Dr. Mike Trangle
Appearances
Health Chatter
Mental Health - Clinical by Population & Age
Or, you know, you get pulled over for a taillight and then awful things happen when the police check you out. I mean, or there have been wars and fights and people get traumatized by that. Or there is abuse, physical or sexual abuse. There's always been trauma, I think, throughout civilization. I think... It's sort of probably a little bit more of a more recent thing that people say that's awful.
Health Chatter
Mental Health - Clinical by Population & Age
It's not OK. We have to try and stop it and we have to try and sort of help nurture and heal the people that have been victimized by it. But I'm not sure that's what you're asking.
Health Chatter
Mental Health - Clinical by Population & Age
Sure. So it's one being recognized. in your community and broader communities. And I think you're also saying that not only is it being recognized, but it's sort of like being normed that it's totally not okay, and we gotta prevent it, then we gotta do something about it. I think that's what you're saying, right?
Health Chatter
Mental Health - Clinical by Population & Age
Let me help you with this. I think what you're saying is there are different sequelae caused by trauma. The classic one that gets talked about is post-traumatic stress disorder, PTSD. You've heard of it? Yes, I have. If we're talking about what are the criteria of that, one, you have to be at least six years of age or older and you've got to be exposed with actual or threatened death
Health Chatter
Mental Health - Clinical by Population & Age
serious injury, sexual violence in one of a number of different ways that the threat could be. You could be directly experiencing it or a series of those kinds of events yourself. You could be witnessing it in person as it occurs to other.
Health Chatter
Mental Health - Clinical by Population & Age
You can learn about it that a close family, a relative or a close family friend has been threatened or maimed or whatever it is by violence, whether it's accidental or whether it's intentional. There are even studies that if you're a police or fire responder that are exposed to it repeatedly, you can get post-traumatic stress disorder. But you said age six. Tell me more about that.
Health Chatter
Mental Health - Clinical by Population & Age
That's the youngest. If you're younger than six, by definition, you might be traumatized, but somehow it's not clear that it really causes PTSD. You know, like I said, we're always sort of learning more, and I don't think it's been studied in the youngest group that much to know for sure, you know?
Health Chatter
Mental Health - Clinical by Population & Age
So what happens is, so you get exposed to it, and then you have recurrent things that are not kind of like memories of the traumatic thing and reactions to it that you can't control. And you have distressing dreams. You might dissociate. You might have flashbacks.
Health Chatter
Mental Health - Clinical by Population & Age
um and for a brief moment you feel like you're back there again if it's a flashback and you're totally in the moment re-experiencing the terror and the hopelessness and the powerlessness that are typically associated with it you know and um You even have things that remind you of when you were traumatized and abused or whatever it was. You try to avoid it. You can't stop thinking about it.
Health Chatter
Mental Health - Clinical by Population & Age
I did my term there and I'm no longer on that.
Health Chatter
Mental Health - Clinical by Population & Age
And it continues to sort of torture you psychologically. And you have like adrenaline surges and anxiety. You know, it affects how you think. You become vigilant. You become insecure, kind of scared. And, you know, you build up sort of like exaggerated responses, both physiologically and psychologically at exposure or things that would remind you about it.
Health Chatter
Mental Health - Clinical by Population & Age
You know, sometimes you personalize it and blame yourself, even though it wasn't your fault.
Health Chatter
Mental Health - Clinical by Population & Age
I don't even know if it's, if it's, if it's being done anymore, frankly, if you're talking about like for depression or other kinds of things in a hospital or in an outpatient setting, it is still being used and it's still being more effective things that for people that have sort of intractable non-responsive depression.
Health Chatter
Mental Health - Clinical by Population & Age
All right. Um, but, and even before that, when it was more barbaric, they, they gave, uh, you do insulin. So people would get into kind of have a, have a little seizure insulin. Wow. Because diabetic kind of like another seizure kind of thing. Yeah.
Health Chatter
Mental Health - Clinical by Population & Age
Um, but, but, um, Clarence, you were saying something that I neglected to mention, but typically if you have a post-traumatic stress disorder, whatever you experienced takes on a life of its own and you almost like continue to re-experience it as you go through your life and in following months and years, you know, and yeah.
Health Chatter
Mental Health - Clinical by Population & Age
You know it's like your thoughts and your beliefs and your reactions to things that remind you of it became strong become stronger. kind of persistent it distorts how you think about things and how you feel about things and you might like just lose your interest in doing things your normal enthusiasm. your normal ability to sort of just be calm and serene.
Health Chatter
Mental Health - Clinical by Population & Age
You might get detached and estranged from other people. And sometimes if it's a really bad case, you sort of like lose your ability to experience positive emotions, you know, happiness, satisfaction, loving feelings.
Health Chatter
Mental Health - Clinical by Population & Age
and your arousal almost becomes super sensitive you get exposed to it and you're gonna and over time you react stronger and to less uh stimulation that reminds you of it it like grows if that makes sense it does and i think you've been doing that because that's part that's part of the reason for the conversation is that i know that there are
Health Chatter
Mental Health - Clinical by Population & Age
Or at least people come up with idiosyncratic but scary and upsetting ways to explain it to themselves. And sometimes they sort of if it's a chronic or repeated exposure, it's not at all unusual for people to dissociate and feel like I'm numb, I'm not really there, or to feel like it wasn't me. I'm so detached, I have no reaction to it, you know?
Health Chatter
Mental Health - Clinical by Population & Age
Or I feel like it's just not real, that it's just a dream I'm having, you know? powerless and trapped in a situation that's just awful. Okay. Thank you.
Health Chatter
Mental Health - Clinical by Population & Age
Yes. Yes. That's definitely true. Let's describe it. Let's just clarify what a panic attack typically is.
Health Chatter
Mental Health - Clinical by Population & Age
If someone's having a panic attack. Yeah. it's an abrupt onset, usually within just seconds, but certainly it tends to reach its peak within just a few minutes. And during that period, so it's an abrupt onset and you have your heart speeds up, you have palpitations, it's pounding, you might sweat, you might shake. If you're hyperventilating as part of it, you feel short of breath.
Health Chatter
Mental Health - Clinical by Population & Age
and feel like you can't, maybe you're smothering. You may have chest pain, not at all unusual. You could have nausea or vomiting, dizziness, lightheadedness. Sometimes some people feel hotter or colder than normal. Numbness and tingliness when you're hyperventilating goes along with that, typically in your fingers or toes.
Health Chatter
Mental Health - Clinical by Population & Age
And you might, once again, feel like it's not real, but it's also very common for people to feel like, oh my God, I'm having a heart attack, I'm dying, you know?
Health Chatter
Mental Health - Clinical by Population & Age
and you have to have uh at least a month of a lot of worry about this is this going to happen again oh my god you know losing control uh and you it has to be severe enough that it's starting to interfere with you doing your normal occupational or social sort of activities
Health Chatter
Mental Health - Clinical by Population & Age
I think your latter comment about a mixed bag is much more accurate. Okay. But take a step back and think about, we're talking about individuals experiencing something, right? And how do I want to say this exactly? if you like, sometimes people interview other people, especially on TV or news shows, and they say, are you an angel or are you a devil?
Health Chatter
Mental Health - Clinical by Population & Age
And it's like a dramatic thing, you know, one extreme or the other.
Health Chatter
Mental Health - Clinical by Population & Age
Yeah. But, but I think in reality, if you take any individual walking around and, You know, they have certain kind of genetics going on inside their bodies, which, you know, increase certain tendencies to have certain issues come up and spare them from some risk for other issues. At the same time, they go through their life and they're growing up in a family where they learn certain attitudes.
Health Chatter
Mental Health - Clinical by Population & Age
And ways to react that are somewhat biological, but also learn from how your parents react to you or siblings or your teachers. You may get abused and have other things you're reacting to, you know, as life goes on. you may excel in certain areas and develop confidence and a sense of how good you are enough that way.
Health Chatter
Mental Health - Clinical by Population & Age
But everybody sort of is affected by a whole array of biological, genetic, psychosocial, and other things going on around them. And so you could say that, Mr. X is going through life and his wife just tells him, I want a divorce after 30 years. If he doesn't react with being shocked or upset or bummed out, assuming he was happy with the marriage, even if she wasn't.
Health Chatter
Mental Health - Clinical by Population & Age
And that's a normal adjustment reaction. It's not necessarily a mental illness or a problem. If it persists and it becomes prolonged and it interferes with his ability to sleep and function, you know, and it lasts for a certain amount of time and the amount of time depends on what the diseases that you're talking about.
Health Chatter
Mental Health - Clinical by Population & Age
But it's a multitude of factors that go on, all of which affect how you function, how you cope and how you think and how you feel. Depending on the situation, in certain of those cases, you could say, oh, my God, this is a, you know, 70% chance that it's biological and genetically determined. Or another one, we don't know, but it's probably less of a chance of that.
Health Chatter
Mental Health - Clinical by Population & Age
So depending what it is you want to change from your armamentarium, if somebody just got found out about divorce, I think talking it through with somebody and having some therapy and some context is probably the preferred method.
Health Chatter
Mental Health - Clinical by Population & Age
You know, if it's all of a sudden there was no medical thing and you weren't using drugs, but all of a sudden you have a manic episode, that's probably biological and genetic. And you want to approach that by doing sort of a workup to make sure it's not a physical and that drugs, you know, either they're taking certain things or withdrawing from them that could cause manic reactions.
Health Chatter
Mental Health - Clinical by Population & Age
But it's still more in the medication realm. If it's, oh, my God, this person has been using meth and other amphetamines constantly, and now they're deeply depressed, it's probably withdrawal. And it's sort of how are you going to get them through withdrawal and get them to sort of get off the meth? And it's still sort of more medical, but it's not medications per se, you know.
Health Chatter
Mental Health - Clinical by Population & Age
So I guess to answer your question is yes to all of them because it depends on the individual and what's going on with them. And they're all necessary. And the bigger issue sociologically these days is people have a hard time accessing mental health, substance use, medications, therapy, inpatient beds or treatment programs in the mental health realm, you know.
Health Chatter
Mental Health - Clinical by Population & Age
I think you're right. I mean, as we learn more and, and, and more research comes out, you find those connections and realize it's an integral part of what you need to work up to see if it's an issue of causing things, uh, or treat. So like sleep is a great, is a great one, you know, where, um,
Health Chatter
Mental Health - Clinical by Population & Age
lately we've been seeing sort of how the effects of lack of sleep and significant insomnia affects your mood, you're much more irritable, potentially higher risk of depression, higher risk of cardiovascular problems and strokes. But even it's not just that, I mean, you could say that if you have very poor gums and teeth,
Health Chatter
Mental Health - Clinical by Population & Age
that increases risk for certain kinds of things that we didn't know about before 15 years ago, you know?
Health Chatter
Mental Health - Clinical by Population & Age
Yeah, you know, and once again, it's like, if you take pain, you know, how much of it is genetic? How much of it is learned in your family? You know, if you would be a... old bachelor farmer that's Finnish or something, you know, and it's very stoical, you were taught to ignore that and don't complain about it. You know, if you grew up in a different family, it might be the opposite.
Health Chatter
Mental Health - Clinical by Population & Age
You know, it's a huge thing. You can't stop talking about it. I need to leave. Give me those pills. I don't care if I get addicted, whatever, you know. Yeah, yeah, yeah, yeah.
Health Chatter
Mental Health - Clinical by Population & Age
Well, it's kind of like I'm saying, you got to give me a context and a situation and I can tell you how we would treat it optimally. But if you say mental health in general, kind of what I'm highlighting is sometimes it might be therapy because I just learned about my divorce and I need to kind of think it through. Sometimes it might be I'm manic and I need to sort of decrease stimulation.
Health Chatter
Mental Health - Clinical by Population & Age
I need to make sure I'm not withdrawing or using different chemicals, but then I might start somebody on a mood stabilizer, you know? It depends on which issue you're talking about.
Health Chatter
Mental Health - Clinical by Population & Age
You know, and in a lot of ways, you're putting your finger on a really important issue. It's like we have such a sprawling, complex sort of not even it's not a well-functioning system, but system of care. And people don't know how to get in. They don't know where to start.
Health Chatter
Mental Health - Clinical by Population & Age
You know, and the resources are such that the people that sort of have a good broad base and what's going on psychologically with therapy, with genetics, with medications, with drugs. But there's such a shortage of those people and it's hard to get in. It's like, we don't really have a system where you have somebody comprehensively looking at somebody and saying, this is who you should see.
Health Chatter
Mental Health - Clinical by Population & Age
You know what I mean? It's word of mouth. Can you go to your primary, you know, if you have a primary care doc, a good strategy is go to that doc and say, can you get me in to see somebody in your system? Assuming they're not at a small boutique private practice, you know?
Health Chatter
Mental Health - Clinical by Population & Age
uh but uh because the lack of resources and it seems like a lot of the systems of care the wagons have uh it's like a wagon train and they've circled the fire yeah protect themselves and if you're in the circle you can get in if you're not you're at a lot you know um
Health Chatter
Mental Health - Clinical by Population & Age
and uh yeah you need to sort of go to see somebody who's whatever it is i'm i'm a devout freudian psychoanalyst or something you know and everybody i see needs analysis you know you want to see somebody that has a perspective and an open mind and can think about uh what really fits and best matches this particular patient you know yeah yeah yeah you know it seems like it's um
Health Chatter
Mental Health - Clinical by Population & Age
But you should repeat that again. That is such a startling figure. 10% of people that acknowledge and think they have a problem can get in and get help.
Health Chatter
Mental Health - Clinical by Population & Age
I mean, it's just... You know, if that was happening with people with heart attacks, there really would be an uproar around it.
Health Chatter
Mental Health - Clinical by Population & Age
Correct. And if we go back a step, if you start with behavioral health, it's a bit broader. And the two subcategories that are generally thought of as part of it are mental health disorders and or substance use disorders.
Health Chatter
Mental Health - Clinical by Population & Age
It's kind of like what I was saying that the problem is worse and the access has been worse too. Exactly. And there's a whole host of reasons for it, ranging from underfunding the resources needed to evaluate and treat folks with mental health problems and substance use disorders,
Health Chatter
Mental Health - Clinical by Population & Age
um it uh it's changed a little bit now but it also you wouldn't get paid as a psychiatrist like you would as a cardiovascular surgeon right right the esteem isn't quite there so it's like uh and the payment wasn't there so it's like um and now we have a
Health Chatter
Mental Health - Clinical by Population & Age
Because of the economics of it, there are less inpatient beds, there are less clinicians out there, but the population continues to grow, the need continues to grow. People are beginning to do some stuff in the legislature about putting some money into maybe increasing resources for training programs.
Health Chatter
Mental Health - Clinical by Population & Age
increasing resources for training programs so we can get people from diverse communities trained and supervisors to train other people from those communities. That'll take a while. And they still they've done some token things, but the rates haven't gone up to really attract people to the field as much as other areas.
Health Chatter
Mental Health - Clinical by Population & Age
but it's been sort of neglected and underfunded and increased the amount, the degree the underfunding has kind of accumulated over the years. That's a long way to go. So it's starting to change, but unlike Virginia Slims, we have not come a long way, baby.
Health Chatter
Mental Health - Clinical by Population & Age
I think there's so much overlap between the two that it's a little bit arbitrary to say, let's just talk about one and not the other, as they sort of interact between and influence each other. And sometimes they're comorbid, sometimes one causes another, et cetera, and so forth.
Health Chatter
Mental Health - Clinical by Population & Age
You know, and I think that whoever's listening, if you think about, if you know who you're legislatures are in the Senate, in the Minnesota Senate and House. And if you have any communication or if you don't, maybe you should strike up some and say, we need to better fund mental health and substance use resources. You know, please do so as issues come up in the legislature.
Health Chatter
Mental Health - Clinical by Population & Age
Right. And to some extent, I'm going to go back to my major as an undergrad, which was philosophy. And how do you when do you say it's a discrete, separate entity? And when is it sort of one thing merges into another? To some extent, the guiding light is folks in the American Psychiatric Association who come up with the definitions in something called the DSM. Now it's five text revised.
Health Chatter
Mental Health - Clinical by Population & Age
But research is being done to sort of say, does this sort out separately than that? Is one at later stage of it? or just sort of a subtype. And you actually can do studies, both genetic studies, epidemiological studies, to sort of figure out what is the latest that we've learned and we're constantly learning. So it's not like somehow the world,
Health Chatter
Mental Health - Clinical by Population & Age
came about, whether you're religious, you can say one way, if you believe in evolution, a different way, but somehow that it's fixed that way. My point is things continue to evolve both in our bodies and in the world around us. And our understanding of that continues to evolve as we learn more. So don't view it as like, here are the 10 commandments and they're never going to change, you know?
Health Chatter
Mental Health - Clinical by Population & Age
Yes. And you're hearing about it more now because during COVID and the pandemic and the shutdown and the impact on schools and people being home and not just that, but the rise of the internet and how that impacts people, the prevalence of those have increased. You know, so traditionally, I would say before, several years ago, if you say, what's the basic 12-month prevalence of depression?
Health Chatter
Mental Health - Clinical by Population & Age
You know, most people would say it was about 7%. And it tends to be higher in people that are younger, like 18 to 24 years of age, like three times higher in that range.
Health Chatter
Mental Health - Clinical by Population & Age
you know, about twice as high, and it's increased lately, just as anxiety has increased. You know, if you look at the statistics of anxiety, in the U.S., some of the studies before the very most recent ones show that a little less than 3% of adults had anxiety problems, generalized anxiety. In the world, it was sort of listed as about 1.3%.
Health Chatter
Mental Health - Clinical by Population & Age
prevalence in the world, but how much of that is affected by cultural norms and whether you, in certain cultures, you don't have good words to describe it, or there are taboos against acknowledging it that, you know, which is probably true everywhere, but it could be greater in some civilizations and some societies than others.
Health Chatter
Mental Health - Clinical by Population & Age
So the thought is that there's less reporting and less acknowledgement of it in some other third world countries kinds of things.
Health Chatter
Mental Health - Clinical by Population & Age
Yeah. So first of all, if somebody has a problem that comes up, you got to sort of figure out what's going on with me, you know? And I would say because of the stigma and lack of knowledge, and if you go back a ways, more often than not, people might have a mental health disorder, but not be aware of it.
Health Chatter
Mental Health - Clinical by Population & Age
not recognize the symptoms, the cluster of symptoms that sort of lead one to think maybe this is more depression, or maybe this is more anxiety, or maybe it's not generalized anxiety, it's a panic attack. So you have to recognize it, you have to get diagnosed, and then you have to have treatment available and accessible. All of which, for mental health issues in the U.S. or in other countries,
Health Chatter
Mental Health - Clinical by Population & Age
have been sort of problematic. I think in the last 30 years, 20 to 30 years, there's been enough education and public service announcements and stuff so that the stigma about acknowledging to yourself or to others, maybe they have a problem that's a mental health problem is a bit less than it used to be. So there's probably a more likelihood someone would say, yes, I have it.
Health Chatter
Mental Health - Clinical by Population & Age
At the same time, traditionally, there was a lot of discrimination against uh paying for and treating it you know so example just take in the us um if you had a physical problem and you were old and had medicare or experience depending on uh how sensitive you are to the word old experience and have medicare um
Health Chatter
Mental Health - Clinical by Population & Age
Medicare paid 50% of the cost for physical things and only, I'm sorry, 80% of the cost for physical medical problems and 50% for psych problems, behavioral health, mental health problems. Now, maybe about 10 years ago when parity came up, that got rectified, or 15 years ago, I don't remember the exact time. So there's already sort of a barrier to accessing it.
Health Chatter
Mental Health - Clinical by Population & Age
As a patient, you would have to pay more. And that's been true up until just very recently, you know, and maybe 10, 13 years ago, the U.S. passed the first Wellstone Parity Law, but it was never enforced. In fact, there were rules about how to even enforce it and what it meant, how it was defined for years, for a number of years after it was passed by Congress.
Health Chatter
Mental Health - Clinical by Population & Age
And even then, they then passed rules, but it was ignored and not enforced. And even until like a year and a half ago, there was a study done by a joint study by HHS, federal level, labor. And there was a third department there, which I can't remember what it was. Labor, health and human services, and another department, commerce maybe. And they saw that health plans were enforcing it.
Health Chatter
Mental Health - Clinical by Population & Age
Nobody was making them enforce it. So there was another more recent version passed. There was one in Minnesota that passed. It also wasn't enforced. There was another one passed. It's starting to get enforced a little bit, but it's way lagging.
Health Chatter
Mental Health - Clinical by Population & Age
And that's true for outpatient resources, whether it's for a therapist or to see a psychiatrist to get evaluated and do medications, or whether it's to get into a hospital. These days, there was a study that just came out in Minnesota about what percentage of patients that are showing up in emergency rooms can't get access to needed treatment.
Health Chatter
Mental Health - Clinical by Population & Age
And there was a law passed called EMTALA that started out because of women in labor getting turned away if they didn't have insurance. And it obligates hospitals that have emergency rooms to evaluate and treat and stabilize patients that show up in their ERs.
Health Chatter
Mental Health - Clinical by Population & Age
I mean, I think trauma has always existed as long as there have been people, and people that have been mistreated, neglected, and treated poorly. Whether it's you're a child in a classroom and you get ignored, but other people get called on because of your skin color, or because you have ADHD and you're annoying to the teacher.
Health Chatter
Infectious Disease
You know, and Stan, I would even add an additional context to that. I personally am trying hard to get rid of the infectious disease, chronic disease nomenclature. Because today, so many infectious disease caused conditions are actually chronic manifestations of immune dysregulation. Yeah. And so long COVID is a good example of that.
Health Chatter
Infectious Disease
I can go through, I mean, look at number one causes of cancer, hepatitis B, et cetera. So when you look at the tie, there's actually a lot of continuity between infectious diseases and what we call chronic diseases. And I mean, I think One day we will find that, you know, whether it's neurologic disease, whether it's immunologic disease, whatever, has in its origin an infectious disease trigger.
Health Chatter
Infectious Disease
And I think so that's why, you know, we look at these. I look at the holistic, what is the whole picture? So a good example is just what you said with long COVID. You know, what's going on there? probably at least five or six different immunologic dysfunction issues that are occurring that you can't just treat one or the other. It may be this one you have, somebody else has another one.
Health Chatter
Infectious Disease
Why do you have such fatigue? Why do you have the kind of conditions, that brain fog that we're talking about? And our studies today show that there's not a one or two diagnostic test approach here because it's really about major immunologic dysfunction in a number of different ways.
Health Chatter
Infectious Disease
Well, you know, Clarence, I tell you what, I have a problem here that you might want to be aware of, okay? So in 2000, I wrote a book called Living Terrors, What American Needs to Notify the Coming Bioterrorist Catastrophe, 2000. I think I bought 14 of the 18 books sold in the next year. And then when 9-11 happened and anthrax became a New York Times bestseller.
Health Chatter
Infectious Disease
OK, 2017, it got a little bit more circulation than me buying copies. But then when COVID hit, it became a New York Times bestseller. OK, now I have another book coming out this next year on the big one. You know what we need to do to prepare for the real pandemic of the future. And and I'm terribly afraid to put this out because I'm afraid I might predict we'll have it. Just bury that. Okay.
Health Chatter
Infectious Disease
I know, you know, you know, this is, this is where I think in public health, we need to offer more what I would call just plain common sense because all the things I've just talked about, why these diseases are increasing and, You know, it has nothing to do with some magical, mystical insight. It's just A plus B plus C. How do you get there? You know, what does it mean when we see all of this?
Health Chatter
Infectious Disease
And so I think that, you know, it's an issue of, well, let's walk this through and see what this means. OK. And and, you know, for example, today, agriculture has changed dramatically. you know, with large animal production facilities, millions of birds, et cetera, that poses this whole new way of amplifying virus and mixing it up. I could go through a laundry list.
Health Chatter
Infectious Disease
Look at antibiotic resistance today. I mean, we use antibiotics, unfortunately, like candy as the defensive drug of the century. Okay. If in doubt, Over Medicaid. Okay. And we're losing our antibiotics because you don't have to be a superstar to understand these kinds of things.
Health Chatter
Infectious Disease
So I think it's more a matter of how do we bring reality to our educational experiences to those who are out there and understand what's going on. Let me just give you one other example. You know, I happen to spend some time in working on prairie restoration and burrilla forest restoration, etc.
Health Chatter
Infectious Disease
People are all talking about climate change right now as being very critical as it relates to tick movement and so forth and potential Lyme disease. Well, ironically, it's not climate change. Climate change can play a role, ultimately. It's all about the fact that 120 years ago, we started stopping forest fires.
Health Chatter
Infectious Disease
And as a result of that, we've seen the successional forests in the east, the middle east. We used to be prairie oak savannas in the upper Midwest, right up towards the boundary waters. And today, because there's stop fires, we've seen the white-footed mollusk in a whole totally different environment emerge. And at the same time, we've seen population centers develop in those areas.
Health Chatter
Infectious Disease
And so, you know, we should not be surprised that we're seeing this whole new effort or involvement of ticks and so forth because they're now living in forests that never existed before because every 50 to 100 years they burnt. I mean, it's just something that's simple. It's just that simple.
Health Chatter
Infectious Disease
Well, you know, Clarence, you hit on the question of the century for public health, I think. You said it so well. this is a huge challenge. And one of the reasons that in my new book coming out, I say we're less prepared for a future pandemic than we were before is because of the loss of trust. And I think that that is a huge issue. You know, my own personal approach to it is, first of all,
Health Chatter
Infectious Disease
Humility, humility, humility. Say when you know, and if you say you know it, why do you know it? How do you know it? Can't be personal opinion. It can't be. If you don't know, say that. But then tell people what you're going to do to try to find out. And tell them, I'll let you know when we find something new. It may not answer the whole question, but the bottom line is, this is why we're at.
Health Chatter
Infectious Disease
And so I think we need a major new understanding of how do we do public health communication. I think it's one that we're desperately needing much more work in. And so, you know, we won't gain back the trust as long as people perceive that we think we know everything. We're going to tell them exactly what to do. And oh, by the way, that didn't work.
Health Chatter
Infectious Disease
Well, you know, at the risk of being, raining on a parade here, I think that article was in some ways misdirected. And what I mean by that is that clearly the zoonotic issues of animals and humans is very important. And the next pandemic will have at its root cause an animal reservoir of some kind that spills over into humans. So that's not even a question.
Health Chatter
Infectious Disease
But the challenge is there really are only two infectious agents today that has the potential to cause a pandemic. influenza and coronaviruses. And because for a virus to cause a pandemic, it's got to be able to be what I call a virus with wings. In other words, it will move quickly around the world. It will be one that respiratory transmission will play the most critical role.
Health Chatter
Infectious Disease
And I'm talking about effective respiratory transmission. And we will not have seen it before in a way that immunologically
Health Chatter
Infectious Disease
some of us might be protected by having previous experience so the article did a great job of laying out these events that occurred i mean i think the group for example in the zoos in new york were absolutely essential in identifying what happened with west nile they really oh god they were very important but west nile has never posed a challenge with a worldwide pandemic
Health Chatter
Infectious Disease
You know, it's going to cause problems. It's going to continue to cause problems, but that's not where it's at. Mpox, you know, unless Mpox takes on a virus with wings-like issue where it's respiratorily transmitted, you know, contact, particularly sexual contact, will not be a reason for a worldwide pandemic.
Health Chatter
Infectious Disease
So I think that one of the things that we need to understand is, you know, what are the diseases that kill us? What are the diseases that hurt us? What are the diseases that concern us? What are the diseases that scare us? And how do we distinguish between them all? And so I would say right now, we need to focus heavily on coronavirus and influenza.
Health Chatter
Infectious Disease
And today I have the lead article out in Foreign Affairs. on our lack of preparedness for influenza or coronavirus pandemics of the future, and really goes into what we need to do. You know, our influenza and coronavirus vaccines are good vaccines, but they're not great. They lack long-term durability, easily evaded with new variants or new strains, and We don't really understand that yet.
Health Chatter
Infectious Disease
We're still using, for influenza, largely 1940s technology. We make it in chicken eggs. I mean, it's crazy. So we can do a lot better. And so I think that's what we want to focus on. So taking pandemics off the table would mean having... coronavirus and influenza vaccines that could be pre-delivered, meaning that, you know, they cover such a broad brush.
Health Chatter
Infectious Disease
If I got vaccinated today, no matter what Mother Nature threw at us tomorrow, we'd have some pretty good protection. And I actually believe that's possible. Our center at the University of Sidra actually leads the world in that we are responsible for the overall influenza vaccine roadmap work, as well as the coronavirus vaccine roadmap. So WHO, NIH, All these use our materials.
Health Chatter
Infectious Disease
And we have seen real advancements made in these vaccines, but we're still a decade or more away from really having game-changing flu vaccines at the rate of we're supporting it right now.
Health Chatter
Infectious Disease
So I think that article was helpful in illustrating how, in the meantime, we're still going to have a lot of these skirmishes that show up that still are challenges, and they're still very important, but they're not pandemic-causing. And, you know, one day maybe there'll be a new virus class that will come into play that will be a pandemic virus.
Health Chatter
Infectious Disease
You know, if Ebola ever becomes airborne, if, in fact, MPOX becomes much more efficient at airborne transmission, then I might be saying there's a third category. But right now it's flu and coronaviruses.
Health Chatter
Infectious Disease
Well, thank you both for your point and your question. To the point, I have always put forward that science is not about facts. Science is about learning. And you lay out the process of science is basically do this, doesn't work, you try that. You do this, you do that. Okay, and you learn from that. And then over time, facts will change as you learn more.
Health Chatter
Infectious Disease
But you prepare the public in advance for that and tell them, you know, this is what I'm going to do to learn more about that. And I think that for me, that has never felt uncomfortable or as if somehow I'm failing. And therefore, I don't get defensive. I say, I don't know. This is what I do know, though. This is how I know it.
Health Chatter
Infectious Disease
And I think that too many of us feel obligated to be right and have the facts. that then locks us into, oh, wait a minute, that's not what really happened. And so I think that people understand what is happening. And let me give you, I think, an example of where we can learn. If you look at the US Weather Service and you look at the Hurricane Center, they have all these different models.
Health Chatter
Infectious Disease
They always tell you what the different models show, but this is what it could be. And You never hear people saying, they misled me. They told me I was supposed to do this and that because they gave me the variability. But you know what? They're pretty often right on the mark or close to it. But sometimes a curveball gets thrown in and suddenly it shears off to the right or to the left.
Health Chatter
Infectious Disease
And I think that we in science and medicine need to do much more of that kind of scoping to say, This is what we know. This is what we don't know. This is what we're finding out and go from there. So this is part of the communication issue I was talking about for public health.
Health Chatter
Infectious Disease
We need to better understand how to communicate with the public in a way that they can understand where we're coming from.
Health Chatter
Infectious Disease
Yeah, well, it's true. At the same time, some of the biggest challenges I've had is with my own colleagues. It's not the public. And the colleagues get out there and say things, okay? I mean, for example, there was a lot of BS put forward by some groups during the COVID about what masking could do or not do.
Health Chatter
Infectious Disease
And what I mean by that is, is that, you know, N95 respirators are highly effective in reducing the likelihood of becoming infected. But they equated anything you put in front of your face. And even if it was down below your nose, OK, well, that's not masking from a protection standpoint. Yet I heard people and saw people promoting all those things.
Health Chatter
Infectious Disease
And the public said, wait a minute, why are you telling me this now? You said I could do this. It was not said with credibility. And everybody has an opportunity to have a voice. Everybody can say this is what, you know, it is. And they become believable. And, you know, TV producers and oftentimes reporters don't know the difference.
Health Chatter
Infectious Disease
And so they get reported and then they become officially, officially the official, you know, and that's the challenge we have today. So, you know, all you can do, I think, is just stick with the track record and, you know, acknowledge what you know and what you don't know. So I think that's it.
Health Chatter
Infectious Disease
The question you raised about the biologics, the irony about this is it's not in many cases a big challenge. And why? Because the kinds of immune compromising conditions that these drugs cause, like enhancing TB or things like that, are frankly diseases of low and middle income countries, not high income countries. And they're only selling these drugs in high income countries.
Health Chatter
Infectious Disease
So if you were to take the same drug and deliver it to Gaza right now, you would have a very different side effect, you know, the implications for, you know, any kind of adverse event, very different than if you gave it to the people who attend the University of Minnesota, you know, cancer clinics. And so that's the biggest issue we have today is that
Health Chatter
Infectious Disease
And for most of these drugs, they're not going to be a problem for us other than, you know, the other immunologic issues it might cause. But this is why these drugs are never meant for the low and middle income countries. They couldn't afford them to begin with. And second of all, that's where the real challenges are with the diseases.
Health Chatter
Infectious Disease
Well, thank you, Stan, both you and Clarence. It's a real honor to be here.
Health Chatter
Infectious Disease
Well, you know, this is an interesting one, because this is another one where I got crosswise with some people. You know, I have served in every presidential administration since Ronald Reagan, some official role. During the Trump administration, I was actually the science envoy for the State Department and pandemic preparedness for the world, ironically.
Health Chatter
Infectious Disease
So and I was on the Biden-Harris transition team for COVID. So that, you know, no one, I think, hopefully would accuse me of being politically motivated. You know, my job has always just been a private in the public health army and report to duty and do what I can to help. Okay.
Health Chatter
Infectious Disease
So I think from that standpoint, that's really an important point is, you know, just basically put it out there as you do. But again, the challenges that I saw often were coming from my own colleagues in public health who were had points of view that, you know, differed and therefore they, they, they, that became the battleground and the public is sitting there listening to this. Okay.
Health Chatter
Infectious Disease
You know, what, what does it mean? Not mean. And I think that that's the challenge that we had was there's not a way to come up with a single public health voice. I understand that. I agree with that. Um, And there's not a way to understand outreach.
Health Chatter
Infectious Disease
A good example in Clarence, I know that you're probably likely very aware of this, but one of the most wonderful, absolutely incredible activities that took place during the pandemic was the Black Barbers and Black Hairstylists programs, where the group out of the University of Maryland in particular were working on Black Barbers. And I got very involved with this.
Health Chatter
Infectious Disease
I even had my own name, Big Mike, okay, in this program. I mean, I love these guys. And their outreach was remarkable because they knew how to outreach. And when they were sitting in that barber chair and they had their trusted barber who now, because they had taken courses and they were being educated on the current issues, they became trusted voices in the community.
Health Chatter
Infectious Disease
And they did more good, and they still are doing more good than a whole lot of us with all kinds of academic degrees. And, you know, and so I think part of it also is how do you find the trusted voices in your community in that community. And, you know, I would just say, again, one of the greatest successes in the whole pandemic if there were any was the black barbers and hairstylist program.
Health Chatter
Infectious Disease
And I think that's what we're looking for today is how do we find those kinds of trusted voices that can be informed, that can run the day, okay?
Health Chatter
Infectious Disease
And when you were getting your news and your updates from that barber chair versus some far right or far left cable TV show, I bet you you're getting a heck of a lot better information in the barber chair than having some talking head on one of those talk shows. I don't know, Clarence, if you want to add to that, but I think that's... Well, no, no, no.
Health Chatter
Infectious Disease
Well, as I alluded to earlier in our discussion and talking about my conversation with the late D.A. Henderson and the fact that global population immunity to the pox virus has largely evaporated with the aging population and the fact that we had our last case of smallpox in 1978 and the vaccine ended in 1979. Right.
Health Chatter
Infectious Disease
And so imagine that everyone literally born over the last 45 years has never been exposed to either smallpox or to the vaccine. And it turned out that as we realized that once you had protection against smallpox, whether vaccine or clinical illness, you basically had quite good protection against all the other orthopoxviruses, monkeypox, buffalopox, horsepox, et cetera, okay?
Health Chatter
Infectious Disease
All these are viruses that can infect humans. And there was very few diseases in the world where there was more widespread immunity in the population because either you got smallpox or you got vaccinated up until 1979, okay? Well, now today we look at the low-income countries and the median age in many of these countries is in the 30s and young 40s.
Health Chatter
Infectious Disease
because that is the population pyramid is there, okay? And, you know, I mean, I can tell you just Kinshasa, for example, you know, which is now at the heart and the DRC of some of these really severe health challenges, you know, working in HIV there in 1985, there were 3 million people living in Kinshasa. Today, Kinshasa has 24 million people and with almost no urban planning going into it at all.
Health Chatter
Infectious Disease
And if you've ever been there, it's like, oh my God, And so now once that virus starts spreading either by droplet or by contact, it really moves. And as you pointed out, the idea of borders, let me just give you another example of, you know, I came out strongly opposing border closings for the whole COVID situation saying, you know, it was useless.
Health Chatter
Infectious Disease
It's like taking a garden hose to a, you know, 5,000 acre forest fire, okay? And people said, oh, you don't care. You just, you know, well, we tried to arm ourselves with all this testing on planes coming in on the West Coast. OK, by God, we're going to keep that out.
Health Chatter
Infectious Disease
Never thinking about what some of us did think about it, but the hires up didn't, is that that same virus is going to go from China to Europe, to Europe, to the United States. And the whole East Coast was totally left uncovered in terms of that.
Health Chatter
Infectious Disease
And again, and so what happened, we saw these huge outbreaks that occurred in Italy and places like that, that had come from China and then to New York City. Why was New York City light up like a light early on? Because they didn't come in the West Coast, came in the East Coast. You cannot effectively basically protect a border. You have to assume that this is going to move. And they move quickly.
Health Chatter
Infectious Disease
Virus with wings move fast. And so I think that that's one of the things, again, that in our new book, we go into some extent about border issues and say, don't waste your time on it. It's still going to happen. No matter what you do, even if you slow it down a little bit, it won't materially change where you're at three months or five months or six months. Instead, plan for it.
Health Chatter
Infectious Disease
Plan is going to come in. Plan that New York City could get hit hard. Plan that that's going to happen as opposed to thinking, you know, and unfortunately, you Say, oh, we're under control. We got it under control because they weren't sending on the West Coast coming in. OK. Meanwhile, the East Coast was on fire.
Health Chatter
Infectious Disease
So I think that's the kind of thing that, again, we can anticipate. Hopefully next time we won't count on the geographical or, you know, country borders as such serving as an efficient wall against a virus. It will not. It will not.
Health Chatter
Infectious Disease
You know. To me, contact tracing is... And we wrote several papers on this and regarding this. And we found that there was no value squeezed for the juice once it took off because it was so extensive. It was so out there. And contact tracing was what we were trying to accomplish. Well... We wanted to let people know that they might have been exposed.
Health Chatter
Infectious Disease
And then, therefore, what are you going to do if they're exposed? Well, tell them not to go anywhere, particularly if they get sick. Well, testing was such a problem. And following up all these people was such a problem. You know, at one time in Minnesota, we had over 250 people doing contact tracing. I mean, I couldn't imagine that in public health. I couldn't imagine that. And you know what?
Health Chatter
Infectious Disease
We likely had very limited impact at all. And so I think that's why by the end of the first year, all government bodies stopped doing contact tracing. It just wasn't effective. It was like, again, taking that garden hose to the 5,000 acre forest fire.
Health Chatter
Infectious Disease
Yeah. And I think that's the challenge. I mean, you know, I mentioned earlier about lockdowns. So he wasn't supportive of lockdowns. The vast majority of lockdowns that actually took place were really not lockdowns. They were an illusion. Take, for example, Minnesota. You know, the government, the governor put in place, you know, stay at home order basically from work, except for essential workers.
Health Chatter
Infectious Disease
Well, first of all, let me just say that what has happened is still happening in the sense it's unfolding. I hope we can talk about that today because we're in another surge occurring right now. And the big question is, what do we do about it? How is it different or is it different than from before? And what does this mean about, are we in a pandemic or not? Are we over it? What's going on?
Health Chatter
Infectious Disease
Now that clause was important. Do you know it turned out that about 83% of the Minnesota's workforce is considered a central worker? Now tell me, is that a lockdown? So I mean, part of it was, and the poor governor got hung then with that issue of, oh, look, you shut down the economy. It wasn't they shut down the economy. It was the fact that people were too afraid, period.
Health Chatter
Infectious Disease
It didn't matter what the political leader said, okay? They just didn't want to go into public spaces out of fear for getting infected, okay? So to me, that again is just trying to set the facts straight and say, oh, so what makes a difference? What doesn't, okay? And I think you're going to see
Health Chatter
Infectious Disease
even through this election cycle, more and more discussions about, oh, you destroy the economy by doing these lockdowns, when you really realize what happened. You know, to call them lockdowns was to say, I'm smart. And we all know that's not true.
Health Chatter
Infectious Disease
Well, first of all, everyone will always acknowledge there's never enough funding, okay? But what does that mean? Well, today, as I mentioned earlier, the lead article in Foreign Affairs is my piece on that very issue as it relates to influenza and coronavirus vaccine preparedness, okay? And the lack of funding. So we are and have had a model for public health funding that is based on a biennium.
Health Chatter
Infectious Disease
Every 2 years it's based on very limited foresight into really the future. Now take the Defense Department funding when they decide to build a new aircraft carrier from start to finish is 14 years. They basically fund it for the whole 14 years. Okay, fast forward funding.
Health Chatter
Infectious Disease
They take into account all the different issues that could come up and the cost overruns that might happen, et cetera, et cetera. Nobody, nobody complains about that. That's the approach that we find necessary. If you look at our influenza vaccine work right now, I mean, the vast majority is being funded by the US government, which is fortunate, but it's less than a billion dollars.
Health Chatter
Infectious Disease
And there is no long-term future planning for funding. It's biennium to biennium. And talk about if you wanted to find a magic bullet that could take off the table one of the very worst wars of all against another pandemic virus, you'd think we'd be investing in this like the defense. We're not.
Health Chatter
Infectious Disease
And I go into that in some detail in this piece today about why we need a new mindset to deal with what is our current cost of investing versus the cost of not investing. What's the potential return on investment? And I do believe we can get much, much better flu vaccines and much better COVID vaccines or coronavirus vaccines in general.
Health Chatter
Infectious Disease
And that could fundamentally change the game on when the next pandemic emerges, what that's all about then. But we don't do that. We're back. We're still making in this country the vast majority of our flu vaccine in chicken eggs. Yeah, this is 1940s technology, guys. Yeah. I mean, what's wrong with us?
Health Chatter
Infectious Disease
So I think there's a lot of there. But let me just start off by saying in the 2017 book that I wrote, Deadly Sinners, Organs, Killers, Germs, I devoted several chapters to what an influenza pandemic would look like in a more severe way. And what had unfolded was exactly that, but just a coronavirus.
Health Chatter
Infectious Disease
You know, these are vaccines that when you give them and the fact, you know, I'm again, a counter voice right now. I'm urging people do not get your flu vaccine right now. Do not. get it when it's closer to the actual advent of flu season and let the public know when that's starting. So if we start to see activity in Minnesota in November, let the public know. Why?
Health Chatter
Infectious Disease
Because we have clear data today that anywhere from 3% to 12% per month reduction in protection occurs after vaccination. So it's just waning immunity. So if I get my dose now and it's not till four or five months from now, flu season really starts, I may have lost 50% of the protection of that vaccine just as I'm getting into the flu season.
Health Chatter
Infectious Disease
So, I mean, I think that's the kind of thing. What if we had a vaccine that could give us long-term protection against a variety of different strains? Shouldn't we be funding that like we fund the Defense Department? So that's my mindset. I don't try to say, well, the Defense Department gets lots of money. I'm talking about cost investment related to return on investment.
Health Chatter
Infectious Disease
You know, C.S. Lewis once said, if you don't know where you're going, any road will get you there. And, and, and, We do that really well. Yeah, no kidding. So I think that's the challenge we have today. You know, we're all going to die. All of us on this screen are going to die someday. And whoever's the last one here, shut out the lights and wish you best. Party's over, right? Yeah.
Health Chatter
Infectious Disease
So we're not trying to avoid death. So if we're not trying to do that, which is often the way people measure what we do or don't do, what is it? We're trying to have healthy lives for as long as we can of sound mind and body. free of pain, cognitive function, positive, et cetera. Okay. So what do we do to help accomplish that?
Health Chatter
Infectious Disease
And, you know, realizing that as we age and we're now the aging population where we understand, oh, you know, we didn't realize falls were really all that hard on people, but you know, they are kind of tough on older people, et cetera. So I think it's more investing in what is the return we want. What do we want? Kids should not be dying from vaccine preventable diseases. They should not.
Health Chatter
Infectious Disease
That should be a clarion call. OK, so I think it's things like that that we need to put in order to say this is what we should be doing.
Health Chatter
Infectious Disease
And what was difficult for me was the surprise that I had about how we responded without really understanding what it meant to have a pandemic. What I mean by that, for example, is I was one of those lone voices early on in the pandemic. In fact, in early March of 2020, I wrote a piece in the Washington Post saying, do not do lockdowns. Do not do that. Do not try to take an aggressive approach.
Health Chatter
Infectious Disease
Well, first of all, it's a real honor to be with you. Thank you. I'm very, very honored to be here. You know, I think it's fair to say that if you are a student of public health or considering to be a student of public health, this is a great time to get involved because we've got lots of challenges. We need you. I am encouraged by that.
Health Chatter
Infectious Disease
I have a set of graduate students right now that are as good as any I've had in all my 50 years in the business. And I have a hope. I have hope. And I hope it's not a strategy. It doesn't hurt to have it. Okay. And I think that that's really where we're at right now.
Health Chatter
Infectious Disease
And again, I hope that our conversation today helps give people a sense of where we're at, what we need to do, and hopefully engages them in the critical, critical area of public health.
Health Chatter
Infectious Disease
You know, if Stan asked me to walk over broken glass barefoot, I would. He's a good man.
Health Chatter
Infectious Disease
And the reason why was because I too didn't want anyone to get infected, but I knew this was going to be a two or three year journey at the least. And you can tell people to do some extreme things for short periods of time. But over time, they won't maintain that. And then you kind of lose the credibility of, well, wait a minute, why did you recommend that?
Health Chatter
Infectious Disease
And now why are you saying, ah, forget it, never mind. And so I think that we didn't really understand the implications of what a long-term podcast, or I mean, a long-term situation might look like. And on a podcast in early March, I predicted that we could easily see 800,000 deaths in the next 18 months. And it was interesting. You know who my most severe critics were?
Health Chatter
Infectious Disease
Were my colleagues for scaring the hell out of people needlessly because nobody could imagine that. Well, unfortunately, 18 months after I said that, we hit our 800,000th death in this country. And so I think it was a function of public health and clinical medicine, along with government leaders coming to understand what it meant to be in a truly significant pandemic.
Health Chatter
Infectious Disease
And then accordingly from that, you know, make the decisions about what to do and how to do it. And, you know, my whole point was, you know, if whatever we do keeps you from dying in those first few months, that's great. But if you die in the second six months, you're dead. Or if it's the third six months, you're dead. Oh, by the way, if it's the fourth six months, you're still dead.
Health Chatter
Infectious Disease
And so our goal is how do we in the long term minimize death? the potential impact that a pandemic has that's sustainable. And clearly the vaccine played a key role in coming on board. And yet we saw how that vaccine tore up the political, social, cultural issues of this country. And what has happened with that?
Health Chatter
Infectious Disease
I mean, I think that people today have no real clue of the negative impact that that vaccine has had on the vaccine world. You know, we're now seeing remarkable drops in immunizations for kids. Even veterinarians are seeing it vaccinating their dogs and cats. And it's no longer a function about safety. It's about don't tell me what in the hell to do. And we're seeing that over and over again.
Health Chatter
Infectious Disease
Did we understand when we mandated COVID vaccines that that could be a side effect of doing that, is that we would create more of a rebellion? Now, I'm not saying don't get your COVID vaccine. I'm up to date. I just got another one a couple weeks ago, okay?
Health Chatter
Infectious Disease
But the bottom line is, is that we, I think, didn't realize that the implications of doing something may be one, two, three orders down the road. And so for me, that was the biggest surprise is people not appreciating that. And understanding we're in this for the long haul. And how do you get through a long haul is what this is really all about.
Health Chatter
Infectious Disease
Yeah. And we surely did along the road have to learn. I mean, you know, if there was no other word that should have been a front and center guiding principle for public health, it should have been humility. Because in fact, there was a lot we had to learn.
Health Chatter
Infectious Disease
For example, I oversaw an effort early in the pandemic, April, May of 2020, with some of the best and the brightest in both the modeling world, in the infectious disease world, experience with pandemics, John Barry from 1918 Flu, Mark Lipsitcher Group. And we put together a publication that's still on our website saying, how might this end?
Health Chatter
Infectious Disease
Will this be a situation where finally there'll just be enough people who've been infected and immune that will hit this magical thing called herd immunity where transmission will no longer be sustained? Or will in fact that never occur and you just have these recurrent infections over and over again but maybe getting milder over time, is there some residual immunity that's so protective?
Health Chatter
Infectious Disease
Because we know just like influenza viruses, the coronaviruses do not provide long lasting protection. And sure enough, we ended up realizing in the summer of 2020, oh my God, look at these new variants. These variants are, you know, derivations on a theme and they're more immune evasive. They're more infectious in some cases, et cetera.
Health Chatter
Infectious Disease
And it creates a whole new risk picture that you were never out of risk of getting COVID beyond, once you got beyond four months or so of being vaccinated or having previously been infected. So that too, you know, led us to say, wait a minute, skip this herd immunity stuff. This isn't going to happen. Okay.
Health Chatter
Infectious Disease
What can happen is we hopefully can see milder illness over time if we have some protection on board. But today we know, you know, the vaccines for COVID as well as for influenza are good vaccines, but they're not great. They're not great. They don't provide durable immunity.
Health Chatter
Infectious Disease
The variants which occur with COVID, with coronaviruses, you know, are actually happening at an amazing pace, several a year, whereas flu, we might see one a year. And so I think that these all led us to also realize that This is something we're going to have to manage over the long haul. And right now we're sitting in a 10th surge of what you call, in this case, possibly the post-pandemic era.
Health Chatter
Infectious Disease
But we're seeing transmission rates right now that rival many of the previous peaks we had in 2020, 21, 2022. The good news is less severe illness. We're not seeing 20,000 deaths a day as we did during Omicron. We're seeing 600 deaths. uh, we're seeing 650 deaths a week and 20,000 a week, I should say, or 200,000 a week back in the Omicron time.
Health Chatter
Infectious Disease
So I think the bottom line message is expect the unexpected, be humble and just know that, uh, you know, it won't last forever in the way it started, but it's around now for good. It's
Health Chatter
Infectious Disease
Yeah, well, I think, again, we really haven't appreciated the mental impact that COVID's had. And, you know, I think that one of the lessons I've learned in my career was, you know, when I started at the University of Minnesota as a newly minted undergraduate, and then within days started at the Minnesota Department of Health,
Health Chatter
Infectious Disease
in 1975, you know, I got asked many times, why are you going into infectious diseases? That's horse and buggy stuff. You know, this is done. We're over, man. I mean, we're going on to the next generation of public health challenges and we're going to fix them. Okay.
Health Chatter
Infectious Disease
And no one really had a full understanding of just how complex this world is and why we would see the return of some of the infectious disease problems that we had not even imagined could be this bad. I mean, I go down a laundry list of issues. And so I think that one of the things we have today is what I call creative imagination. You know, what's happening.
Health Chatter
Infectious Disease
I can remember very well, one of my mentors and who, someone who has had a dramatic impact on my career was the late D.A. Henderson, who was really the father of smallpox eradication in his office out of WHO. And D.A., was one of those brilliant minds that kind of thought about things, not just in the abstract, but, you know, creative imaginations I talked about.
Health Chatter
Infectious Disease
And we talked at length about in the 1990s, what would happen when the population ages and we've not used any kind of smallpox vaccine, nor have had smallpox as a clinical illness in our communities for some decades. Today, the vast majority of the population in low-income countries are younger than 45 years.
Health Chatter
Infectious Disease
Well, it was 45 years ago we stopped vaccinating for smallpox and we stopped, you know, basically clinical cases from occurring. Much of the world's population, particularly in low-income countries, have no protection against pox viruses today. Well, lo and behold, why should we not be surprised? Monkeypox is now returning in a big way because we now have this very vulnerable population. You know,
Health Chatter
Infectious Disease
We have, for example, today a situation where the large urban areas of low and middle income countries, particularly low income countries, are nothing largely than, unfortunately, major garbage environments where there's all this discarded garbage, plastic, et cetera. And that is ideal habitat for breeding the 80s mosquito. because they want to live close to humans.
Health Chatter
Infectious Disease
They want to live where there's this little bit of water in a plastic container or a piece of plastic or a piece of junk that water collects in. Very different than the mosquitoes that cause malaria that are much more open water mosquitoes, et cetera.
Health Chatter
Infectious Disease
Well, when you look at what's happened with the urbanization of low-income countries in this world, you can see this dramatic explosive growth of 80s-related vector-borne diseases. Dengue, yellow fever, Chicken gun you. I can go down the list. And because of that now, we're seeing unprecedented occurrence of vector-borne diseases we'd never seen before like this.
Health Chatter
Infectious Disease
And so I could go through a number of different issues today about why the world is different and why are we now seeing these diseases that make for a much greater challenge than it ever was in the earliest days of my career. A major challenge.
Health Chatter
Mental Health - Where We Stand
You know, we should probably make a distinction between something happens and you have a reaction to it. Okay, yeah. You know, which in a technical sense is called an adjustment reaction or adjustment disorder. Okay. It's unlimited and it doesn't last for more than three months kind of thing, you know?
Health Chatter
Mental Health - Where We Stand
And... So if you think about it, you know, you've got chest pain, the ambulance takes you to the ER, you know, and they say, well, you're having a heart attack. You know, you've got a few waves and ST elevation in your EKG. Right, yeah. Maybe I'm talking Dr. Babel there, but you've got symptoms of it and you have proponents and stuff.
Health Chatter
Mental Health - Where We Stand
And then they want you to sign and say, well, we're going to do a – radiological study. And if we find something, we want to sort of do a stent. We want you to give us permission to do both in one fell swoop. Yeah.
Health Chatter
Mental Health - Where We Stand
Yeah. Okay. So, you know, and then you go there and they find, oh, you got a blockage in your main artery that they call the widowmaker.
Health Chatter
Mental Health - Where We Stand
Right. You know, the LAD. And, um, You know, anybody's going to be panicky at that. You know, you'd have to be like artificial intelligence to not react to that.
Health Chatter
Mental Health - Where We Stand
So it would be weird if you weren't. having a really scared, terrified reaction to that.
Health Chatter
Mental Health - Where We Stand
Well, you know, it depends how much of a blockage you have.
Health Chatter
Mental Health - Where We Stand
Exactly. So anyway, he goes through the surgery and you don't die. Then you find out I have no damage or I have a medium amount of damage and my ejection fraction is not as potent. My heart isn't pumping out the blood as strongly as before, you know. Yeah. You don't know if you have permanent damage or temporary damage or how much.
Health Chatter
Mental Health - Where We Stand
You know, so you're going to continue to be pretty darn worried about that, you know, and you go to cardiac rehab and eventually it kind of wears off and you go on with your life, you know, and most people won't stay in that acute reaction for that long unless they somehow get depressed, you know, because you can also have a depression and whenever you're depressed.
Health Chatter
Mental Health - Where We Stand
uh everything's not as good you know you're more pessimistic it's not going to work out well you don't have your energy you don't have your concentration you don't have your normal sort of sense of optimism you don't initiate things you know and a subset of depression can be an agitated depression with a lot of things yeah not everybody gets that but so um it can be blurred by other things happening but if it's just a pure adjustment reaction
Health Chatter
Mental Health - Where We Stand
Yes, it's both. How do I want to say this? I think theoretically what you're talking about is a psychiatrist and or therapist coordinating and talking all the time with the internist and staying in touch. Right. Wonderful goal. I don't know that it necessarily happens that way most of the time.
Health Chatter
Mental Health - Where We Stand
People are busy. They have their practices. You know, you might send a copy of your evaluation. If something comes up and you're really worried, you might give a call. But it's the exception, not the norm.
Health Chatter
Mental Health - Where We Stand
So if you look at it nationally, 54.7% 54.7% of adults with mental illnesses do not receive treatment. Wow. Okay. And it's, how do I want to put this? It's not good anywhere. The state that has the best access, according to this MHA study, is Montana, which is not what I would have expected. Neither did I. And they don't have that many people. Well,
Health Chatter
Mental Health - Where We Stand
And that means four in 10 adults with mental illnesses do not receive treatment. So only 60% of people get in. Wow. And that's the best state. Right, right. You know, if you look at the average, 28.2% of all adults with mental illness reported that they were not able to receive treatment they needed. 42% of that group said they couldn't do it because they couldn't afford it.
Health Chatter
Mental Health - Where We Stand
Other people find out that there just is a shortage, whether it's therapists, whether it's psychiatrists, they're busy. The workforce is shrinking as the baby boomers retire and they're not being replenished because the schools to train them and put them out I don't want to say this.
Health Chatter
Mental Health - Where We Stand
To me, this relates, if you want to talk about the root cause of a fair amount of this, I think if you think about the stigma and how that has impacted things, until just about 10, 20 years ago, if you had Medicare and had a medical problem, Medicare pays 80% of your doctor costs. If you had a mental health problem, they would pay 50%.
Health Chatter
Mental Health - Where We Stand
You know, mental health and being a psychiatrist or being somewhere, anywhere in the mental health diaspora has never been, how do I want to say this? You have Dr. Welby's growing up. Yeah. And Casey. Yeah. Traumatic. They're great friends, great love lives, and they make a lot of money. Not Dr. Welby, but the other ones. But you had very few shows kind of lionizing psychiatrists.
Health Chatter
Mental Health - Where We Stand
And it wasn't prestigious. It didn't pay that well, and less people went into it, which means you have workforce issues in terms of access. And if you don't pay well, you also have less people going into it, not just prestige, but money-wise, they're combined. And it's always been that way. It might be changing lately because there's such a shortage, they have to pay more.
Health Chatter
Mental Health - Where We Stand
And health plans, well, even Medicare, I mean, have been able to get away with it. I mean, there was a parody law that got passed a long time ago, but it's just beginning to be enforced a little bit now. Did that answer your question? I think I started to ramble a little.
Health Chatter
Mental Health - Where We Stand
Isn't there a song like that, You Are Always On My Mind? You Are Always On My Mind, exactly.
Health Chatter
Mental Health - Where We Stand
Let me broaden this a little bit. I know mental health matters or chatter or whatever it is. What is it called again?
Health Chatter
Mental Health - Where We Stand
Health chatter. It's not just mental. OK, that's good. Because it's worse for substance abuse. And I want to ask the conversation. OK. For most people that have substance abuse disorder in the U.S., 93.5% did not receive any form of treatment.
Health Chatter
Mental Health - Where We Stand
That's very impressive. Only 6.5% got in for treatment.
Health Chatter
Mental Health - Where We Stand
You know, how do I want to say this exactly? Yes and no. Okay. I mean, behavior problems or EBD, emotionally, behaviorally disturbed, are more school education labels. And they're not clinical psychiatric diagnosis. Interesting.
Health Chatter
Mental Health - Where We Stand
Yeah, yeah. So when you say behavior problems or EBD, I don't know what it means. It means with a given patient and I've worked in hospitals for a long time, it's kind of meaningless, you know? It's like, what, what are the cluster of symptoms? What's the actual diagnosis, you know? And, um, generally, uh,
Health Chatter
Mental Health - Where We Stand
uh these days psychiatric units are such a shortage of beds the people that get into psychiatric units are people that really are sort of like um if they wouldn't be there they wouldn't be safe yeah yeah yeah they're there for safety's sake not to control behavior per se yeah yeah yeah which of course which of course we we um causes its own reverberations down the pike
Health Chatter
Mental Health - Where We Stand
If you're not going to treat them there, where do you treat them?
Health Chatter
Mental Health - Where We Stand
problems is not necessarily ideal but if you don't have other places or ways to intensively engage not just the patient but the family you know to get them better they don't get better they just get kicked like a can getting kicked down the road you know they go to juvenile detention and they have something ordered but it doesn't really happen very reliably whether it's in-home other stuff and things just get worse if you have a system that's not been adequately funded
Health Chatter
Mental Health - Where We Stand
they tend to not be the panacea that people tend to think or that tends to be sort of highlighted in dramatic movies and TV shows. Yeah, yeah, yeah, yeah. And even if they do work, they oftentimes have some side effects
Health Chatter
Mental Health - Where We Stand
that uh mean and if you're talking about for people with schizophrenia or psychosis it's more than a little you know they have significant side effects that cause people to say it may not be worth it you know yeah um
Health Chatter
Mental Health - Where We Stand
But it's like you almost always need to do working with the individual and the family and their psychology and the kind of lives they live and what kind of support systems they have, how they think of themselves, what can they do differently, whether it's cognitive behavioral therapy, other kinds of things. You want to sort of do a balanced approach that's not one simplistic answer.
Health Chatter
Mental Health - Where We Stand
Well, you know, part of what I thought you were going to ask more about, I got a million statistics, but it's the same as what I've already said. So I don't think to go over adolescents versus adults. Yeah, we'll get into that for sure. But if you think about access, I don't think it's a simple thing. And it's like, You know, you got the stigma, you got the expense involved.
Health Chatter
Mental Health - Where We Stand
Some of the data that I have here shows that if you have private insurance, the co-pays are about twice as much for mental health, even now. And the deductibles compared to medical things. So that hasn't stopped. It's. workforce issues, it's balance of life issues, you know, and you got to know you have a problem, you know, and it's not a lot of people don't know what they have.
Health Chatter
Mental Health - Where We Stand
It's not like I got chest pain. I mean, if somebody has a panic attack, they're probably going to end up in the ER, but otherwise it's something's wrong, but it's not what you don't know what it is necessarily. You got to figure out, I have a problem. And a lot of times, you know, people sort of just say, what's the matter with me? You know, I'm just not thinking clearly.
Health Chatter
Mental Health - Where We Stand
I got to like get through this. I got to, I'm not, what am I, too wimpy or something? And you don't know that you need help. And then you got to feel like it's okay if I need help. And then you actually have to get in.
Health Chatter
Mental Health - Where We Stand
and find out whether you can you know get in and and since there's a shortage it's not easy to get in you got to jump through a number of hoops you got waiting lists yeah the uh if you look at the health plan networks they oftentimes have phantom people in them you know uh people that aren't taking anymore and that kind of stuff um So it's just not easy, you know.
Health Chatter
Mental Health - Where We Stand
And there are a lot of barriers to surmount to think about, know what you want to do, and then actually get in. I'm on the board of Minnesota Konami, and they do an annual survey. We do an annual survey. And what they found, it's not really statistically, it's not like publishable.
Health Chatter
Mental Health - Where We Stand
in terms of the rigor you know um but what they found is uh people had a great difficulty accessing all different kinds of services whether it's inpatient beds whether it's residential treatment whether it's just psychiatry especially child psychiatry or therapy and they found out especially for psychiatry that a lot of people just give up and stop trying
Health Chatter
Mental Health - Where We Stand
they can't get in they call so and so so many people they're not taking they're not even on the list anymore blah blah blah they don't take insurance you know right but it's not easy and a significant percentage of people just stop and they give up and they just never get in so mike let me ask you we did we did a show um
Health Chatter
Mental Health - Where We Stand
Yeah, you have to, if I have a patient coming to see a new person, you know, if I'm Um, let me, let me back up a second.
Health Chatter
Mental Health - Where We Stand
Say I have a mental health issue and depending what it is, you know, if you look at the two most common things, anxiety disorders and depression, you know, I'm really pretty fearful and nervous and scared about, I'm going to see someone, I don't know what the heck this person is going to do for. And, um, I don't trust it necessarily. I'm kind of vigilant and, uh, um,
Health Chatter
Mental Health - Where We Stand
finding someone who is a good match that could kind of get me and that I can learn to trust is huge, you know, or if I'm depressed, the issue is I'm not myself. I have no energy. I have no initiative, you know, um, I was sort of one of the leaders of a diamond study that happened in Minnesota.
Health Chatter
Mental Health - Where We Stand
And as Juergen Unitzer would say, who was the guy that sort of like with Wayne Caton developed sort of a collaborative care model, which is by far the most evidence-based thing to treat depression and other diseases turning out. He would sort of say, one of my first patients said, when I'm really depressed, I can't even get out of bed anymore. I get dressed. I don't shower.
Health Chatter
Mental Health - Where We Stand
I don't do my daily hygiene. I just don't have the energy. I don't have the initiative. I don't care. I know it's not going to help. Nothing's going to get better. What's the use? And for me to get up and call a doc and say I'm not doing well is way more than I can handle. And so you're taking people that are at their worst and they're not functioning well.
Health Chatter
Mental Health - Where We Stand
And you're asking them to sort of like fight the system, which is stacked against you to get in. And it's too much.
Health Chatter
Mental Health - Where We Stand
You know, and it's funny because ideally the system, if you talk to people that say it needs to be designed so there's no long door and that people will get you in. and get you in a timely way. But each agency has their own way to protect themselves. And there are sociologists that have done studies looking at therapy
Health Chatter
Mental Health - Where We Stand
patients and it's like uh in the old days this might have been the 60s or 70s they would say that the kind of patients that therapists like to see are young verbal uh attractive and i don't know what the obvious i don't remember what the uh intelligent and i don't know what the s was but yeah uh it's not your disheveled schizophrenic who's homeless and wants to do something about it you know um and those people somehow don't seem to make it in
Health Chatter
Mental Health - Where We Stand
One, they're not as competent and two, David Mechanic did some of the studies looking at how institutional barriers sort of creep up to make it a little nicer workplace for some people.
Health Chatter
Mental Health - Where We Stand
You know, um, Uh, I've been a leadership vice chair and chair of the governor's mental health advisory council for a while. And we heard from a lot of people during COVID, especially people with substance abuse, um, they couldn't go to groups.
Health Chatter
Mental Health - Where We Stand
You know, they couldn't stay so clean and then say when they started using again, you know, and, um, um, what turned out to be a huge lifeline for them was just a telephone, you know? Uh, yeah. And there was a huge fight going on in those days about what people are going to pay or not pay for audio only, you know, but you got a lot of people in rural areas, a lot of people in
Health Chatter
Mental Health - Where We Stand
in the inner rings where they don't have, you know, it's not just a rural, but it's also if you don't have money or a good network in the city, there are a lot of people that didn't have good internet access, couldn't do the video or it was in and out. And they found that just calling and talking to your CD counselor or your shrink on the phone was the lifeline.
Health Chatter
Mental Health - Where We Stand
And they said, that's what kept them alive. Wow. And we argue vociferously that, one, it got added to the pandemic exemptions. And then just recently, they extended the study. Instead of just saying we should pay for audio only for CD and mental health, they just extended the study for a year or two. It's not going to come up again in a year.
Health Chatter
Mental Health - Where We Stand
And it's those kinds of things that are life and death for people that I think legislators and sometimes health plan people don't get. you know, right.
Health Chatter
Mental Health - Where We Stand
People talk about it like it's either all one or all the other. If you're deaf, then you're trying to maximize, optimize how it goes. You do it in person. Sometimes you do the televideo. But if it's not available that day because the internet connection keeps going out, at times you use audio. At times you do face-to-face. At times you do Zoom.
Health Chatter
Mental Health - Where We Stand
It doesn't have to be talked about like it's this or that. It's both and. Correct.
Health Chatter
Mental Health - Where We Stand
I am fairly optimistic. I do think things are getting better, and I think there's sort of a glacially slow but sort of steady kind of progress towards more and more people realizing it's not your fault if you have a mental illness or substance abuse. You are just as deserving as anyone else to be treated fairly and equally.
Health Chatter
Mental Health - Where We Stand
And little by little, I think everyone's starting to get that and more resources are being put into it. And I would say 20 years from now, it'll be a lot better, even if it doesn't happen instantly.
Health Chatter
Mental Health - Where We Stand
You don't have access. You don't have the same access problems. Correct.
Health Chatter
Mental Health - Where We Stand
And that's because you got money put into it. It's a procedure based thing and it pays well.
Health Chatter
Mental Health - Where We Stand
My perspective is a little bit twofold or color. Yeah. When anyone starts their chronic career, and I started as a clinician, through psychiatric residency, seeing patients, both adolescents and adults, and doing a combination of inpatient and outpatient work, and then adding substance use disorder work.
Health Chatter
Mental Health - Where We Stand
And early on in anybody's career, you want to sort of master your trade, you know, perspective and competencies. So as I went along my career, I sort of knew more and got better, get experience, you know, so you're loving by knowing more patients and your own life experiences. At the same time, it's been very apparent to me that early in my career, you know, Nobody talked about mental health.
Health Chatter
Mental Health - Where We Stand
You know, if you think about it, somebody got sick, got hospitalized. You know, they never got cards. A lot of people visiting letters. You know, I don't know if they got cakes or dinners left over. You know, one of the spouses was in the hospital and stuff. It just wasn't done. It was like it was like a dirty word almost. Yeah. So much shame. and avoidance about it.
Health Chatter
Mental Health - Where We Stand
And I would say over the decades, I think both families first, and then patients to a lesser extent started realizing there's stigma involved here, and it's totally unwarranted. People don't choose to have mental illnesses. People really don't choose to have substance abuse disorders, but they still have to deal with the fallout coming from that.
Health Chatter
Mental Health - Where We Stand
And as that has gotten more acceptance by the advocacy groups that it's OK, and maybe we need to fight for our slice of the pie, things have changed. It still has a long, long way to go if you look at the statistics. But I think in some sense, the core, one of the core issues is this is not my fault. I shouldn't need to be ashamed or hide, you know, that kind of stuff.
Health Chatter
Mental Health - Where We Stand
I'm sorry, Matthew. You raised your hand and I didn't even look up.
Health Chatter
Mental Health - Where We Stand
Well, think about the pejorative terms that got used when we were growing up. Someone was a retard. Yeah. Mental retardation is one of the things we deal with, whether it's because someone has a uh, Down's syndrome, you know, or other kinds of things, someone's psycho, you know, which usually means psychotic disorder, you know, or crazy or you're yellow. I mean, that could be your coward.
Health Chatter
Mental Health - Where We Stand
It could be an anxiety disorder, you know, but the way it's, especially amongst teenagers who are sort of like rudels in teaching each other and stuff, um, And if you think about it, something that used to be considered a mental illness decades ago was being gay, let alone getting into all the trans, lesbian, binary kinds of things.
Health Chatter
Mental Health - Where We Stand
But that was also sort of, if you want to insult a teenage boy, you would call him gay or something, you know, because there was so much shame associated with it. That, as more evidence came out probably 20 years ago or so, it got removed from being a disorder, a mental health disorder, you know. But initially it was plugged into that category without good evidence.
Health Chatter
Mental Health - Where We Stand
And it's kind of interesting that there seems to be a renaissance of hate and prejudice against trans people these days, right now, that's sweeping the country. And not just in the US, other countries too. But it's kind of interesting how politics certainly doesn't follow evidence.
Health Chatter
Mental Health - Where We Stand
And how and why somebody brainstorms, let's pick on these people so we can divert attention from something else now, or at least get more support now. That's a mystery. I'm not a politician, but it's still a mystery to me. And I don't understand that.
Health Chatter
Mental Health - Where We Stand
Well, just take the internet. Yeah. And not getting into fringe segments of it. Yeah. There's abundant data that for a minority of teenagers,
Health Chatter
Mental Health - Where We Stand
people that are going through the developmental stage where they're trying to figure out who they are, separating, individuating from their parents, and who am I, what's my identity, when I'm not just reacting to my parents, either modeling from them or trying to separate and fight with them to become my own person. But during that turmoil, the minority of them can find
Health Chatter
Mental Health - Where We Stand
fellow people struggling with whatever they're feeling, whatever they're struggling with, and get some support. So in a modest, small way, it's kind of useful in that way. In a bigger impact, and for many more people, the perfectionism and the unreal expectations and the trolling and a vehicle to sort of get out your hatreds and your own feeling bad and taking it out on other people.
Health Chatter
Mental Health - Where We Stand
You know, it's diminished self-esteem, whether it's self-image, whether it's just self-esteem, whether it's whether you can be okay with yourself and happy and reasonably content with life, or you feel like you're a failure. Yeah. So like many things, I think it's had a mixed reaction.
Health Chatter
Mental Health - Where We Stand
And depending on which subgroup you fit in and how you use it and how much of it you use, it could be a little bit of an aid or it could be a big bummer.
Health Chatter
Mental Health - Where We Stand
Okay. If you look at the Mental Health Association of Minnesota, 2019-2020 survey showed that 20.78% of adults were experiencing mental illness. Okay. If you look at... There's a... How do I want to say this?
Health Chatter
Mental Health - Where We Stand
Right now, the percentage of people that talk about symptoms, and it's a little bit lower, enough cluster of symptoms to give you a diagnosis has been increasing pretty rapidly, especially anxiety and depression, and more so in adolescence than adults. And if you're talking about a certain point in time, let me see. I have it right here. Give me a second. Okay.
Health Chatter
Mental Health - Where We Stand
So like in Minnesota, 28.3% of adults in Minnesota have depression and anxiety lately. Okay.
Health Chatter
Mental Health - Where We Stand
Symptoms of. It's more acute. More acute. Or it could be a worsening of a chronic one if they're lumped together.
Health Chatter
Mental Health - Where We Stand
I would say the theme that I've seen when I looked at sort of the literature for this is Minnesota is not looking good and the U.S. is looking a little worse. Not a lot worse, just a little worse. So there's like 32.3% of adults have depression or anxiety right now compared to 28.3% in Minnesota. And that sort of ratio is pretty consistent for most everything.
Health Chatter
Mental Health - Policy Implications
The worst ones were Kansas, Oregon, which is a little surprising, Arizona, Alabama. Yeah. Yeah.
Health Chatter
Mental Health - Policy Implications
You know, can I just say one thing? You're right. We do need to be more involved. But when you compare that to the general medical rankings, which are a little more consistent. Right. You know, Minnesota does really pretty well. If you look at longevity, we're one of the top ones.
Health Chatter
Mental Health - Policy Implications
But but there are there are consistent states that basically have better access and better quality and better ways to get people in to help them get in Massachusetts. Minnesota, Wisconsin, some other New England states, Hawaii tends to do okay there. But in mental health, we're at best just average.
Health Chatter
Mental Health - Policy Implications
Yeah. You know, It's so multifactorial. But if you think about it, just in the U.S., compared to other countries, other countries may have national health services and everybody gets access to care, it gets paid for. The U.S.,
Health Chatter
Mental Health - Policy Implications
is all over the map and depending what's going on with state legislatures and politics and whether you don't wanna pay for stuff with taxes, you know, less people get covered by insurance, it's harder to get into MA, there's less money available for disability kind of wraparound services and stuff.
Health Chatter
Mental Health - Policy Implications
Um, so, you know, in Minnesota tends to, in terms of social support compared to the whole vast U S tends to be, tend to have a sort of a little better safety net for mental health, social services. Um, uh, but, uh, and a little, and more people here tend to get insured one way or the other Minnesota care covers the working or, you know, some of that kind of stuff, but what's available.
Health Chatter
Mental Health - Policy Implications
But but it's still we don't even think about it. It's like the air we breathe about how the population in the U.S. is stratified by wealth, by whether you're employed, whether you can qualify for M.A. or not, by whether your county is a richer county and chooses to sort of have more county based services for things. And it's not that way so much for medical things. Yeah.
Health Chatter
Mental Health - Policy Implications
It's worse, you know, and traditionally it's changed, but traditionally it's been, even if we might pay for medical stuff, we would pay less for mental health, Medicare, you know, the national thing was 80% paid for, for medical and 50%, you know, until about 15 years ago, you know? And yeah,
Health Chatter
Mental Health - Policy Implications
you know, chemical dependency services weren't paid for at all, you know, and how hard or easy you make it to get into those services. And the other thing you think about is, how do I want to say this? In mental health, the tradition has been If you have a problem, you have to prove it's a bad problem. You've had it for a while before you'd have access to services.
Health Chatter
Mental Health - Policy Implications
Not at all like, I had a heart attack and I need something. My leg, I need rehab services. Here you've got to prove that it's bad, it's serious. Much worse than for medical things. It's always been sort of unfair. And it's just...
Health Chatter
Mental Health - Policy Implications
You know, I think I agree with what Biden was saying. You know, he did a thing like a week ago or whenever it was. And he said, one of our priorities is to really enforce parity. And we're really mean at this time, even though it's the fifth time around and it's been meant, but not really enforced, not really followed up on really for at least 20 or 30 years. It's been lip service. Yeah.
Health Chatter
Mental Health - Policy Implications
And I don't know exactly, the Department of Labor is now soliciting feedback on how they wanna sort of really mean at this time and enforce parity. And one of the things that they're highlighting in what they're proposing at least, they're still getting feedback on it is, Every health plan has to have a statement of purpose on what they mean by parity.
Health Chatter
Mental Health - Policy Implications
They have to have clear definitions on what limitations are and why. And they have to have a written analysis comparing the limitations and measuring it. and measuring outcomes. Although in a funny way, outcomes are, you know, historically have been weird. You know, it's like, how many people have we covered on this or something? It's a raw number. It doesn't give you a percent of the population.
Health Chatter
Mental Health - Policy Implications
It doesn't compare you to medical. How many people get in? How long do you wait to get in for X, Y, or Z? You know? And if you don't measure it routinely, you don't know where you're at. And if you try to improve it, you won't even know what parts are improving and what parts aren't improving.
Health Chatter
Mental Health - Policy Implications
You know, so one of the things that we proposed, for example, here, we being sort of a consortium of mental health folks, is what we proposed and didn't make it through the legislature. The only thing that really made it through the legislature, not the only thing, there were a lot of things that made it through the Minnesota legislature. But one of the things we proposed that didn't was that
Health Chatter
Mental Health - Policy Implications
Everybody that's paying for mental health services and CD services should be measuring how long it takes to routinely get in, not in emergency cases or urgent cases, how long it takes to get in and whether you can get back in in a timely way. And it should be compared to the medical services.
Health Chatter
Mental Health - Policy Implications
So if I'm waiting to get in to see a psychiatrist, it shouldn't be any longer than it takes me to get in to see a primary care doc or an orthopod or a heart person. You know, dermatology is hard to get into these days. Right. Yeah.
Health Chatter
Mental Health - Policy Implications
But we're worse than dermatology. At the same time, at the same time, we've been proposing that we sort of in a supervised safe way, expand the workforce so that we're including nurse practitioners. physicians assistants that have specialized training in, in psychiatric behavioral health issues, both mental health and substance abuse issues.
Health Chatter
Mental Health - Policy Implications
And that we measure that and compare them to nurse practitioners in medical surgical kinds of places. We're proposing your measure. If you break your leg, how long does it take in to get into a rehab or a transitional care unit? We should do the same thing that people are now sitting on inpatient psych units waiting to get out, but they're not safe to go home.
Health Chatter
Mental Health - Policy Implications
How long they're waiting to get into a foster home, how many they're waiting into a residential treatment center, those kinds of things and compare those. And I think doing that, that expecting the health plans to improve, we said by 25 percent each year until they're within 10 percent of what it takes to get into the medical surgical would really go a long way.
Health Chatter
Mental Health - Policy Implications
You know, so let me ask you, get in. You're not going to get help. You're not going to get better.
Health Chatter
Mental Health - Policy Implications
Yeah, I mean, more and more people are dying for lack of getting in and getting what they need.
Health Chatter
Mental Health - Policy Implications
And like we talked about earlier, we're sort of in a period where the percentage of people with anxiety, worsening anxiety and depression is skyrocketing. Suicides are going up. We know that deaths of despair from sometimes intentional, sometimes accidental opiate overdoses are increasing majorly. I think the urgency is there. It really is a crisis.
Health Chatter
Mental Health - Policy Implications
Yeah. How do I want to say this? I mean, COVID... isolated people, remove them from their normal habits, less exercise, less going to work and getting whatever social supports you might from colleagues there, as well as more pressures. One of the things that showed, though, was that for mental health and for substance abuse disorders, video or just telephone, audio only, can be a lifeline.
Health Chatter
Mental Health - Policy Implications
You know, there was a surge in kind of telehealth, both audio only and televideo. And the surge has sort of gone down and it waxed and then it kind of waned, except for behavioral health, where it stayed right up there. I was the immediate, unlike for the psych society, the immediate past chair of the Governor's Mental Health Advisory Council. And we heard in spades there, it just...
Health Chatter
Mental Health - Policy Implications
how crucial it was, especially for people that had substance use disorders and their group stopped because of COVID, but being able to talk to somebody, whether it's televideo video or audio only was a lifeline for many of them. And it just kept them alive. They, they didn't relapse as much. They didn't overdose. Uh,
Health Chatter
Mental Health - Policy Implications
And it was the same thing for people that were rural or old people that aren't technologically sophisticated and couldn't get televideo stuff going or didn't have good internet. That really is hugely important. It doesn't replace, it's not an either or, but your internet is on the fritz. If you can talk to somebody on the telephone, it can, it could just be so helpful, you know?
Health Chatter
Mental Health - Policy Implications
When do you use it? But having it in your armamentarian is, and having it in your armamentarium in a way where it's not more costly. During the pandemic, televideo was paid for at the same rate as face-to-face. And when that emergency ends, some health plans are talking about paying less for it or not paying for audio only or paying less for that. I hope that doesn't happen.
Health Chatter
Mental Health - Policy Implications
There's been an emergency extension, but that question is going to get called and hopefully people can band together and say, don't shortchange people. It's necessary. Absolutely. Behavioral health problems.
Health Chatter
Mental Health - Policy Implications
I'm gonna answer this uncharacteristically, a little more diplomatically than I sometimes would. This is health chatter now. You can say what you need to say. I'll do both. I think there's a reason to sort of, I think there are always a few bad apples. And there are a very small number of people that try to do fraud and abuse.
Health Chatter
Mental Health - Policy Implications
And many of our payment systems, whether it's Medicare, whether it's Medicaid, whether it's private insurances, are always on the watch for that. And I think it's been overdone, over claimed, and there are all these rules and regulations to try and catch these things.
Health Chatter
Mental Health - Policy Implications
And I think they cause, I don't think you can ignore it, but I think it's made it much more difficult and scary for people to try and do it. And because of that, you're always have some tension to be about how do we avoid that? How do we enforce things? But at the same time, how do we make it easy enough for people that need it to get in?
Health Chatter
Mental Health - Policy Implications
And that caused too much rigmarole and this and that and steps and delays and weights and barriers. And I think we are far more people harmed by the barriers than we do by catching fraud with our existing systems. Yeah, no kidding. And I. and how do I want to say this? Nobody wants, you know, healthcare is getting more and more expensive for everybody. And how do you keep the costs down? You know?
Health Chatter
Mental Health - Policy Implications
And once again, I think we've done a much better job of keeping the, I think we've done a poor job of keeping the costs down, but even a better job of screening people out and limiting what they get.
Health Chatter
Mental Health - Policy Implications
yeah yeah in in the pursuit of trying to keep it affordable and not hitting sort of the the uh um classic things you don't think about that are really problematic you know like uh looking at costs you know and trying to figure out how do we keep how do we keep them down whether it's uh um
Health Chatter
Mental Health - Policy Implications
all the things with the, all the sort of like hoops we have to jump through, how many people have to, how much time, effort, energy goes into sort of doing that, the delays that go into that. It's a very costly part of our system. And I don't know.
Health Chatter
Mental Health - Policy Implications
You know, when I was president of the Minnesota Psychiatric Society, it wasn't immediate. It was a few years ago now.
Health Chatter
Mental Health - Policy Implications
And it's more broken in behavioral health, I think, than anywhere else around.
Health Chatter
Mental Health - Policy Implications
Yeah. I mean, the ones that people notice, you know, are somebody that has a psychotic episode and acts strange and scary, talks to themselves. But in a lot of ways, if you're depressed, you know, most people, not, not, not everybody, but most people kind of shut down, you know, and, and they, they, they lose their, they lose their optimism. They lose their energy. Their sleep is affected.
Health Chatter
Mental Health - Policy Implications
They're, they get totally pessimistic. They, they may show up at work, but not think or do anything that speak up. They may just stay at home and they sort of fall into isolation and you may not know them because they're not, you're not seeing them anymore, you know? And, and, you know, um, how do I want to say this?
Health Chatter
Mental Health - Policy Implications
Uh, there's such an interrelation between people that I, I'm a, I'm a woman and I get depressed. You might be a little more like a woman that's really upset about something. You may be a little bit more likely to get depressed. If you're a guy, you might be drinking more or using drugs more. And it shows up that way, you know, it's cause and effect both ways, you know, but, uh, um, and, and, um,
Health Chatter
Mental Health - Policy Implications
You know, we don't really have a good way of measuring all the suicides. It's always undercounted. You know, some car accidents, some overdoses, you know, that kind of stuff. It's they're not really accidents always, you know. Yeah.
Health Chatter
Mental Health - Policy Implications
I think people, how do I want to say this? People are reticent and avoid asking people because of the shame and stigma and just discomfort.
Health Chatter
Mental Health - Policy Implications
And, and if you have somebody you care about and you kind of know, I think it would be great if you sort of say, you know, I noticed you're not your normal self these days, you know, it's something going on or, you know, you're doing okay, you know, and, and just shut up and listen, see what they have to say, allow them to talk and, and, um, You don't have to cure them.
Health Chatter
Mental Health - Policy Implications
You don't have to this and that, but you don't. Most people welcome being asked and somebody reaching out in a sort of a supportive, neutral way. And then maybe you can problem. You don't have to cure. You know, you don't have to be an expert, but you can reach out, let them know they're not alone. You notice something could be an entree. Maybe you should get some help.
Health Chatter
Mental Health - Policy Implications
But if you don't reach out and just sort of try to begin a conversation, not in a blaming, shaming way, but in a supportive, I care about you way.
Health Chatter
Mental Health - Policy Implications
Exactly. You know, you know, and actually ask them what they how are they doing?
Health Chatter
Mental Health - Policy Implications
You know, it's not even finding the words. There are studies that people have done saying that if you just look somebody in the eye, you know, and smile at them, it's a way of recognizing them, saying they exist, noticing you. And a smile means, you know, I mean, if you notice them and you like frown and make a fist, it's the opposite bad effect. But if you smile...
Health Chatter
Mental Health - Policy Implications
it's a warm, encouraging gesture that helps people feel a little better.
Health Chatter
Mental Health - Policy Implications
And folks with some of the serious chronic mental illnesses like schizophrenia or something that are struggling with voices or homeless and they don't smell so good because they can't get an adequate place to sleep and shower and change clothes. One, it's way overstated, the potential for violence. And everybody is scared of that. But just because you're psychotic,
Health Chatter
Mental Health - Policy Implications
I mean, how do I want to say this? The odds of you being violent are like not much different, a smidgen higher than anyone else. And the odds of you being victimized by violence are much, much greater than everyone else.
Health Chatter
Mental Health - Policy Implications
you know, but, and just acting like they're real people and human and as deserving as you of respect and courtesy goes a long, long way, you know, and challenging some of those assumptions.
Health Chatter
Mental Health - Policy Implications
And I think many of us have been behavior modded a little bit to talk psychobabble, but you know, that if you do that once in a while, someone will ask you for money or change or something, and you want to avoid that. Can you don't, you know, And but people overreact to that, you know. Yeah.
Health Chatter
Mental Health - Policy Implications
And it's just so helpful to just smile, say hello or nod, you know, as well as sort of engage in a conversation, you know. Yeah. Yeah. Before we run out of time and I don't know exactly when that is, but I want to at least mention one thing that that I have strong feelings about, you know,
Health Chatter
Mental Health - Policy Implications
In the psychiatric world, there's been sort of one kind of thing that's really evidence-based as being more effective than other things and much more accessible. Given the shortage of psychiatrists and other mid-levels and even therapists and stuff, it's hard to get in. And one of the models is something called collaborative care management.
Health Chatter
Mental Health - Policy Implications
is where it's a model where it's based in the primary care clinic and the primary care doctor's office. And And it's something that is between 90 and 100 studies talking about how it's much more effective and cost effective and works faster than other studies.
Health Chatter
Mental Health - Policy Implications
And it expands the access by having a psychiatrist consult to the primary care doctor just one or a couple hours a week, depending on how large the panel is. And there is a care manager there. who is someone who has a role of educating patients in mental health issues, following up with them.
Health Chatter
Mental Health - Policy Implications
Like if that person gets diagnosed with depression, maybe they get referred to a therapist and told to start an antidepressant. He or she might call the patient after that and say, were you able to get an appointment with a therapist? Does it feel okay? Did you get in? Do you need any help troubleshooting?
Health Chatter
Mental Health - Policy Implications
Because if you're depressed, you don't have your normal perseverance and energy and initiative to follow up on things. Or it could be they call and they say, did you get your script? Did you take it? Any problems or side effects or there's something to troubleshoot here? You know, and that person educates, follows up.
Health Chatter
Mental Health - Policy Implications
The patient that comes in is on a registry and we track how they're whether they're getting better or not, whether we actually measure their anxiety level or the depression level, make sure it's getting better. If not, we troubleshoot and modify their treatment plan. There's someone who can pick up this person is complaining of insomnia.
Health Chatter
Mental Health - Policy Implications
I mean, I think that's an understatement. Understatement, okay. So not only do I agree with that, I think it really is understated. And I don't know how to say it exactly, but I don't want to be redundant from what I said on one of the earlier podcasts we did. But I mean, there are certain things, if all of a sudden you have a heart attack or something, it may scare you and make you anxious
Health Chatter
Mental Health - Policy Implications
So you can kind of the psychiatrist can give them advice about let's look at their sleep hygiene. Let's look at how they're doing any any caffeine or other things that might interfere with sleep. Either they're taking it, it keeps them awake or withdrawing from something that keeps them awake. You know, that kinds of stuff. And It's used in all the mental health illnesses.
Health Chatter
Mental Health - Policy Implications
The primary care doc does the prescriptions, but the psychiatrist runs the list and gives advice to the primary care doc and to this care manager. And it works really well.
Health Chatter
Mental Health - Policy Implications
Well, if you go to, if you're in that primary care clinic, you'll, you'll see the care manager and they'll screen things and, and then they'll talk to the psychiatrist about it. And the psychiatrist might be giving advice on 80 to a hundred patients, you know, not, and they're there every week. One either, either physically or virtually and, and giving advice.
Health Chatter
Mental Health - Policy Implications
And it's something that was good enough that Medicare adopted it and pays for it. Most private health plans do, but not all. But in Minnesota, Minnesota MA doesn't pay for it, which is not a small percentage, if you think about it.
Health Chatter
Mental Health - Policy Implications
And if you're a primary care doc and you want to use this for everybody that's depressed, you want to have to pick and choose, depending on their insurance type, who you can give it to. Or else you give it and then you lose money. Then you say, I can't continue to do this. I'm going to stop doing this.
Health Chatter
Mental Health - Policy Implications
So there was a bill in the legislature this last session, which was introduced primarily to sort of mandate that Minnesota MA pay for it. It got transfigured in the legislative process and it mandated that all private plans pay for it. Medicare already pays for it, but it excluded Minnesota MA.
Health Chatter
Mental Health - Policy Implications
No, no. And it just needs to be available for everybody, and it needs to be, and it would be really nice if we follow up on it this year. And, you know, and Minnesota DHS, we presented it to them. They made some good, they thought it was a good idea, but they wanted to sort of look at it more, and the timing was short, and they took it out of the governor's budget.
Health Chatter
Mental Health - Policy Implications
But I hope they follow through, and if not, I hope the legislature makes it happen either way, or ideally both. Yeah. It becomes mandated. And I think DHS goes with it. And it's one of those things where it got caught up in this thing where the fiscal note, they couldn't figure it out and they didn't do it. And it really saves money. There's an ROI with it.
Health Chatter
Mental Health - Policy Implications
But on the other hand, how they fiscally account the ROI, Like a lot of things, if you treat mental illnesses or substance abuse, it decreases your medical costs down the line. But you still have to pay for it initially. And whether they're really going to cost account that, how they'll do the fiscal note, I don't know. I'm sure there'll be a battle over that.
Health Chatter
Mental Health - Policy Implications
But it's one of the things we should really all support in this next year's legislative session. And the Commonwealth has recommended that all states mandate that MA pay for it. Then it's like, I think a little over half the states have done it so far, but not Minnesota.
Health Chatter
Mental Health - Policy Implications
I think the most positive thing is, um, Most people are starting to realize and understand, and at least partially, not completely, appreciate that mental health and substance use disorders are really important. Yes. They're worsening and they deserve attention, effort, and to get better.
Health Chatter
Mental Health - Policy Implications
Um, but it's not taboo to talk about it, you know? Yeah. And you can, and I think mental health stuff, not so much substance abuse disorder. I think that's just plain discrimination and you have to, uh, buck up and try harder. And it's a character flaw in, in, in the myth, not in reality, you know? Um, but for mental health issues, um,
Health Chatter
Mental Health - Policy Implications
Whether that will that focus will stay there or it'll kind of peter out. I don't know. There's less stigma talking about it. And I don't know. You're including it in your podcast. I don't know if it was five years ago, you know.
Health Chatter
Mental Health - Policy Implications
it's just scary to people and they want to deny it or suppress it or not want to talk about it and they they don't even relatives you know historically even though it's better now want to avoid any shame or stigma associated with it and it's sort of like uh uh you know it was avoided more than anything you know let alone research you know um and it wasn't like it was uh um
Health Chatter
Mental Health - Policy Implications
the gun lobby you know the tobacco lobby saying you can't research we're going to put that into federal law because of politics and uh financial districts you know interests it was more sort of widespread than that so you know you've been in the field a long long time has it
Health Chatter
Mental Health - Policy Implications
Yes, it has gotten better. We now have much stronger lobbying. And I think in some ways, the strongest lobbying for sure in Minnesota is NAMI, the National Alliance for Mental Illness, mainly composed of folks that are family members. And they've been empowered and have done a superb job of speaking up about those issues. I may have a little vested interest.
Health Chatter
Mental Health - Policy Implications
I've been on the board of NAMI for a while, but even before it, I was admiring them and stuff and speaking out. And the other kind of powerhouse nationally, a little less so in Minnesota, but up and coming, is nationally it's the Mental Health Association, which is composed in some sense with a higher proportion of people with lived experience, as well as others that are interested parties.
Health Chatter
Mental Health - Policy Implications
Here, the chapter in Minnesota is called Mental Health Minnesota. Renamed, but also sort of, they're finding that people listen to them and seek them out and are more interested like in Mental Health Minnesota in the old days doing surveys. What do you think?
Health Chatter
Mental Health - Policy Implications
There are ambassadors who can speak to the experience to both in different chapters throughout the state and let people know whether it's county employees or mental health providers. There are advisory groups that are getting more potency. And it's really important that that happens.
Health Chatter
Mental Health - Policy Implications
So let me just dig into it here. So in 1996, more than a few years ago, in the federal level, there was a Mental Health Parity and Addiction Equity Act that was passed. It took Congress more than 10 years to actually come up with rules of how are they going to define it and how they were going to try and see if anything happened.
Health Chatter
Mental Health - Policy Implications
You know, and then they came up with rules that sat on a shelf and nobody noticed. Then in 2008, this is where Wellstone and Domenici came up and they passed the, what was it technically called? The MHPAEA, very, very sexy title, but Mental Health Parity and Addiction Enforcement Act, you know? And came up with stricter kinds of things to try and enforce it. And it also didn't get enforced.
Health Chatter
Mental Health - Policy Implications
Like a year and a half ago, two years ago, they did an audit, which was a joint audit, looking at health plans and seeing if they were actually complying with the treating mental health issues and substance use disorder issues equally, and found that no health plans did in the nation. This was a joint study done by Department of Labor, HHS, and what was the other department?
Health Chatter
Mental Health - Policy Implications
I don't know, it's in my notes here, but there were three, labor, health and human services, and commerce, that's the other one. And basically no health plans were doing it. It still wasn't being enforced. Minnesota came up with a law that got passed and also isn't being enforced much.
Health Chatter
Mental Health - Policy Implications
You know, Minnesota got a grant maybe three, four years ago, a one-time grant to hire somebody to try and look at enforcing parity. And the first thing they found out, this was through the Department of Commerce, was that nobody even knew that Commerce was involved. We all fought to complain or let them know if there were problems or issues.
Health Chatter
Mental Health - Policy Implications
And with this dedicated person, they started getting the word out there and they started getting some complaints and we're now seeing some, and then that grant went away. So the dedicated temporary kind of person to work on that went away.
Health Chatter
Mental Health - Policy Implications
And commerce tends to be a small department with a lot of, unlike other departments in the state of Minnesota with a lot of duties and not enough people to do it, to do the duties. And yeah,
Health Chatter
Mental Health - Policy Implications
One of the things that I and NAMI and Minnesota Psych Society lobbied for was, and it finally happened, was to come up with dedicated funding to have basically a two-person department called the Enforcement Department within Commerce, which hasn't started yet. It's supposed to start next January.
Health Chatter
Mental Health - Policy Implications
But if you notice, Minnesota had earlier this year did an enforcement action with a fine against health partners. And more recently, they did it against, who was it they did it against more recently?
Health Chatter
Mental Health - Policy Implications
No, it was a health plan. It was either Medica or Blue Cross Blue Shield. Yeah. But they didn't know their enforcement.
Health Chatter
Mental Health - Policy Implications
Well, how do I want to say this? You guys have a core of researchers and you care about data. And you want to factually base whatever opinions you come up with. Correct? Correct.
Health Chatter
Mental Health - Policy Implications
Yes. I think that hasn't been done in mental health much. It hasn't been measured much, which is what one of you were saying earlier, right?
Health Chatter
Mental Health - Policy Implications
So there were measures that came out in 2023 from Mental Health America, which is the consumer-based association that I talked about. And if they look at adults, Minnesota is ranked, and this is in, they're trying to look at the prevalence of mental illness, which tend to be, as well as how high your access is to get care for people and whether they get better.
Health Chatter
Mental Health - Policy Implications
Okay, so they have a series of measures looking at prevalence and access. In that, I'm scrolling through here. In that one, Minnesota was ranked number one is the best, number 51 is the worst. Minnesota was number 36. And looking at the same thing for youth in Minnesota, Minnesota was 21.
Health Chatter
Mental Health - Policy Implications
in looking at just the prevalence of mental illness, which I think if you think about it, is how much is going on at this point in time. So you might have people that got depressed, but got treated and got better. And then it wouldn't be, our prevalence rate would be a little bit lower. And in that ranking, we are number 41, even worse.
Health Chatter
Mental Health - Policy Implications
And access to care, which I think is hugely important. Right. And you look at how many adults could just, who had things but did not receive treatment, who report having an unmet need, who are uninsured and then have a harder time getting access, who are living with more than 14 plus days in a month and could not see a doctor because of costs.
Health Chatter
Mental Health - Policy Implications
Or, you know, basically, so it's people that really need help and aren't getting it. Minnesota is 14. So a little bit better than that in access.
Health Chatter
Mental Health - Policy Implications
In the overall adult rankings, they vary from state to state. It's not like one is good in everything. Yeah, right. So the overall ranking, Wisconsin, Pennsylvania, Massachusetts, Delaware did okay.