Yale Global Health Review: Young Mind Global Health

Young Mind Global Health: A Conversation with Dr. Sten Vermund on Ways Today's Youth Can Address Global Health Issues

Currently serving as the Dean of the Yale School of Public Health, Sten H. Vermund (MD, PhD) is a pediatrician and infectious disease epidemiologist focused on diseases of low and middle income countries. His work on HIV-HPV interactions among women in Bronx methadone programs motivated a change in the 1993 Centers for Disease Control and Prevention (CDC) AIDS case surveillance definition and inspired cervical cancer screening programs launched within HIV/AIDS programs around the world. The thrust of his research has focused on health care access, adolescent sexual and reproductive health and rights, and prevention of HIV transmission among general and key populations, including mother-to-child. The Yale Global Health Review had an opportunity to sit down with Dr. Vermund and discuss his views on three top global health issues of our time—HIV/ AIDS, prescription drug overdose, and cancer—and his take on the roles that younger generations play in addressing global health and applying global health knowledge and research to our daily lives.

Why do you think HIV/AIDS in still a big problem in our technologically-advanced society?

That’s a great question. I think the answer is that HIV/AIDS is steeped in the social determinants of disease. The individuals at highest risk of HIV tend to be persons in the general population of resource-limited parts of Africa, and in the rest of the world, tend to be persons in key populations, such as men who have sex with men, persons who inject drugs, female sex workers, and persons who are not very careful about sexual risk protection. Many of these populations are disenfranchised from the seats of power, the seats of influence. In the LGBT community, [and] particularly [with] gay men, there’s tremendous stigma around the world, including in the United States. A typical LGBT individual who may have the consciousness that they are same-sex attracted is subject to rejection by their family; rejection by their friends; rejection by their church, synagogue, or mosque, and are subject to a lot of mental health strains. A lot of those people look inward: they don’t disclose; they suppress their sexuality, or they live two lives. In that sense, they may be harder to reach for safer- sex messages. That’s certainly true for sex workers [and] persons who use drugs—both of which are illegal—and we drive people underground.

In Africa, where the general population is at risk, [and] particularly in Southern Africa, where the most intense epidemic is raging, you have some very strong social norms. A teenage girl who is subject to the intentions of an older man may be flattered, and she may have trouble staying in school, paying school fees, uniform fees, [and] transportation to school. If an older man helps her stay in school, and she provides sexual favors to that older man, that may be a [worthy] tradeoff… to her because she wants her education. She might be fond of the older man, too; I’m not denying that she might have affections for him. [However,] what you and I might see as a clearly exploited relationship, she may see as something she’s willing to put up with... because of the benefits it accrues to her life. These social determinants are hard to deal with.

Now, we’re dealing with society’s prejudices and stigma. We’re dealing with economic realities of young women in Southern Africa who want to better their lives. We’re dealing with taboo topics and persons who are often demonized or deemed illegal somehow. In the South African Constitution, the rights of gay people are protected. To my knowledge, that’s one of the only constitutions in the world that guarantees the rights of gay people. The US Constitution doesn’t guarantee the rights of gay people…. I feel like not every country is as advanced as South Africa in some of its policies towards gay people. At the same time, [however,] South Africa has the largest AIDS epidemic in the world, and a young girl in South Africa, particularly in a place like the Kwazulu Natal province, has [an] extremely high risk of acquiring HIV while she is an adolescent or young woman. Some of the highest rates in the world are from that area. [Consequently,] there’s South Africa, progressive on [the rights of gay people], but struggling [in trying to control the epidemic in which gay people are a target population]. The US may be more gay-friendly than many countries, but we still have bullying. We still have murder of gay people because they are gay. We still have an underground gay culture. Black gay men are much less likely to be out than white gay men, and they’re much more likely to be married [to women] than white gay men. So how do we reach black gay men who do not want to be found, especially when they are [already] married [to women] and have another life? These are challenges that we face, and because of these social and behavioral roots of the AIDS epidemic, we [the United States] may be the most technologically advanced and medically-advanced society, but none of that technology helps us with the problems that I’ve just articulated. It’d be great if we had an HIV vaccine, but we don’t. It would be great if we could cure HIV, but we can’t. So we’re not as technologically advanced on that side as you might think.

What would you say is the biggest aspect— if there is one big aspect—of HIV that could be addressed in order to ameliorate the epidemic?

It would be immensely helpful if HIV stigma were reduced massively so that people felt comfortable testing for HIV, with HIV risk-reduction counseling, and with needle exchange if they have a drug problem. [They] would come out of the woodwork, would come out of the shadows of society, and we could engage them more successfully. At the same time that many of us feel that way, there is a subset of society that feels the opposite—that we’re too tolerant of drug users, gay men, and sex workers. They want a more putative approach—fire and brimstone, these are damned by God— and that just exacerbates stigma. I don’t see [the amelioration of the HIV/AIDS epidemic] happening in the current political climate, where we have the forces of reaction in the White House. We don’t have a progressive view the way we did with President Obama. I think that right this minute, we’re in a bit of a stimy period where it’s really going to take community action and local action to address this issue of stigma.

Would you say that you do or don’t see any remedy in the near future for the AIDS epidemic?

Like I tried to imply, I think at the community level, at the local level, there’s a lot we can do. There’s a lot we can do in New Haven[, Connecticut]. There’s a lot we can do in Birmingham, Alabama. There’s a lot we can do in Casper, Wyoming. I think that’s where a lot of our energy has to be put right now. I don’t think that we’ll get a lot of federal leadership in this area as we did under the previous administration. We just have the wrong people in positions of authority, who are not sympathetic to these issues. What would you say the younger generations could do with our power, or [in the process of] trying to obtain our power? I’m somewhat optimistic about the younger generation because the younger generation often does not have some of the prejudices of the older generations, particularly around LGBT issues. I’m a little worried about the younger generation around gender issues. The “Hook-Up Generation”... does not strike me as good for women, for example. I don’t think that’s good for men either. I’m old-fashioned in thinking that sexual engagement ought to be tied to affection and love rather than convenient physical release. So the more you have a “Hook-Up Generation,” the more casual sex you have, the more multiple partners. That’s exactly what fuels the HIV epidemic: multiple partners, unprotected sex, whatever. [However,] I do feel like on the LGBT side there are much fewer hang-ups that young people have about gay people than older people have, and that could fuel a reduction in society- wide stigma. I think the younger generation is more used to universal condom use than the older generation because they grew up in the AIDS era. [A modern-day adolescent or young adult might think] “of course I’m going to use a condom when I have sex. I don’t want to get HIV or an STD,” whereas the older generation was more loosey-goosey; we didn’t have a lethal STD lurking. That might be a good thing.

Why do you think the prescription drug overdose epidemic is a big problem in our society?

Well, when I was in medical school, which was the 1970s in New York City, there were an estimated 400,000 opioid addicts in the United States. Most of them were heroin addicts, some of them were prescription. 200,000 of them were in New York City, and 200,000 were in the rest of the country, mostly big cities. Today, that estimated number is 2.4 million, 6 times [the previous statistic], and we still have about 200,000 in New York City. That is, then, 2 million excess opioid addicts, and it’s no longer restricted to the big cities. Appalachia, New England, parts of the Deep South, and parts of California [have all been affected by the epidemic], and [the effects are] very rural, as well as urban. It’s an objective fact that we have a bigger epidemic. It’s not “do you think we have a bigger epidemic?” We do. Much of that, if not most of it, was fueled by the prescription patterns that became prevalent in the early 21st century.

In the 1980s/1990s, there was an increased awareness that doctors were undertreating pain, and they even started talking about pain as the fifth vital sign. The vital signs are heart rate, respiratory rate, blood pressure, [and body temperature]..., and you were supposed to measure pain just like you’d measure vital signs. This incentivized people to use more pain medication. The problem is that pain is a subjective report, whereas vital signs are objective reports, and it’s difficult to manipulate... objective [data]. [You could] go under a heat lamp, and get a fever [or] you can take a drug to increase your blood pressure, but people don’t generally do that. Pain is subjective. Look at birthing [“in various societies around the world”]. [In] some societies, women are completely silent when they deliver a baby, [and when asked about the pain after birth,] say it was moderate. [In other societies], people are screaming bloody murder in the delivery room, and they [say] it was the worst pain they’ve ever had in their lives. Well, guess what? The pain was identical for the two women. The birthing process is identical, but it was culturally modulated. There were cultural features, where in one society a woman was encouraged or expected to express herself and express her pain and release it that way, and [in the other] one, the woman is expected to be stoic and not release it. [There] is a lot of subjectivity.

My son went to get his wisdom teeth taken out maybe ten years ago, and his dentist gave him a two-month supply of oxycodone. My son took zero of those pills because his father recommended that he try something non-opioid and see if it worked, and it worked. We didn’t need any of those…. If he had taken two months of these pills, he would have become addicted. So there was the dentist who didn’t have a clue. There are many doctors who haven’t had a clue, and in their misguided efforts to reduce pain, they inadvertently addicted a lot of patients. They were helped to do this by the pharmaceutical companies. The pharmaceutical companies had very big campaigns to try to increase sells of their products, and there was a lot of misrepresentation: [imitating pharmaceutical companies] “Oh, you can’t get addicted with our products. Our products will help control the pain, but they’re not going to simulate addiction because you’ll use them in moderation.” That was simply wrong. Many people got addicted. So [there was] ignorance on the part of the medical professional, [as well as] some criminal activity on the part of the medical professional.

There were doctors and nurses who set up pill mills near freeways, who didn’t take any insurance. Cash—$200—in the barrel, ten minute interview, and standard questions. The addicts knew what the responses were, so they could fill it out, and it’d seem like a legitimate request. However, the doctors and nurses knew it wasn’t legitimate. They were just making millions of dollars a year by prescribing this stuff. There were well-meaning doctors who did the wrong thing—overprescribing—and then there were criminal doctors and nurses—a much smaller number—who criminally prescribed…. Then a whole raft of patients who started out often with a legitimate need for pain relief became addicted.

Now, we’re doing a better job turning off the spigot of legal access to opioids, but what does an addict do? Well, an addict is an addict, and unless they’re in a treatment program—and we don’t have enough treatment programs—they will look for an alternative supply, and that’s heroin. You would do well to read a book, written by Sam Quinones called Dreamland…. It tells [the story of] how we got into such as mess, and it also articulates how the Mexican black tar heroin filled in where the Mafia and other drug dealers were not operating and created new models. You could order your heroin the way you ordered pizza by calling someone up and having them deliver to your home. [This was] a whole different model of heroin delivery that was more suitable for rural areas and more suitable for areas that were more stigmatized for heroin use—not the big cities.... They didn’t concentrate on New York, Miami, Chicago, and L.A. They were looking for smaller markets.

Another reason [opioid users] switched to heroin was because it was cheaper. An oxycodone tablet might go for $20, [but] you could get the equivalent of 20 oxycodone tablets for that amount in heroin.... Now, we have people injecting [frequently]. Well, guess what comes with injection? Hepatitis C virus, Hepatitis B virus, and HIV. Have you heard about... Scott County, Indiana? [This HIV breakout involved] a whole bunch of white people—not your stereotypic urban poor, who were the old-fashioned heroin addicts—the new era heroin addicts, many of whom were middle-class, many of whom were poor. It was a 200-person-plus HIV epidemic from sharing needles…. There’s a lot of evidence of the upsurge of HCV, and the upsurge of HIV is inevitable unless we roll out enough drug treatment slots to help people stop sticking a needle in their arm. What would you say is the most important aspect to address in order to ameliorate this epidemic? Well, right now, the horse is out of the barn. 2.4 million Americans are addicted, and we have to offer them opioid substitution therapy. We have to get them on methadone and/or buprenorphine so [that] they can get back to functioning as parents, as citizens, [and] as breadwinners because an active heroin addict is not functioning in those three spaces…. If they’re on methadone or buprenorphine, they can avoid withdrawal, but they can also go to work and... take care of their kids. [We need to have] enough alternative treatment programs—opioid substitution therapy in drug treatment programs— for these 2.4 million people to get off of prescription drug addiction, off of heroin addiction, and transfer that into a manageable long-term-care environment, [possibly] state-of-the-art addiction services—same thing that rich people get. Everyone needs to get that. We do need much better monitoring of physician prescription patterns, and high prescribers need re-education as to the alternative approaches because we don’t need to be addicting a new generation either. We need a lot in the way of job training because one of the reasons somebody might start using an excess of opioids [is because] they got injured on the job, or they had a sports injury. There’s something that led them to need pain medicines.

It’s a vicious cycle: if you are disabled from an injury, and now you’ve become an addict, how are you going to do your job? You need to be stabilized so you can function and you need to get some job retraining so that needs of Appalachia, needs of rural New England can be met by people who are working in spaces where there are opportunities. That doesn’t mean to reopen the coal mines because nobody wants to buy the coal. There isn’t much demand for coal these days.... Those coal-mining regions need to be re-tooled into call centers, technology centers, or tourism centers. There needs to be complete revitalization of these swaths of impoverished rural America [in order] to think through what is possible to do there, how we [can] lure manufacturing there, and how we [can] lure alternative industries there, [an action] which neither Democrat nor Republican has done a good job of.

For the younger generation, what would you say we could do to address this drug overdose epidemic?

Well, we’ve had overdoses here in the city of New Haven. There are drug treatment centers that are desperate for additional assistance. Volunteering in such a center, working with the outreach workers to lure addicts into the center… [by] mak[ing treatment] appealing to them and mak[ing treatment] worth their while, educat[ing] them as to the benefits of these centers [would all be beneficial activities]. I think there’s a huge primary prevention agenda. Imagine somebody as yourself, a Yale freshman, going in to talk to eighth graders in public schools [in New Haven,] Bridgeport, Hartford, or anywhere for that matter, about the opioid epidemic in New England and making it real for people. You could probably partner with a mother or father who has lost their adult… or adolescent child from this epidemic who would be happy to be in a speakers’ bureau with you. There are organizations of such parents who are eager to do this public outreach. We often talk about treatment of the addict as a high priority, and I fully believe that as a clinician and as a public health professional; it’s absolutely essential. But we don’t talk as much about primary prevention: going into the middle schools, the high schools, and educating [students] about opioid addiction. What do they know about prescription opioids? What do they know about unscrupulous pharmaceutical practices? What do they know about what it really means to be an addict, how easy it is to become an addict, and how intractable heroin addiction is? Heroin addiction actually changes brain chemistry patterns, and the more experienced you are with heroin addicts and opioid addicts, the more convinced you are that long-term opioid substitution therapy is a much better option than detox. Detox has a 95 to 98 percent [regression] rate, which just doesn’t work. We don’t fully understand why it doesn’t work, but it’s very ineffectual.

Why do you think cancer research, or just finding a cure for cancer, is still a big concern even when this has been an issue for so long?

I’m not fond of the term “finding a cure for cancer” because cancer is many different diseases. The etiology of cancer differs. The pathology and pathophysiology of different cancers differ immensely, and pathways of the origins of cancer differ immensely. There are many, many different cancers. The only thing they have in common is the overgrowth of cells, and to think of “a cancer cure,” I think, is very naïve. Now, I hope some future Nobel Prize winner your age proves me wrong, and there’s some fundamental, underlying, common denominator of all cancers, and if we fix that, we fix all cancers, but I doubt it. I doubt it very much. In my parents’ generation, if you had acute lymphocytic leukemia as a child, [there was a] 95 percent death rate. Today, [there is a] 5 to 10 percent death rate, so there are some cancers [where] we can cure almost everybody. [Acute lymphocytic leukemia] was a death sentence; now it’s almost curable. We’ve made a lot of progress, and cancer [death] rates in the US have dropped. They haven’t increased in recent years….

Having said that, five-year survival for pancreatic cancer twenty years ago [was] about one percent. Five-year survival for pancreatic cancer today [is only] about two or three percent, so there are cancers where we’ve made almost no progress. [With] something like pancreatic cancer, we’re going to need fundamental, basic science insights because current therapies don’t work. We also need early diagnostics because the pancreas is retroperitoneal; it’s behind the peritoneum, which is the sac that holds our insides and our abdomen, so you cannot palpate the pancreas.... [You can only use] imaging, [but] you can’t have a rare cancer and then go image everybody. We found out about pancreatic cancers kind of late, which also hurts us, but what if there were blood tests, and [they] revealed pancreatic cancer? We could screen people. What if we had fundamental insights about the etiology of pancreatic cancer so we could have immunotherapies like what’s working well for melanoma? [With] melanoma, we’ve had breakthroughs with immunotherapy, and lethal melanomas can sometimes be treated. I think people have to realize that there are many types of cancers which have completely different etiologies, and they are probably going to need completely different insights on the basic science side that could translate to... [the] diagnostic [and] therapeutic side.

Would you say that the fundamental, basic science insights would be the “remedy” in the near future for addressing cancer?

For our incurable cancers, the ones [with which] where we’re doing a very bad job, we have to have basic science insights because our clinical insights are not getting us anywhere. Then, we’re going to need to understand the environmental and molecular mechanisms of cancers, what causes them, and what the molecular mechanism [is] that leads to the disorder: the proteomics, the genomics, the metabolomics.... For the more curable cancers, there’s still a lot of progress that is being made in the clinical environment. There are a lot of cancers where tweaking existing drugs can make a big difference by reducing side effects, by improving efficacy. Drugs like Levac that have come on in my professional lifetime are extraordinary drugs that have transformed oncology. I don’t know that Levac came from more fundamental understandings of the etiology of cancer. That [was just] pharmacologic innovation for which there was some reason to believe that it would be an anti-cancer drug, [but] it turned out that they were right. Some of these drugs that reduce angiogenesis are similar. We know that an almost universal feature of cancer is that the cancer stimulates blood vessel proliferation to feed these new cancer cells. If you can inhibit new blood vessel proliferation, you could starve the cancer cells. That’s just a kind of generalizable observation. I don’t know if that comes from basic science; it comes more from translational science and then generated hypotheses around pharmacological approaches, which panned out. People like Judah Folkman up at Harvard [are] pioneers in this area.

Then [there is] the diagnostic side. There are people working on blood tests for cancer, and the University of California, Irvine, has had some news lately with some great, substantial insights from some of their investigations. To me, it’s a broad panoply of activity. It is on the basic side, it’s on the translational side, it’s on the drug developmental side, [and] it’s on the clinical side. The whole field of radiation therapy, or radiation oncology, has been benefited by physicists and engineers who have developed more targeted X-ray fields so that you reduce the side effects of radiation therapy. You focus [the X-rays] on the cancer cells, and you have better cancer-killing effects. That didn’t come from basic science unless it came from certain physics basic science or optics. That came from engineering innovation. You can be doing almost anything in the cancer field and be making contributions. We need contributions across the board. Some people don’t do well with their cancer because they don’t have health insurance or they live too far or they’re subject to the stigma of cancer, and they abandon their cancer care. They [could also] live in a developing country where, if you live in the capital city [healthcare professionals will] help you, but if you live in any rural part of Africa or Asia, [healthcare professionals] can’t help you. There’s a whole public health side to cancer that’s also valid.

What would you say the younger generation could do to better address the innovative side of cancers that we know more about or start delving into the basic science to explore more of the [unknown cancers]?

We’re always happy when a young person wants to embrace science at any level because the needs are tremendous, and we have to replace the older generation, such as myself. We’re very pleased to see people entering at any level: basic science, translational science, clinical science, public health science…. I think a young person needs to think about what excites them. One person is going to say “It is a disgrace that 6,000 women a year die of cervical cancer, a completely preventable cancer.” They may go into adolescent HPV biovaccine advocacy. They may go into immigrant or refugee health. They may go into health of Native American or Native Alaskan people. They may go into health disparities and disparities between the rich and the poor. Somebody else may say that it’s a disgrace that pancreatic cancer is a death sentence. “I had an uncle die of pancreatic cancer,” they might say, “and I wouldn’t want a dog to die the way that person died, and I want to do something about it.” That person may want to go into basic science. That may be the only place we’re going to make a breakthrough on pancreatic cancer.

There are plenty of health disparities that we can address, and we can reduce cancer by earlier screening, more effective therapy, more effective assistance for people who need to adhere to their therapies, and that’s on the clinical/public health side. There are plenty of horizons on the basic science [side]; that’s the most promising area. So I would [advise] a young person [to match] their interests and passions with their profession, and that [makes for a] happy person. [This is] similar to what you do on the personal side: if you find a partner, you want to find a partner with whom you share common values, common life aspirations, mutual respect, all that stuff. You match professionally just the way you try to match personally, and that [makes for] a happy person.

In addressing all of these global health issues, how do you think the younger generations can collaborate to ameliorate global health on a large scale?

There are youth movements in [the arena of global health]: The Consortium of Universities for Global Health; the American Public Health Association International Health Section; AMSA, the American Medical Student Association; the National Medical Student Association…. There are advocacy organizations [as well]. The ONE Campaign that Bono... founded [is] aching for student volunteers. Right here in town we have the Unite for Sight organization, and [in addition to running the big conference in April,] they do lots of volunteer work all over the world. A Yale graduate founded the Global Health Corps, which sends young people to international service for a year at a time…. Did you know that the international headquarters of Save the Children is here in Connecticut, a 25 minute drive from [the Yale School of Public Health]? There are an abundance of international agencies and advocacy organizations that would welcome student engagement.

On the other hand, how do you recommend that members of the younger generations on an individual level address public and global health issues within their community, city, state, or even country?

I would recommend they don’t try to do it on an individual level. I think joining forces with like-minded people is the only way to get [change] done. I think sometimes you can be old or you could be young, and you can be a little bit grandiose. I’ve known people to go into global health because they want to save the world, and that’s great motive, but it’s not a very good organizing principle because when they find out they’re going to have trouble saving the world, then they get demoralized and [change professions]. I feel like it’s good to understand that you need context in which to make a real difference, and you need the communities in which you’re partnering to engage. It may be that [linking with] community-based organizations, advocacy organizations, political organizations, and public health organizations is going to be far more effective. Paul Farmer didn’t do anything by himself. He created Partners in Health, and he did it with thousands of people. He gets credit, but he’ll tell you he didn’t do it alone. [He] had colleagues from the very beginning; [it was a] group effort from the very beginning. I think linking to an organization that is making a difference, that inspires you and [in which] you can find a volunteer niche or an employee niche someday, would be the way [to address public and global health issues within your community].

Tomeka Frieson is a first-year in Berkeley College with the prospective major of the History of Science, Medicine, and Public Health. Contact her at tomeka.frieson@yale.edu.