Mark Siegel: The Craft of Teaching Doctors

Transcript

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

Howard Forman: And I’m Howard 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. Mark Siegel, but first we like to check in on current or hot topics in health and healthcare. So, what do you got, Harlan?

Harlan Krumholz: Well, every once in a while, a news story sort of lifts above all the others, and I think we’ve had that this week. It’s about a breakthrough that you and I have talked about that really changes the way we think about what’s possible in the treatment of a disease that’s just devastating and has implications for a lot of other cancers as well. And that’s pancreatic cancer. Something that means a lot to me. My grandfather passed away at age 90 of pancreatic cancer. And once he got the diagnosis, metastatic pancreatic cancer, it was really little that could be done, little that could be done. And he was at the far end of the spectrum of age, maybe up there, but it can affect people at younger ages all around.

And when people get it, it has largely been considered a terminal diagnosis that will rapidly, rapidly lead to someone’s death. Well, and there were big mutilating surgeries people would try. There’s lots of regimens that have been tried over the years, but it has not made much progress until now. So, there’s a drug called daraxonrasib that’s a... believe it or not, it’s an oral therapy. I mean, you don’t have to come and sit there and get all these infusions. It’s an oral targeted therapy for cancers that are driven by this switch that many cancers have that gets them to sort of proliferate without control. It’s called RAS. And this is a multi-selective inhibitor of this mutant RAS.

What happens is, we’ve all got this and when the thing kind of mutates and gets just turned on, then the cells just proliferate. And it’s been almost impossible to figure out how to target this. And in this case, they were able to find something that actually turned it off. It was a Phase 3 trial published in New England Journal of Medicine, presented at the major cancer meeting, ASCO. And they enrolled patients previously treated—so they sort of like were at the end. They had metastatic pancreatic ductal adenocarcinoma and this lethal cancer that there was really nothing else to do that had progressed.

These patients were randomized to this new drug or maybe to continue with chemotherapy but without much hope, and the results were pretty striking. Now the median overall survival in this study was 13 months with the new drug compared to 6.7 months with chemotherapy. It doubled the median survival. But from my point of view, it was really interesting because if you look at the survival curves as you kind of got out to a year, this is a better way for me to think about, because that median survival is like, okay, six months, I know it’s a doubling, what’s it really mean?

And when you looked at overall survival in people who had this sort of RAS mutation, half of them were still alive at one year versus only about 20% who were on the sort of usual chemotherapy approach. And if you looked at the overall population, that was almost just about the same. And if you looked at every subgroup, the hazard ratio—the hazard ratio sort of tells you risk reduction—were all like 0.5 or 0.4 or in the 0.3s, which means you were getting a 50%, 60%, or 70% reduction in risk.

And then if you looked at, another thing the oncologists like to look at, this progression-free survival, which means not only do you survive but the cancer doesn’t seem to be advancing and you were close at six months, 60% of the people who had been treated with the experimental drug, this KRAS inhibitor were progression-free survivors versus 30% in the chemotherapy group. And that’s between 50% and 60% progression-free versus something between like 30%, 32% in the other group. That’s huge. So, I think let me just say that there’s some, this is amazing, and one of the things that occurred to me was, well, what took so long? We’ve known for a long time that this RAS is a central driver of pancreatic cancer and more than 90% of the cancers have this pathway activation that’s sort of causing this through what they’re calling these KRAS mutations. The mutation occurs, and then the thing doesn’t turn off, essentially. And so it signals growth, and then the tumors just keep growing and spreading. It’s like the light’s on, I can’t turn it off, or the spigot’s on, I can’t turn it off, and it just leads to people dying in the end. And so, it’s not that they didn’t know the target, but they couldn’t find a drug. It was considered kind of undruggable.

It was sort of a, you know, we find these things to inhibit, there needs to be kind of a lock and key. How do you interrupt this mechanism? And it was difficult for small molecules to bind with it, and it didn’t have kind of obvious pockets. It was sort of thought to be very slippery, and they couldn’t figure it out. And this reflected kind of a different strategy. It targets this active on state. It binds this part of the cell and forms a complex and engages this active RAS and blocks the downstream signaling. And this was really considered to be a triumph of a lot of things, structural biology, AI, designing what can work. It was not just one thing, but it was like science coming together.

And then this company sort of tried to put everything together and to make it work, and it’s been extraordinarily impressive. I’m just going to end with this, Howie, because I think it’s, you can go into this paper, you can look at it a bunch of different ways. I don’t think there’s anybody who hasn’t been impressed by it, but the other thing is that they’re going to look at it in lung cancer, solid tumor. This RAS and KRAS mutation is not specific only to pancreatic cancer.

So, the prospect here is that these RAS-addicted cancers, they’re calling them, are among the most common and difficult-to-treat cancers and they’re extensive and that this has the potential to fundamentally change the game for so many people suffering from so many different cancers that have been resistant to really providing a cure. And this is just the beginning. So, anyway, I think this is the big story. I’m excited about it.

Howard Forman: Absolutely.

Harlan Krumholz: I’m not an oncologist, but I enjoyed learning about it. And it’s a triumph of our new life sciences revolution. It’s a triumph of what’s possible, given the breakthroughs that are happening in biology and life sciences. And it’s just wonderful to see the translation into benefit for patients.

Howard Forman: People said it was the first time in their memory that there was a standing ovation for a presentation at ASCO. And there’s videotape of the audience standing up and applauding this because it was such a dramatic change to what historically has been, as you’ve pointed out, one of the most lethal diseases, almost the epitome of the worst cancer you could have.

Harlan Krumholz: Yeah. And as you know, the former U.S. senator, I think from Nebraska, Ben Sasse, who became president of the University of Florida, came down with pancreatic cancer and has been on podcasts talking about this because he was one of the early people in the trials and has lived longer, much longer than what people had expected. And again, I want to get back to this: “doubling, yeah,” but people may say, “But that sounds like six, seven months. Is it a big deal?” It’s a huge deal. And it’s better than looking at median survival to me is you had almost half the people at six months progression-free survival and overall survival was a difference between about twenty—18%... 18%, 20% at a year.

Now they’re going to have to do longer follow-up, and the numbers in the follow-up started to diminish as you went out with the follow-up, but all this is just to say, it’s very promising for a disease that had little to hope for. So, this isn’t sealing the story. We’re not done by any means, lots more to learn, but it’s exciting to see the concept validated. Many people will have some hope now, and then they’ll need to refine the intervention to make it better.

Howard Forman: Yeah. I’m glad you covered that.

Harlan Krumholz: Thanks. Okay. Hey, let’s get on to Mark Siegel. This’ll be a great interview day.

Howard Forman: Dr. Mark Siegel is program director of the Internal Medicine Traditional Residency Program and a professor of pulmonary medicine at the Yale School of Medicine. He’s a critical care pulmonologist with board certifications in internal medicine, pulmonary medicine, and critical care medicine. On the clinical side, he attends the medical intensive care unit and stepdown unit at Yale New Haven Hospital. He is a dedicated educator, something that we’ll keep coming back to. He is the recipient of several teaching awards, including Yale’s 2025 Fisher Graduate Medical Education Award.

His research has centered on the factors that influence end-of-life decision-making by ICU clinicians and the family members of critically ill patients. He’s also involved in investigating the factors that underlie critical illness and new therapies for treatment. He received his bachelor’s degree in English from Columbia University, his medical degree from Columbia College of Physicians and Surgeons, and then completed his internship and residency at the hospital of the University of Pennsylvania. He has been a full-time Yale faculty member since doing his pulmonary critical care fellowship at Yale ending in 1995. So, I want to start off, first of all, it’s such a pleasure to have you on the podcast.

I want to point out for our listeners, what I did not talk about is that you on a weekly basis send to a wide list that now includes Harlan and me a letter that is nominally toward your residents in the program that is just a model of conveying your values and what drives you to be the best clinician and educator and scholar that you can be. And I mean, you post it on Substack, I believe, so I think there are ways that people can access, and we’ll put that in the show notes as well, but I just wanted to ask you the amount of time it takes to do that every week, what motivated you to start doing that, and how has it developed over time?

Mark Siegel: Well, I’ll start with the origin story. So, I have a huge residency program and am responsible for 157 trainees who work under my directorship. And a few years ago, I found that I realized that I was actually saying things repeatedly to one resident after another, questions like, “How do I decide which fellowship to pursue?” or “How do I become a better doctor?” And it got to the point where I realized I would probably be better off writing something to the program at large so I could be efficient and not repeat myself all the time. I also at the same time have always loved writing.

And when I realized that I was actually sending these messages out to large audiences, I recognized also that it was an opportunity to just work on my writing skills. And so, it became a weekly thing that I would send out on Sundays. I think it’s probably getting close to 10 years. Along the way, I actually realized that other people wanted to read them too. So, I kept adding people to the bcc: on the email, both the two of you and Dean Brown and Dr. Gusling, our chair. I mean, everybody’s on it. And what I recognized also, it was a way of keeping in touch. And as I know the two of you have thought about a lot, one of the problems that we face in modern medicine is fragmentation.

People don’t know all the people that they work with, even Howie, I hate to say this, but the last time I’ve gone down to radiology to stand there side by side with my radiology colleagues and look at a study together.... And so, it was a way of bringing the community together for people I wouldn’t necessarily see every day but were still very much part of our residency family.

Howard Forman: And I do want to just, before I turn it over to Harlan, just point out for people that this letter is very personal. I mean, you mentioned the fact that your daughter was getting married and therefore, there would not be a formal letter. I do feel I read your letter every week. It comes on Sunday, it comes at the perfect time for me to be able to look at it. And so, I feel like I know what’s going on in your life. I know whether you hurt yourself on a bike ride. I know whether you got a new car.

I feel like I really know you from it, but it does give specific advice to your residents about getting a letter of recommendation written or what they should be thinking about as they embark on the next stage of their career and then you give references of things that are on your mind this week and things that you’re reading or listening to. It really is a remarkable contribution, and I do hope you get a wider reading than even just a list that includes Harlan and me and our dean.

Mark Siegel: That’s very kind of you to say that. I actually think that one of the subtexts there is I want my residents to know that I’m a real person. I did internship and residency, just like they did. I have a life outside the hospital. I’ve got my vulnerabilities like falling off my bike and I think it’s helpful for them to know that. I hope it makes me seem somewhat more accessible than I might be if they didn’t know me quite as well.

Harlan Krumholz: I think it’s a great recruiting tool too, because people who are considering coming here may want to know what they’re getting into and who the leadership is. And I think it’s a great outreach instrument, let alone a good teaching thing. And I like how I really enjoy it too, Mark. Thank you. I wanted people who are listening to know that we have an extraordinary leader of our residency program in internal medicine. Mark is truly an exemplar. Mark, when I think about it, what strikes me, and some of this is from what I read, I feel like I know you well in a way because of the way you share about what’s going on, and what’s going on with the residency is I get the sense you are exactly where you are supposed to be.

And there are a lot of people in our world who are looking for the next thing and actually they’re never quite satisfied or feel at peace like “I’m looking to be a chair,” then “I’m looking to be a dean,” and “I don’t know what I’m looking for.” And then sometimes they’re not as engaged in the journey and enjoying the present moment as they are trying to construct a trajectory or something that will make them feel whole. It’s rare when people have actually find that space. So, can you just talk a little bit about how did you get to inhabit this position and what is your philosophy about it that has enabled you to so embrace the present moment and to not be looking ahead or behind but just enjoying what you do?

Mark Siegel: Well, that was lovely, Harlan. I feel like you reached into my soul here. So, it goes back to when I was much younger, one of these people who’s kind of like coming from this classic Jewish family where you were going to be a doctor from the time you were in elementary school and I never even contemplated doing anything different. And I got to undergrad and realized while I liked and enjoyed biology and other classic pre-med types of subjects, I really loved English and history. And there was a moment there where I thought maybe what I really want to be is a college professor and write and study the world.

And then it occurred to me then that I actually thought maybe I do want to be a doctor, but I didn’t really know, as a lot of undergraduates may not know, that there’s such a thing called academic medicine. My idea of a doctor was more based on the doctors I knew, like the pediatricians I would have seen growing up and having a shingle out in front of your house. And I suddenly realized that you could be a college professor and a doctor at the same time by joining a medical school faculty, and that’s really how my life unfolded after that.

I always knew from the moment I started medical school that I wanted to be on a medical school faculty and that I really loved teaching, and I can’t imagine anything more fulfilling than being by a patient’s bedside with a trainee, medical student, resident, fellow, the give and take and the discussions and watching the lights go on in their eyes. And so, when I finished training, as you may know, I was actually the MICU director at Yale for many years, and so I got completely immersed in the critical care world and did so at a time when Yale was just developing its clinician educator track, as it was then called.

And that’s when I realized I was right at home and that Yale would support me, and I’m very grateful for that. And then in 2011 when Cyrus Kapadia, who was my predecessor, retired, Jack Elias, our chair at the time, asked if I would consider doing the switch and that’s when I realized I was completely at home. I loved the mentoring, the teaching, the being in people’s lives, and that’s how I ended up where I am today. It’s taken me a few years since I started to realize exactly what was entailed in this position. But as you said, Harlan, I’m exactly where I want to be, and we all have opportunities to move on, as you know. The job queries come every once in a while, but I would never want to be doing anything else.

Harlan Krumholz: No, that’s extraordinary. Tell me your secret about how do you get to know 157 people in the kind of level of detail that you do because for me it would be enough to know everyone’s names. I know this because you know, how your reputation and stories, not just what you write, but what is widely known in the institution that you care. I mean, you care deeply, but that’s a lot of people that you get to know. How do you do it?

Mark Siegel: Well, I’ll tell you one thing that’s a secret. It’s more than 157 because I have files on I’m sure well over a thousand. It starts very early. When I recruit residents, I make it my business to read everybody’s applications and to read their personal statements and to understand what excites them and what contributions they hope to make. And I also spend a lot of time with them individually. It’s an extraordinary number if you think about it, but the ACGME actually requires program directors to meet with each one of their residents once a year, and I meet with many of them more than once a year, but at a minimum I meet with each one of them once a year, usually for about an hour.

And during that time we talk about their progress as trainees but also their lives and their families and their career aspirations and personal hopes, and they give me feedback about the program. So, if you add it up, I’m actually spending about 157 hours a year one-on-one with the individual trainees and that doesn’t even begin to get into when I’m attending and on service with them or going to conferences practically every day with them, writing letters for them for their fellowships. So, yeah, I guess a lot of it is getting to know them well through time and caring.

Howard Forman: That’s great. The care that you take in your selection process is also something that to me is exemplary. I’ve been part of the residency selection process here. I’ve been part of admissions processes for other programs, but when I read about what you engage in and, you talked about it before, reading each of the essays, it gives me a lot of hope or aspirations for what every program should do. But we live in a challenging time now where for our listeners who may not know, there are three steps to getting credentialed as a physician and one of those steps used to be an essential grade that was supplied. It no longer is.

The second step now does take on sort of a higher priority for some people. There are some medical schools, including Yale, that don’t give grades. There are some medical schools that do and don’t rank people. Harlan and I have often talked about how can you really be holistic and how do you find people who are going to be great physicians, not necessarily just great fund of knowledge. What have you learned over the decade that you’ve been doing this now that helps you select people appropriately and build such a cohesive and strong group of residents?

Mark Siegel: Yeah. So, it’s two-way and it’s important to recognize that the applicants are choosing us ever so much as we’re choosing them. The most talented residency applicants are also going to have opportunities at all our peer institutions, Harvard, Columbia, UCSF, Penn, etc. And so, there’s a component of this where they have to look at us and decide that Yale is the place for them because of the opportunities that we have to offer through scholarship and the quality of our hospitals and clinics and wonderful faculty that we have. And so, I think there’s no understating how, or I can’t overstate how important that is. There are also features of our program that I think are very attractive.

We’re a very close-knit community with some very social people who have great emotional intelligence. And you may have heard that our residency motto is “As good as any, nicer than most,” which is something that we really live by. And so, I think for applicants who are looking for that, it’s very clear, and we’re transparent about those values. On my side of it, so we get thousands of applications a year, and it’s become a little simpler over the last few years because now there’s this system that is being used called a signaling system where applicants can highlight the fact that they have a particular interest in our programs. So, that helps me focus somewhat on certain applicants.

And there are so many metrics to look at, some of which are very easy and straightforward. So, it is helpful when you see a USMLE step two test result because it’s truly the only metric that is generalizable across the multiple schools that trainees come from. And as you pointed out, there’s a lot of variability between the schools in terms of their willingness to give grades and rankings versus giving nothing at all. And I spend quite a bit of time reading as much as I can in the text of their evaluations to get a sense of the quality of their work.

And then on top of that, I’m really interested in their extracurricular activities, particularly leadership and the quality of their scholarship in terms of research and publications, particularly if it’s first author publications in good journals. It just helps me understand who they are and then on top of that, letters of recommendation and personal statements. The one question that you might ask, given the volume, is there any role for artificial intelligence in any of this? And there have actually been a couple of instances where I’ve tried to use some artificial intelligence software that’s built for medical school applications.

There was a company, I’m forgetting its name, that tried to share some software that I think some of my colleagues may have used, but I actually found that one of the limitations of the software is that it couldn’t actually rank applicants in any particular way. And so, it wasn’t agreeing with me. If artificial intelligence was going to be valuable, it would have to be able to help me see people who I would want for our program faster and more comprehensively and more consistently than I do it, and I just didn’t see that happening. So, for example, I thought I was doing a better job identifying people who would thrive in our institution.

So, basically it’s just a narrowing down trying to figure out who we’re going to invite for interviews and then they come and interview with us and then we do the best we can. But the challenge ultimately is that the people who apply to our program are all very talented, and the differences between them are really just a matter of judgment as much as anything else. I do want to add one other thing which you guys are probably aware is we’ve been very open to recruiting international medical graduates to our program more than a lot of our peer institutions have been.

And I actually would point that out as being something that I am particularly proud of, that we seem to be able to recruit some of the best physician trainees in the world. And part of it is because not a lot of institutions have been as open. These have become some of our most talented trainees, and Harlan has worked with several of them who have—

Harlan Krumholz: You know that that wasn’t always that way. Actually, I had some people I couldn’t get in here because they had to apply to the primary care program because they would consider them but the main program wouldn’t. And my students were the first ones to get in, and correct me if I’m wrong about that, but the first ones and they were so good. They were so good that they opened the door, and you have transformed the program into being extraordinarily open-minded and saying, “Talent lives everywhere. People should be able to compete fairly for positions and let’s get the very best people in the world.”

And you’ve done that spectacularly, but I’m really proud of the people that actually paved the way, Aakriti [Gupta] and Behnood [Bikdeli], that in the beginning that you know, they were so spec—they have fabulous careers now. I mean, in their time at Yale they treasure, and you have made this pivot in a way that is just spectacular, just spectacular.

Mark Siegel: Yeah. It’s good for everybody all around. They’ve been spectacular clinicians. They add a global worldview to our program culturally and they work really hard. I mean, if you think about what somebody coming from overseas has to get through in order to be noticed and to succeed in a program like ours. And to me, the fact that they’ve made it this far is probably one of the best signals that they’re going to be able to succeed in life. And as you’re pointing out, Harlan, they’ve gone on to become faculty who are really making a splash.

Harlan Krumholz: Leaders, leaders. Yeah. And It creates an interesting mix of people. I mean, it’s an interesting mix of people. I was wondering if, and I know we’re getting closer to the end of the interview, but if you can reflect on any trends you’ve seen over time in the kinds of candidates you’re getting in the kinds of residents and what do you know—you probably have the earliest sort of sensor about how medicine is changing with regard to who’s coming in and what they’re doing and what their aspirations are and so forth. Can you share with us some insights about what you’re seeing over time?

Mark Siegel: Yeah. I’d like to answer your question to convey the most positivity that I can possibly convey about the future of medicine and the kinds of people that we’re seeing because I know there’s a lot of criticism out there, and we’re constantly hearing about people advising college students not to go into medicine and talking about burnout and things like that. And I see the exact opposite. I see these extraordinary individuals who are so excited about the contributions that they are able to make. They come with enormous talent with respect to the scholarship that they are going to pursue.

They are incredibly compassionate when it comes to the way they work with patients and speak with patients and listen to what patients are saying to them. They have a real sophistication about medicine’s place in society that I think is far more sophisticated than what I knew when I was at their level of training. And so I really resonate with that level of excitement. Now, there are a couple of things that you’ll sometimes hear, and I know this has been written about, so for example, this concern that trainees today are more concerned about wellness than their commitment to patient care or that they’re considered…and they’re more concerned about their lives outside the hospital and work-life balance.

I actually take a different view than I think some people have taken on that. So, first of all, I think wellness is an absolutely essential part of what we need to have in our lives to be good doctors. We need to sleep, we need to eat, we need to socialize, we need to exercise. And so, I think a doctor who takes care of themselves is going to be much more effective and is going to do a great job taking care of patients. That’s one of the reasons we decided to eliminate overnight call in our residency because we wanted to make sure that people were able to sleep.

But with all that, I actually think that the fact that the residents know enough to take care of themselves and that we can support them in that has actually helped them to be better doctors and to retain their excitement and to have, I think, less burnout. And I think that they’re more poised to make contributions. So, I would say that if anything, we’re recruiting more talented people with more potential who are more excited about their careers and leave residency just as excited about what they’re going to do as they were thinking about coming in.

Howard Forman: I would be remiss as we end this without letting you speak a little bit about the importance of family to you, because I think a lot of your letters speak to family. You’ve written about your mother in a peer-reviewed journal and about her challenge with blindness and you just had the joy of the wedding. So, I just want to see your thoughts about how you share your personal life with the residents, not just to get to know them, but also because of how it has formed who you are.

Mark Siegel: Yeah. I want to say, Howie, I know that you’ve had some really wonderful milestones in your family’s lives recently with the graduations and Harlan’s a grandfather and I’m getting to know your daughter is going to be one of her incoming interns, which we are extremely excited about.

Harlan Krumholz: I’m so excited.

Mark Siegel: Sarah. Harlan sent me this message where Sarah got her new email and how exciting that was. And I said, “I know, exactly.”

Harlan Krumholz: I told him that she got a yale.edu email and I said, “It made me cry.”

Howard Forman: Makes me cry.

Mark Siegel: Yeah. So, I think that family is central to my being. I am really incredibly fortunate to have a mom who’s doing okay at 102 and I was absolutely shaped by my parents and my siblings and I’ve got the most wonderful spouse in the world. My wife is a chef and has kept me fed and clothed and housed for all these years with enormous sacrifices, raising our three daughters. And so, I would say if I’m successful in my life, it’s because of the foundation that I have with my family. And my lesson as a program director is that this is a core part of our being, and families come in different types, but whatever it is, I think having people who love you is essential to living a meaningful life.

And so, I say that’s inseparable from who I am and what I do.

Howard Forman: That’s a great lesson.

Harlan Krumholz: I would just layer one thing on top of which first of all, that’s extraordinary and meaningful and you in your leadership position modeling the ability to talk about family. It’s not something that should be excluded from discussions.

Mark Siegel: Right.

Harlan Krumholz: It’s not about being weak if you’ve got family, there are things in family. It’s part of who we are, the holistic approach. You’re in for being a doctor for the long run and how do you actually get the win on personal and professional? I just think it’s an enormous thing you do by modeling just the ability to talk about it so that it becomes not something that’s extraneous, but it’s something intrinsic to who you are and what you do. So, anyway, I just want to say it’s just another, one of the many things you do that I think truly distinguishes and differentiates what’s going on here.

Mark Siegel: Thank you, Harlan.

Howard Forman: Thank you so much.

Mark Siegel: I want to say one more thing that I don’t know where I was going to fit this in, but I was so excited that you were interviewing Nicholas Christakis last week, and I don’t know if you know that we were residents together.

Harlan Krumholz: Oh, I didn’t know.

Mark Siegel: And what fun it’s been to track his career, and we get together for dinner every once in a while, but we were a crew of four: Amy Justice, Nicholas Christakis, me, and Richard Sutton were all interns and residents together and found our ways to Yale. When I talk about the people who you meet during residency and how they remain parts of your lives for so many decades, that’s just one example. So, it’s just such a lovely coincidence that I get to speak to you a week after you spoke with him.

Harlan Krumholz: That’s terrific.

Howard Forman: Thank you so much, Mark, for joining us for this. So, many great lessons for all of us about how we can all have a better life in medicine and a better medicine in life.

Mark Siegel: Thank you. It’s been absolutely a pleasure to speak with you.

Harlan Krumholz: It’s a tagline.

Mark Siegel: Yes. Great tagline.

Howard Forman: It’s so great to have colleagues like him.

Harlan Krumholz: Oh my God. I just love when someone just hits it out of the park and what they’re doing and they just are—

Howard Forman: He’s just genuine. Yep. Absolutely.

Harlan Krumholz: And by the way, it’s not like he’s ... when I was saying he’s where he is, it’s not that he’s staying static. He continues to evolve, iterate, innovate.

Howard Forman: Totally.

Harlan Krumholz: So, he’s like all in on making this the best place in the world.

Howard Forman: We’re lucky to have him. He’s a great role model.

Harlan Krumholz: All right. Hey, Howie, what’s on your mind this week?

Howard Forman: Okay. I got to do another Ebola update.

Harlan Krumholz: Another Ebola update.

Howard Forman: Yep. 344 confirmed cases, 1,200 suspected and confirmed cases reported over the course of the outbreak in the provinces of the Democratic Republic of Congo, an area larger than Florida. Fifteen cases now in Uganda. Sixty-one confirmed deaths, including one in Uganda. The strain, Bundibugyo, rarer than the Ebola, most people know. And critically, there is no approved vaccine, no approved treatment. It has reached Goma, a city of a million people with an international airport. One American doctor is recovering in Berlin and now today there is an unconfirmed new case in Brazil, unconfirmed. Here’s the one genuinely encouraging development.

United States has now committed over $460 million in the last three weeks, including humanitarian response aid, more than it spent across the entire 2018 to 2020 Ebola response. That money, combined with contributions from the EU and Africa CDC’s $319 million regional plan, has driven contact tracing from a catastrophic 7% of known exposures up to 45%. Still not enough. You need 80% to break transmission chains, but for the first time, the response is moving in the right direction. Now here’s the part we’re thinking hard about. Several decisions made in the name of protection may be working against that progress. Uganda closed its border with Congo—the World Health Organization opposes this.

Documented evidence from 2014 shows border closures don’t stop the virus. They stop the response. Medical supplies stall. Contact tracers can’t cross. Sick people simply use informal crossings with no screening at all. The U.S. has declared no Ebola cases will enter American soil. So, instead of repatriating exposed Americans, as was done successfully in 2014 without a single case of community spread, the Trump administration quietly negotiated a quarantine facility at a military base in Kenya 1,500 miles from the outbreak. A Kenyan court temporarily blocked it, but Kenya’s government is pushing ahead regardless.

Hundreds of Kenyans are in the streets. Lawrence Gostin, director of Georgetown University’s O’Neill Institute, called the decision “unprecedented,” saying, and I’m quoting this directly, “It is likely to cost American lives.” Critics in Kenya have accused the government of trading the country’s biosecurity for foreign aid from the Trump administration, which had committed $13.5 million to Kenya’s Ebola preparedness on the same call in which Secretary Rubio sought approval for the facility. The pattern is consistent. Policies designed to signal protection that in practice obstruct the response expose third parties to risk and may leave the very people they’re meant to protect with worse care than they’d receive at home.

In outbreak response, the instinctively protective move is often the epidemiologically dangerous one. That lesson keeps repeating, and it’s worth remembering long after the headlines move on.

Harlan Krumholz: All I can say is, wow. And it is worthy of a discussion almost every week because it’s a rapidly evolving story. The response is—

Howard Forman: Mixed.

Harlan Krumholz: ... mixed. It’s really mixed. And it just makes me wonder, what have we learned and what are we going to do to fix this? And some of it is around, like you’ve said, our own response and engagement in world global health now. And let me just ask again, I’ve said it to you before, but just so for listeners who are wondering, how much should Americans be worried about it here? What’s the prospect of this?

Howard Forman: Practically, it’s zero. It’s certainly not for anyone like us. The only way that you could get Ebola is by being somebody who is actively infected with Ebola and their peak infection is not during a presymptomatic time. They have no infectivity then. It’s really when they’re dead. It’s when you’re caring for the body either right before they die or if you’re preparing them for a funeral. It’s not an issue for Americans per se, but it could disrupt travel.

It could make it really difficult for us to continue to just be a global part of society where people are allowed to travel all over the world when the exposures are hard to track and we are alerting all of our medical centers now to be aware that if someone comes in with flu-like symptoms or hemorrhage or diarrhea after exposure to international travel or after exposure to someone known to have Ebola, we just need to make sure everybody is aware of this so that it doesn’t become a slightly bigger issue. It will not become a pandemic in America for sure.

Harlan Krumholz: Yeah, yeah. Well, thanks so much. Thanks for keeping us up to date. You’ve been listening to Health & Veritas with Harlan Krumholz and Howard Forman.

Howard Forman: So, how did we do? To give us your feedback or to keep the conversation going, email us at health.veritas@yale.edu or follow us on any of social media, including our Instagram account and our YouTube channel.

Harlan Krumholz: And give us feedback. We love hearing from you. Help us get better. The variety of ways you can do that, but it also helps people find us when you comment on the podcast.

Howard Forman: Health & Veritas is produced with the Yale School of Management and the Yale School of Public Health. To learn about Yale SOM’s MBA for Executives program, visit som.yale.edu/emba, and to learn about the Yale School of Public Health’s Executive Master of Public Health program, visit sph.yale.edu/emph.

Harlan Krumholz: And hat tip to our superstar undergraduate students, Gloria Beck, who is with us here today, Donovan Brown, to our marvelous producer, Miranda Shafer, and to you, Howie, best in the business. Thanks so much. Always great working with you.

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

Harlan Krumholz: Talk to you soon, Howie.