What did the pandemic teach public health experts?

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. As we enter the third fall season with COVID-19 circulating, epidemiologists and public health experts are reflecting on what lessons they've learned from the pandemic. Here with me to share his thoughts is professor Chris Morley, the chair of the department of public health and preventive medicine at upstate. Welcome back to "The Informed Patient," Dr. Morley.

Thanks for having me back, Amber, it's always a pleasure to be with you.

People working in public health already knew that creating an effective vaccine and convincing everyone to take it were two different challenges. You already knew how to project how many people could die and the impact on hospitals and the healthcare system. And we have already had the ability to do things virtually, but the pandemic accelerated the use of telemedicine. So, did we learn anything else beyond that?

Chris Morley, PhD: I think you raised three good points about what we've learned, and I could expand upon each of those briefly.

So you said we knew how to produce vaccines and that we knew it was different to produce good vaccines and then communicate about their use. But we actually have learned a great deal more about how messaging rolls out and how not to roll it out, frankly, and how contentious things can be. When I say we've learned, I think there are a lot of us who have ideas. I don't know that we're doing better as a society, because we still have people who are unvaccinated. So I think there's still more to learn about how to communicate about things like new, technologies in general, especially when around contentious issues.

We also -- when you said we learned how to predict how many people would die -- we actually found out that our old models, like the SEIR (susceptible exposed infectious recovered) model, that was often used by infectious disease epidemiologists, actually have some holes in them, especially when you've got something that's so acutely and rapidly changing, like this pandemic has illustrated. We had very rapid mutation. Often when you do a model like that, you assume people, once they're susceptible, if they get infected or they get vaccinated, then they move to a recovered pool and they're no longer susceptible. But what we found is the virus mutates and as immunity wanes, people end up being susceptible again. And so we were both overestimated, as we learned how to use non-pharmaceutical interventions, we overestimated how rapidly people would distance and mask up and short circuit a surge. But we also learned how quickly our assumptions about susceptibility would change. So we've learned new subtle and sometimes not-so-subtle ways to use old tools and refine them. So it's been a learning curve on that as well, that we've learned to use existing tools.

We also are in a technological phase of education and work where it's been possible to, to teach, to learn, to work remotely for quite a while now. But we weren't doing it actively, and there were still some bumps and still some assumptions and cultural mores against doing things distally, if you could do them in person. And I think we've gotten over a lot of those things. And we've learned how to teach a lot better. I know, as a person who runs the department that runs a master of public health program, we pivoted and learned a lot about teaching remotely and do it a lot more effectively, for example. And a lot of clinics learned how to use telemedicine -- which existed before the pandemic -- to use that a lot more effectively, and they learned what was really important to do in person and what could be moved to a virtual session. So we've learned to use the tools we had at hand in better ways.

Host Amber Smith: Did we have the ability to track viruses in wastewater before this pandemic?

Chris Morley, PhD: Yeah, we actually did. And that was another tool that got adapted to use in the pandemic. So, there were people who were using wastewater testing, but it was often done in highly infectious environments, often in places where an entire village might, for example, might use a single water source. So basically people were employing wastewater monitoring in places like Africa, where we have had a number of infectious diseases emerge including Ebola, and people would use, uh, wastewater testing to monitor when you had other means of laboratory testing not as readily available. But it turns out that yeah, you can search wastewater for all sorts of things. For example, not only is it now being used in many places, including Onondaga county to look for COVID-19 producing viruses, the SARS COV-2 virus, but it also is being used to look for polio. For example, the polio case that emerged in Rockland county was quickly followed up with wastewater testing, and they found there is quite a bit of polio in the water. We are, as I understand it, beginning to look for monkeypox as well. And when you have a dearth of testing capacity or if you know you've got cases out there that aren't coming in for testing, for whatever reason, or that you're going to miss cases if you wait for people to show up in a clinic and get a clinical test, then monitoring wastewater in the community turns out to be a pretty effective way to get a picture of where things are going in the absence of robust clinical testing.

It also is available for use in more confined settings. For example, you could monitor a dorm or an office building or residential complex, and really even more refinedly use wastewater testing to see if something is popping up in a particular location. So there's a number of uses. It was used beforehand, but again, it's being adapted because it suddenly was necessary and so it's come into its own.

Host Amber Smith: I know infectious disease people knew how easily germs transfer in regular daily life. But do you think that this experience with the pandemic, for the general public, has helped them learn the importance of washing hands and not breathing other people's air?

Chris Morley, PhD: Well, I hope so. We have seen other epidemics produce new societal practices. For example, after a number of rounds with aerosolized or airborne viruses or easily transmittable viruses, respiratory viruses like SARS 1 or MERS, or the H1N1 flu that swept through Asia.

In many parts of Asia, people regularly mask. If you have any symptoms at all, the current social more is that you don't walk around without a mask if you are expressing anything that looks like a respiratory virus or infection. I don't know if we're there yet. I do know we're combating two things. People know a lot more about hygiene in the presence of an infectious disease epidemic or outbreak. We certainly have taught a lot more people about that. But we also see I guess its ugly fraternal twin, and that's fatigue. And so, whereas people know what to do, they're also fatigued, and they're confused by what's been several years of often conflicting or complex recommendations, coupled with simply people not wanting to do this anymore and not wanting to do it 24/7.

And I think people know what to do. They understand things. But then they've heard information like, "hey, maybe masks don't work." Well, no, masks certainly do work, but people don't like wearing them. And that's a conflict. How we're going to resolve remains to be seen. I hope people have learned more from this and that over the long term, we are able to adapt better when we have especially respiratory outbreaks.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith talking with Chris Morley who leads the department of public health and preventive medicine at Upstate, about lessons learned during the pandemic.

Do people working in public health have a new appreciation for the effects of isolation and loneliness in the population?

Chris Morley, PhD: Oh, absolutely. But I think, to be fair, we've always understood those things. We always understood that everything that we've done for the past almost -- unfortunately we're coming closer to three years now, or in two and a half years along -- that the things we were doing would have ramifications, and it's always a trade off. Everything's been a trade off. So when we restricted activity, it wasn't lost in us that there would be financial outcomes that were deleterious. We were hoping we would see more rallying of the whole society to support businesses when we asked them to shut down. And unfortunately what we did was just open up very quickly, in some cases. We understand that when we ask people to mask or work distally or learn distally, that there was going to be issues with isolation, that mental health issues were going to be exacerbated, that things like crime, like drug use, suicidality were all going to increase as we place these emotional, financial and social pressures on people. We've always understood that. And the issue has always been counterbalancing and trying to counteract those effects while still looking out for the safety of the public.

So all of these things are equally important. We don't want people to die or get very sick and have long-term complications from COVID-19. We also don't want people in financial ruin or suffering deleterious mental health effects, or any of the other sequela that result. So, I think we've always known, we've had to balance these things, and the fact that we had to lean into some of some urgent measures over the past several years really underscores how quickly the virus spread, how quickly it almost overwhelmed our hospital system and how dangerous the situation was.

Host Amber Smith: What do you think it means that during the pandemic, visits dramatically increased to state and national parks and other outdoorsy venues?

Chris Morley, PhD: Well, I certainly jumped onto that bandwagon and started doing a lot more outdoor activities. I think people did several things. First of all, I think people understood much more quickly than the science was able to document that being outdoors was probably safer than being in a cramped indoor environment, especially with poor ventilation. I think you could even do more outside in terms of gathering than you could if you gathered people indoors. So people understood that outdoor activity was preferable.

I also think that what we were just speaking about in terms of the mental health consequences and the existential fears that people had throughout the pandemic really were amenable to more reflective and meditative activities like exposure to green space and forest bathing can have. There are documented impacts of exposure to green space that reduce stress and anxiety. My team actually had a paper on that several years ago, on the impact of increased exposure to green space on stress and anxiety.

So for those two reasons -- the basic fact that outdoor activity probably still is safer than indoor activity, and the need for reflection and meditation in the face of an existential threat -- probably combined toincrease the usages of parks, natural trails. And I've got to say, we have really lovely places here in Central New York, and I would encourage people to explore those. It is a relatively much safer activity, and we've got just awe-inspiring beauty, all around us. It has good mental health impacts as well.

Host Amber Smith: Some people are saying the way we live now, with more people than ever doing their jobs from home, is altering our cities. And I wonder what impact that is having, or may have, on public health.

Chris Morley, PhD: I think we're just beginning to realize what's going to happen. But I think we're already starting to see a transformation. I mean, there are all these stories about people moving and telecommuting or working part-time. For example, people have cleared out of New York City. They've been moving farther into the Hudson Valley and commuting a couple times a week and working more remotely. And that was before the pandemic. And I think that's increased. What will that mean for public health? Well, as populations become decentralized, how we measure all sorts of things, not just infectious diseases, but societal risksfor all sorts of things like rates of things like drug use or violence will probably be altered. And we will have different approaches to surveillance across the population if cities empty out or people become more dispersed.

As a public health professional and scientist, we understand that there will be social upheaval, some potentially for the better, but some potentially for the worse. As society changes, there are always winners and losers, and we will be looking out for the social determinants of health to be playing out as cities change and city scapes change and become less a center of of work and more center of commerce or play, or simply, as buildings empty out, you will see socioeconomic changes within those communities. And with socioeconomic change often comes changes in the health status of communities in a variety of indicators. So we're going to have to keep an eye on that.

We're also gonna have to keep an eye on isolation that results when people disperse. Obviously people love working from home, but if over time they realize they become more socially isolated -- there are many societies grappling with epidemics of loneliness, for example; that was quite a concept in Britain a few years ago. I don't think that has gone away, and I think that's a real issue that as we negotiate our daily existence with technology and how we interact with one another in person versus technologically mediated interactions, we will learn what the ramifications are over time. As public health, as a field, we'll have to learn to watch for those sequela from those societal changes.

Host Amber Smith: Well, Dr. Morley, I want to thank you for making time to talk with me about this.

Chris Morley, PhD: It's always my pleasure, Amber. It's always nice to speak with you, and thank you for having me back.

Host Amber Smith: My guest has been Dr. Christopher Morley. He leads the department of public health and preventive medicine at Upstate. The Informed Patient is a podcast covering health science and medicine brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu /informed. This is your host Amber Smith, thanking you for listening.