, then it may not be as effective in getting rid of it. So that’s sort of what’s going on right now. The spike itself is evolving. Gosh, this virus is smart, trying to evade our defense systems. We’re trying to produce vaccines that’ll help us develop defense systems, that’d be good, but it’s a race. The virus changes, and we’re just always a step behind. The question is, is that step behind close enough? Is the vaccine helping us produce antibodies that are close enough to what it is today so that it’s still helping us mop up, clean up the virus? So we’ll have to keep a close eye on this. I don’t know if you’ve had much experience either in your work in the emergency department or with friends and family.

Howard Forman: Yeah. I always feel like the emergency room’s the canary in the coal mine for me, and we are just not seeing anything close to the previous outbreaks. I mean, nothing. We see a very typical occasional cough patient who might or might not have COVID, but nothing bad yet. Doesn’t mean it can’t get bad, but right now I’m heartened by the fact that there is nothing catastrophic going on right now.

Harlan Krumholz: Yeah. And this doesn’t mean people aren’t getting sick—

Howard Forman: Right.

Harlan Krumholz: …and then that’s causing them to feel bad or not.

Howard Forman: Right.

Harlan Krumholz: Lots of things, but it just means it’s not escalating to the point where they’re getting so sick they’ve got to come in the hospital.

Howard Forman: Right. No, thanks for giving us.... Thanks for that update.

Harlan Krumholz: Let’s get onto our guest, Josh Sharfstein.

Howard Forman: Dr. Joshua Sharfstein currently leads the Bloomberg American Health Initiative as director and serves as the Johns Hopkins Bloomberg School of Health Vice Dean for Public Health Practice and Community Engagement. He holds a professorship at Hopkins and has also been chairing the Health Services Cost Review Commission of Maryland since last fall. Before coming to Hopkins, Dr. Sharfstein held several other positions in healthcare administration. He served as the Maryland Department of Health and Mental Hygiene Secretary, was a Baltimore City–appointed Commissioner of Health and was the principal deputy commissioner of the FDA. Throughout his career, Dr. Sharfstein has considered how to best manage public health crises and how to make public health institutions more resilient to emergencies.

He’s the co-author of The Opioid Epidemic: What Everyone Needs to Know. He graduated summa cum laude from Harvard with a bachelor’s degree before staying on to obtain his medical degree at Harvard Medical School, and he’s trained as a pediatrician. Both Harlan and I first met you when you were working for Congressman Waxman, and we just had on a few weeks ago Tim Westmoreland. You have done enormous work in the public health space, advancing public health, advancing healthcare reform and so on. I wanted to start off, since you wrote this book in 2019 and the opioid epidemic has really gotten worse. Maybe it’s finally peaked, but it’s gotten worse. Can you give our listeners a little bit about what are the challenges to the opioid epidemic? What are the solutions you put forth in the book? Because I know that you and your wife put forward some ideas about what we could do better.

Joshua Sharfstein: Sure. Thanks so much for having me on the podcast. Let me just start there. The overdose crisis right now is unprecedented, not just the United States but in the world. Over 100,000 Americans dying every year from overdose. We’ve seen this come in waves, and each wave has gotten worse. You said, what are the challenges? The biggest challenge right now is the dangerousness of the drug supply. Because where this particular epidemic started, with more people taking and dying from prescription drugs, that shifted around 2010 to heroin, and then the heroin has been driven out by fentanyl, highly potent opioids, just a tiny bit difference in the amount of fentanyl is life or death.

I was a medical student learning to write orders because we used to handwrite them, and they taught me that you wrote fentanyl and micrograms, m, capital C, g, because if you wrote it as M, little cg, for “micrograms,” then people might not see the C, and you could kill someone because a little bit extra in terms of micrograms would be deadly, and that’s what’s happened. We see this enormous surge of deaths, and so you’ve got to think differently in order to solve it. You said, what are the kinds of things we recommend? One of the really important things is to realize that the treatment medicines, particularly methadone and buprenorphine, do a great job at reducing craving, but they also do a great job competing at the opioid receptor against fentanyl and are highly protective.

It’s really important to get people medications quickly, particularly before the next time they go into withdrawal. So we see in multiple settings, in the ER, if you get someone medicine right there, then they’re much more likely, double the chance that they’re successfully in treatment a month later. If you get people dose of methadone right after they get naloxone, right after they’ve been resuscitated, there’s a study, fivefold increase in follow-up and treatment because you used the chemical properties of the medicine to stave off the withdrawal, address the craving, protect the receptor and gave people a chance to get into treatment and take their own path through treatment, addressing the different issues that people have that have contributed to drug use. So we’ve really got to have systems that get people treatment quickly at every turn.

Howard Forman: For our listeners, naloxone is Narcan, correct?

Joshua Sharfstein: Correct.

Howard Forman: Great.

Harlan Krumholz: We jump around on this show a little bit, Josh, so we’ll pepper you with a few different kinds of questions.

Joshua Sharfstein: Sure.

Harlan Krumholz: It’s such a pleasure to have you on. For anyone who really takes a good look at your career can just see what is it like for someone who’s just made a life of contribution, has found many ways to make contribution. So I consider you one of the national experts, foremost expert in trying to think about how to translate policy into public health, how we can use policy in ways that will elevate the health of people within the population. I want to tap your view on something that I’ve been thinking a lot about lately, and that’s about vaccines and COVID, I know it must be one of your favorite topics, because it’s so contentious. But as I look back on it, I wonder if the push to get everyone vaccinated, I haven’t even bounced this off you yet, Howie, but I’ve been thinking about this.

We got Josh here. It was the push to get everyone vaccinated, in fact, sort of an approach that maybe was a mistake because the vaccine wasn’t known to slow the spread. What it was was to mitigate the impact on individuals and should we have defaulted more to a shared decision-making model where we weren’t forcing it on people, and as people saw that other people were benefiting, that maybe it would’ve grown organically in terms of the number of people who wanted to get access and take advantage of it, as opposed to mandating and then having a reflexive response by large segments of our population to the government saying what I should do with my health.

I’m just trying to think for the future how we manage this because to me it was a problem, not so much with the science but the idea of how the information was received by large segments of our population when the government comes in and says, “Here’s what we’re doing.” I’m just trying to think, have you thought, “How should we do this better in the future if we have a vaccine that can mitigate consequences but won’t slow the spread?” It is not about transmissibility, it’s about impact. Do you have thoughts about what we should be thinking about for the next time?

Joshua Sharfstein: Yes, it’s a great question, and I appreciate that you started with the easy question of the overdose crisis and that’s kind of got me warmed up here.

Harlan Krumholz: We warmed you up, we warmed you up.

Joshua Sharfstein: Yeah, because this is not an easy one. I think that there’s a middle ground between, “Hey, there’s something that might protect you if you want to get protected” and “This is a mandate for as many people as possible.” I think that that middle ground probably looks like a recommendation that’s pretty clear about what’s in people’s best interest for their health and mandates in certain areas where they can be justified. I was part of a commission that kind of talked about what are the conditions under which a mandate may make the most sense. I think maybe you guys have a better sense than me. I haven’t been convinced that there’s no impact on transmission. When people are really sick, they are spewing enormous amounts of virus in every direction.

Did a vaccine keep you from getting a mild case? Not so much. Could you pass it on? You could. But could you pass on a lot more if you were incredibly sick and putting out billions of copies of the virus in these different situations? I would assume so. I do think that there’s particularly people in certain circumstances it really would matter. So as an example of that would be someone in the hospital, someone who’s working in the hospital with vulnerable patients. Is it reasonable for doctors and nurses to be vaccinated so that they are not coughing billions of COVID viruses on people who some of whom can’t even be vaccinated? I think that’s reasonable. I think those mandates in healthcare areas and long-term care facilities were reasonable, but they have to be explained on that basis.

I think that part of the challenge we had is that we started, I thought, with a very strong and transparent effort explaining about vaccines. I like the advisory committee meeting that FDA had. There was a big discussion about what the data meant, and of course there were a lot of people enthusiastic about getting vaccinated. As it went on, it was kind of like “Today’s Tuesday, there’s a new recommendation out there.” There wasn’t nearly as much discussion. There weren’t often advisory committee meetings. There was often not even, some basic questions weren’t being answered about the various pros and cons of different things, and I think we lost a major opportunity because what’s happening when the government is not explaining itself is that that void is being filled by just a massive torrent of misinformation.

So this wasn’t, I think, entirely people debating the finer points like we might do on this podcast. This was partly people getting just horrifically misled at the same time that there wasn’t that much being said by not just people in the government but other people who understood what was actually happening in the studies and what the key considerations were. So I’ll give you a specific example with respect to pediatrics. There was a period of time where the pediatric studies were getting delayed and nobody would talk about why. If there were articles about it, it was entirely from the perspective of unnamed sources saying, “We’re hearing that there are studies getting delayed because of X, Y, or Z.” As opposed to someone like at the FDA or the Academy of Pediatrics or maybe together saying, “Hey, here’s what’s going on with pediatric studies, and here are the different issues.”

Let’s actually talk about it in a way that so when we get into it, people are prepared and there’s some ballast against people just saying, “Well, kids are dying all over the place.” It’s really, really a difficult environment. So I’m sympathetic to the idea that it was heavy-handed in some cases, but I think it’s really you got to see it as part of the overall context. I think the government could have done a better job proposing things, getting comment, having discussions before moving forward with policies, but probably the policies I would’ve picked would be more or less in a lot of cases what happened. I will say this, I volunteered about 50 times for vaccine clinics. I did everything they wanted me to do. Spanish translator, drew up the medicines, medical consult, whatever they asked, I did it. As the pandemic wore on, I asked a lot of people, particularly people getting vaccinated for the first time why they were there. A large number of people at these clinics said, “Well, my employers said I had to do it, so I did it.”

So you have to balance against the idea that if you force someone to do it, they’re less likely to do it. There’s that kind of sense out there. For some people, that may be true maybe, but you have to balance that against some people who think, “Well, if you really want me to do it, then you’ll require me to do it,” and that’s perfectly fine for them. They were just like, “Yeah, it’s no problem. I got required to do it, so I figured now I got to do it.” That probably got us 20 points, something like that, in terms of the vaccination rates. It was not a small number of people that bounced up when some of those requirements took place. I think all these things have to be balanced against each other. I didn’t like just the “new policy every day” poor explanation. I just didn’t think that that really helps so much.

Howard Forman: But by early 2021, we had massive flow of information around COVID vaccines. It was almost difficult to sort of separate the wheat from the chaff at times. It was complicated. I’m wondering now as we’re dealing with the highly pathogenic avian influenza, bird flu, H5N1, which right now is primarily a farm disease, a disease of cows, poultry, and occasional humans that are infected through presumably mostly milking or poultry culling. What are your recommendations? You’re an outsider to this now. You’re not at the FDA. You’re not advising the CDC directly on this, but what could we be doing differently right now or what are we doing particularly well right now with regard to this very early prehuman outbreak?

Joshua Sharfstein: A couple things that I think we’re in a much better position on. One is, we do have tests lined up, and it’s based on a virus that we know pretty well and a platform that we know pretty well. So it’s not quite the problem of scrambling to get a test that works. There are also potential treatments right there that work for influenza that could potentially be useful here. So that’s very good and that there’s work happening on a vaccine already, which I think is really important. So a number of things there are working. The challenge of really understanding how viruses move in populations were fierce during COVID, and they’re fierce on this because these are happening on dairy farms that don’t have the relationship with public health, with workers who may well be suspicious of public health in some cases for good historical or otherwise reasons.

So the challenge is I think come in to really getting a sense of what’s happening now. I think there’s a lot of work trying to build bridges with the farms particularly, understand what’s happening to cows and understand what’s happening to humans. But it’s been hard to really appreciate how much is being done. It’s a little bit opaque. Also, I think most people would say that they wish they understood more about what was happening in those areas. So that’s I think what gives people anxiety. I recently wrote an article with Dr. Nicole Lurie about this, and we talked about how this reflects the importance of local public health because it’s often local public health that has standing relationships with farms or with the local agricultural groups that are on farms that allow you to go in and have a better and more effective surveillance. It’s not so easy to mandate it from on high.

This also goes to the previous vaccine discussion we had. It’s a lot better if you have a trusted local health and healthcare system to get more people vaccinated without having to use more regulatory kind of approaches. It’s just, everything’s easier if there’s a well-trusted public health agency. The problem that we have in this country is that there are so few places that have been adequately funded, it’s just been really hard for a lot of those bridges to be built. This is a moment to realize that our security rests on a foundation of strong public health practice. The ability to reach communities before the misinformation does or to counter the misinformation, the ability to reach into employees and employers that typically aren’t spending their time thinking about infectious disease. That’s not something you can just flip a switch on. It really has to be part of routine public health work.

Harlan Krumholz: I want to just jump now to another topic which is a little controversial that you wrote about, which is the role of AI in medicine and public health. So fortunately today we’ve got an expert in health policy who can tell us a little bit about your thinking about this. So in April, you published a paper on the role of policy in AI-assisted medical diagnosis. I think for a lot of us, we’re grappling with how exactly we can, on one hand, encourage the innovation, on the other hand, protect patients and ensure that clinicians know what is trustworthy, what can they rely on for this.

It all hinges on this paper that came out that showed that Epic, the pervasive medical record company that’s in almost all the academic institutions in the United States had been pushing a program, an AI program that was supposed to be helping people diagnose sepsis, that actually when it underwent scrutiny was shown to be highly flawed and misdirecting clinicians and could potentially have caused harm. So raising all these kind of questions about, what should we be doing to ensure that we’re using these in the right way? What’s the role of policy? What do you think it—ideally, what’s going to happen with this as the capabilities increase?

Joshua Sharfstein: It’s a really important role for policy, and my fear is that the technology will get out there way ahead of the policy, be used in all kinds of ways, and we’ll just be finding about the problems later rather than putting in place a framework that can help. The framework is not having to review every single individual use separately with the whole massive clinical study. I mean, you could imagine treating each use of AI like a pharmaceutical and fully evaluating it; that’s not realistic for a number of reasons. I think you’d be depriving yourself of the potential benefit as you move through four uses instead of considering many. You have to be able to review platforms, have principles, think about the components that are going into models rather than individual models, but at the same time certain models should be evaluated and you should feed that back into the underlying process.

Let me give a more specific example. What data sets are being used to train the AI? That’s what we wrote about. There’s a big concern that AI will be trying to help with diagnosis based on the medical records, which could be filled with flawed diagnoses. So if you’re trying to learn how to diagnose from sort of the routine diagnoses that are made today in clinical practice, you’re not necessarily going to get recommendations that are better than that. The example we used was the fact that a lot of people present to the emergency room with dizziness, and some of those people have had strokes. A lot of times that diagnosis is missed. So if you just train people on what actually happened as opposed to a dataset where you know for sure which was a stroke and which wasn’t, a really good dataset, then the AI could be giving you the wrong answer.

There should be standards for the datasets that are used for really important clinical applications. FDA could set those standards, assure those standards are being met, and then you’re starting in a much better place. In addition, how the models are built, there may be particular rules, certain tests that may need to be done on models to make sure that they’re effective, whatever those structures are. So all that is an area for policy, and it has enormous implications. It’s one thing for people to use AI to predict what your next purchase is going to be, but if it’s about determining the course of your therapy or what you’re going to do or not do, you really need a framework for that, and so I think it’s a really important area.

Howard Forman: We have only a few minutes left, and I wanted to ask you, you are one of the very few people, probably less than a handful of people in the country, who have worked at the highest echelons of city, state, and federal government in healthcare. I mean, literally it’s hard for me to think of other people that have done exactly the type of level work you’ve done. What has been the most fun? Where do you feel like you get to have the most ability to have direct, immediate change and just your experience with that?

Joshua Sharfstein: Sure. Well, the great thing is you can have change at a lot of different levels. The jobs are different, though. When I was the city health commissioner, I felt like everything that happened in the city I was responsible for, and that is a lot of pressure. That was the most pressure of all the jobs that I’ve had. When I was there, every shooting, I got a text message. It was called a “pin” for BlackBerry, but I got that, day or night. I felt like there was an environmental problem in South Baltimore, and it was my responsibility to race over there and deal with it. It was intense. It was fun, but in a very intense way. Federal government is a little bit more distanced, although at the FDA, where you’re directly regulating things, you can have a big impact. It doesn’t get filtered through a lot of things.

We took caffeinated alcoholic beverages off the market, for example, and to this day I hear from people who that was a seminal event in their childhood. They want to talk to me about that experience. The state is a bit of a mix, but at the state I was very involved in healthcare financing, and really rethinking the incentives in healthcare I think is really important. So I’ve had fun, and I’ve struggled in all those positions. They’re different though in kind of the different aspects of it. The federal government has a lot more people and a lot more process than state or local government but also has a lot greater reach. So not all of them is for everyone, but I’ve really enjoyed the positions I’ve been in.

Harlan Krumholz: I’ve got one final question, Josh. So you’ve been a star your whole career just from the very beginning. You graduated from college the top of your class, you end up going to a top medical school, I’ll argue the top medical school. The options are open to you from all different directions. You choose a life of contribution. You choose a life that doesn’t tack you towards salary but towards return on for people you’ll never meet throughout the arm of policy. What was it that pulled you in that direction? As you reflect back on it, what do you think about the decisions you’ve made that have landed you where you are?

Joshua Sharfstein: Well, Harlan, I respect you. I respect Howie so much. So it means a lot to hear that from you. For me, there was a moment when I realized how much personal satisfaction I derived from knowing that there are people out there who are alive or they’re healthier because of work that I’ve contributed to, even if they don’t know who I am. A surgeon, you could say, “Well, with her bare hand, she saved a life.” So that’s just an amazing feeling. She cracked the chest and massaged the heart back to life. You don’t do that in public health. Or if you are doing that in public health, something’s wrong. You’re in trouble.

Harlan Krumholz: You should stop.

Joshua Sharfstein: Yeah, yeah. That’s not good. So in public health, it’s like we launched a big infant mortality program. We had a huge decline in infant mortality. We had a huge narrowing of the disparities in infant mortality. There are hundreds of babies alive because of that effort I played a role in getting that started and other people did all the key work there, but what a great feeling to know that there are all these kids out there. When I was health commissioner in Baltimore, we had a two-thirds reduction or we completed a two-thirds reduction in overdose deaths, and that is a really meaningful feeling. I don’t know who didn’t die of an overdose because of the treatment initiatives or other initiatives that we put into place, but it’s great.

So I don’t view my career as having sacrificed. I’ve gotten great satisfaction at every level. I just really love the feeling of being able to say for this population, for my city, for my state, for my country, I’ve contributed to people being in better health, being able to live the lives that they want to live. Ultimately, public health is not about regulating people or trying to get them to do things. Public health is about allowing people to live the lives they want to live unencumbered by preventable illness or misery or the death of a loved one or the trauma that they could be experiencing because of terrible risks that are out there. We want people to be happy and be free and to live the life they want to live. So I feel like I’ve been able to do that in my career, and so I’ve had a tremendous amount of satisfaction from all that.

Howard Forman: We really, really appreciate it. You are truly an admirable public servant. I just hope that we continue to work with you and I hope that the nation continues to seek your advice because I think you have very good advice.

Joshua Sharfstein: Well, thanks so much for having me.

Harlan Krumholz: Thank you so much, Josh. Hey, that was a great interview with Josh. So glad we had him on the program. He’s just terrific.

Howard Forman: He really is, yeah.

Harlan Krumholz: Yep. But now, Howie Forman, what’s on your mind this week?

Howard Forman: Yeah, I wanted to just take a few minutes to say just some words about our friend and colleague and my longtime mentor and role model who passed away this week. She was to be our guest on the first episode of our podcast in the upcoming season in September. Gail Wilensky was a proud University of Michigan Economics PhD graduate who went on to this incredible storied career in health policy over the last 50 years. Professionally, she was probably best known if people had heard her name for serving in the George Herbert Walker Bush administration as both a health policy advisor and the head of what was then the Federal Medicare and Medicaid Programs, which we abbreviated HIC for the Healthcare Financing Administration. But she also led or participated in so many other major organizations in her career that it’s impossible to include them all.

She was the head of the Medicare Payment Advisory Commission. She led many military and VA task forces really looking after our enlisted men and women and those who have left service and had advised Congress in both parties on matters healthcare related for a long time. She was truly cross partisan, even though she was identified as a Republican. She started her career as a researcher within the federal government serving as co-director of the National Medical Care Expenditure Survey and head of the analytics team, and I’ll let you expand on those contributions in a minute, but I wanted to just briefly touch on who she was to me personally.

I met her in 2001 when I was trying to make a decision about who to work for during my fellowship on Capitol Hill. From that moment forward, she became my friend, my mentor, my role model, and someone who would willingly talk through challenging policy issues without making them political. She came to Yale multiple times over the years to visit with my students, including as the Boroff-Forman lecturer, which is something you had done as well. She was also the JD Thompson Award winner, something else that you have been awarded with. I received this email last night from a long ago graduated student who wrote unsolicited, “Howie, you probably don’t even remember this, but you had her come to our MD MBA crew back in 2009 or ’10. You took us out to dinner with her, and some of the things she said that night I’ve held onto and have helped shape so much of my thinking.” This person now works, as I said, in state government.

She loved talking about her kids, her grandkids, her husband and loved to ask me and listen to me talk about my own parents, my children, my siblings. She leaves a great legacy behind, including having endowed a chair in economics at the University of Michigan, which is currently held by our former Yale colleague Amanda Kowalski. So I’m going to miss her a lot. I know you have strong feelings about her also, and I just wanted to honor her in this way.

Harlan Krumholz: Yeah, that’s so nice, Howie. Of course, you’re the ultimate mentor, so it’s nice for us to learn about your mentors and the people who have made a big influence on you. For people listening, for me, one of the things about Gail was that she was at the lead of transforming the federal agency at that time, the Healthcare Financing Administration, now the Centers for Medicare and Medicaid Services, but the group that’s in charge of the care for all older people and disabled people in the country and those in end-stage renal disease to move towards systematic measurement of quality and to elevate quality of care. Before that, people were just reviewing individual charts and trying to find bad apples or particular situations where maybe bad care was delivered and try to understand it.

But she transformed with Steve Jenks and they had a seminal article in JAMA, Jenks and Wilensky, I’ve cited it a million times, and it really laid the groundwork for us to think about quality as something that we were trying to move the entire distribution of quality forward. Not just trying to find one or two problems, but actually move the entire thing forward. She played a critical role in that. She was always a rational voice. She hearkens back to a time when Republicans and Democrats talk to each other, work together, and were trying to build something together. You never thought of her as being partisan. She was appointed with the Republican administration. She was Republican, but it didn’t come off that way. She was really for the American people and for the public. A lifetime of contribution. I’m so glad you brought her up today.

Howard Forman: Yeah. I’m grateful to hear you talk about her in that way also, because I don’t think I even fully understand the scope of what she’s done, so I appreciate that.

Harlan Krumholz: Yeah, a big loss. Thank you for sharing that, Howie. 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 keep the conversation going, email us at health.veritas@yale.edu or follow us on LinkedIn, Threads, or Twitter.

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Howard Forman: I know that somebody reached out to us this past week about long COVID, and I know, Harlan, that you’re going to speak to that in upcoming episodes as well because I think it’s very important that we do come back to that topic again. If you have questions about the MBA for Executives program at Yale School of Management, reach out via email for more information or check out our website at som.yale.edu/emba.

Harlan Krumholz: Health & Veritas is produced for the School of Management, Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, and to our producer, Miranda Shafer. They are amazing. We so appreciate you guys.

Howard Forman: Yeah, we totally do.

Harlan Krumholz: Talk to soon, Howie.

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