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

Howie Forman: And I’m Howie Forman. We are physicians and professors at Yale University and we’re trying to get closer to the truth about health and healthcare. This week, we will be speaking with Professor Gregg Gonsalves, but first we like to check in on current health news.

Harlan Krumholz: Yeah. So I’ll take that, Howie. So I wanted to ask you, you know anybody who’s got COVID?

Howie Forman: Huh, I feel like I’m the only person in my circle who has not yet been infected. I did go for my booster today, but not necessarily because I personally wanted to but because the university is sort of making me get a booster.

Harlan Krumholz: But there’s a lot of people around us who have COVID, right? And not only—

Howie Forman: Oh my God.

Harlan Krumholz: ... people who have had COVID, but there are people I know, lots of people who had COVID and now have it again. Have you noticed that?

Howie Forman: Yes, absolutely.

Harlan Krumholz: So anyway, people are writing about this. There was a nice piece by Eric Topol. By the way, just for our listeners, I mean, Eric has just done extraordinary service throughout the pandemic. We’re going to have him on the podcast. I thought, that’ll be amazing.

Howie Forman: Yes. I’m so thankful for that.

Harlan Krumholz: People can hear Eric. And his Twitter, terrific to follow and he also has something nice on Substack where he really reviews things. He had a recent one that came out. Eric was writing about a paper that was just published out of the VA. And recently they posted a pre-print. Just for people listening, a pre-print hasn’t been peer-reviewed or published in a journal yet. But they looked at about 250,000 people with one infection, about 40,000 people with two infections, and almost, a little more than 5 million people who are uninfected controls. And they looked to see what’s up with these reinfections? Are they more or less dangerous? What happens to people? And it was interesting because these reinfections, it seemed, were associated with higher risk over time. And so the people who had more infections, and almost like what we call a dose response, that is, the more infections you had, the riskier it was.

And even though this is among variants that we think are becoming less dangerous over time, but actually in the VA, they’re describing it as actually being a bigger problem. And even with regard to mortality as well. Now, people may wonder like, actually, why are these reinfections becoming so much more common? And you may be memorizing about these variants. I know people’s eyes glaze over with all these number of Omicron, BA.2, BA.2.12.1. I mean, it starts to get numbing after a while. But what I think is important for people to know is that there’s a new variant that has been coming out, that BA.4/5 that seems to be accounting for about a third of the infections right now in the United States. It’s new. And people talk about this “immune evasion,” that these variants are able to dodge our immune system that even if you’ve been vaccinated or if you’ve been previously infected that because of the mutations that are occurring particularly on the spike protein, the part that’s sticking out, and that’s what a lot of the antibodies are to, that spike, that these mutations are changing it just enough so that it’s dodging our immune system.

And that’s why you’re seeing so many different people who are able to, have been priorly infected; they think they’re protected. But in fact, this sneaky little virus is finding ways to spread among the population. And this VA study is in counter-distinction to a lot of the studies that came out that suggested that the accurate variants are not as dangerous, but the thing is, they’re infecting more people. And so the result of infecting more people, even if it’s slightly less dangerous as a virus, may actually be causing harm that’s greater.

We’d written about this, and other people have seen it. I think the one thing to comment on too is Eric at the end of this makes a very strong statement that... And I think reflecting a little bit on Congress has yet to pass the COVID-19 bill. I mean, so a lot of the funding for future public health is still in question. And he says the lack of priority in resource allocation stems from the illusion that the pandemic is behind us, which is obviously off base.

Howie Forman: Yep.

Harlan Krumholz: Anyway, we should get on to Gregg, because this will be a great interview.

Howie Forman: I’m delighted to introduce Professor Gregg Gonsalves. Gregg Gonsalves is an associate professor of epidemiology at the Yale School of Public Health. His work involves modeling infectious disease and substance use while also investigating public policy and health equity. Professor Gonsalves has worked on HIV/AIDS and various global health issues with organizations such as the AIDS Coalition to Unleash Power or ACT UP, the Treatment Action Group, Gay Men's Health Crisis, and many more. He is the epitome of an interdisciplinary colleague, working with our law school as an adjunct associate professor of law and the co-director of the Global Health Justice Partnership, a Yale Law School and School of Public Health initiative to respond to problems in health justice, and also works with faculty at our School of Management and beyond.

He is a 2018 winner of the MacArthur Fellowship or “Genius Grant,” as it is commonly known. I first came to know him when he came to Yale’s campus to obtain his bachelor’s degree in 2008 as a 44-year-old man through the Eli Whitney Students Program. Since that time, he has also obtained his PhD from our School of Public Health and obviously enriched our campus with his passion, his deep abiding belief in informing policy with science and evidence, and his commitment to social justice and equal rights for all.

First, let me just start off by saying how much I appreciate you joining us. You have consistently stood up for those who either can’t or won’t be noticed if they do with so much injustice in the world. How do you prioritize your efforts?

Gregg Gonsalves: Well, you said it was a simple question you were going to ask, but it’s pretty difficult. I was on a prep call for a webinar with Partners In Health that’s happening next week. And there are people there who are going to talk on abortion rights and reproductive justice on gun control and on immigration. We had a conversation about, how do you prioritize all of that? I said, “We agreed we should put it under one big umbrella that counts as public health and not try to sort of triage and rank things in order of importance,” because that’s what they like to do, they like to pick you off, right? To say that you work on one issue, and you don’t need to think about the rest of the broad scope of what public health entails in America. And so I would say I do what I know best, which is stuff around HIV, substance use, and infectious diseases, but I’m trying to listen to my colleagues and promote my colleagues’ work on all the other fields that I think are sort of under our big tent at public health.

Howie Forman: Can you comment a little bit on—two things, I guess. One is that you dropped out of college. I would love to know why and when you did that the first time. But the second is that when I first met you, I remember realizing that you and I were contemporaries and you’d come back to college to do your undergraduate degree in evolutionary biology and developmental biology, I think. And you were already so successful, Gregg. I mean, I described it in the bio, but it understates your impact on how we affected change—or how you affected change—during the HIV/AIDS crisis. First of all, how did that happen? And second of all, what can you tell people who think that at the age of 44, it’s too late to go back to school or too late to make a career pivot like that?

Gregg Gonsalves: So we’re contemporaries, and I think you’ll understand this is at... I graduated from high school in 1981. Two events happened around that time, the election of Ronald Reagan and the beginning of the AIDS epidemic. And coming out as a young gay man and a conservative suburban New York family of second-generation immigrants was incredibly difficult. I’d been “the best little boy in the world” and done well at school, was going off to consider a research career in comparative literature. I studied Russian, and none of it made sense. I felt this compulsion to sort of rethink my life in the context of what was happening around me, and I dropped out of school. I ended up meeting somebody who was HIV-positive, the first HIV-positive person I knew, and went looking for information and ended up in ACT UP and then sort of found my people, found my tribe.

And that’s why I ended up never returning to school until I was 44. I thought coming to Yale was going to be like a sabbatical from work. Like it would just be sort of this nice time to sort of reflect. Being in biology courses with Yale undergraduates was slightly terrifying because they’re all heading to medical school, and I was sitting there 44 years old with like a lot of distance between me and the last science course I took. But it was fun.

It was incredibly thrilling. Steve Stearns, who was my advisor as an undergraduate, and Paul Turner, who was basically my co-advisor, really opened up this new world to me about evolution and infectious diseases, which was totally fascinating. I almost left and went to do a lab-based PhD in Europe on sort of immunogenetics and immunodeficiency viruses.

But it’s funny because it didn’t occur to me that that was... I’d never took a linear path from A to B in my life, so it didn’t occur to me that it was odd to go back to school at 44. My mother, who was 88 years old, was a schoolteacher in New York City for many, many years. And then in her 60s, well, she retired from the New York City public school system and became a politician, a Republican politician on Long Island and only retired five or six years ago. So it’s interesting. I watched my mother sort of pivot after retirement into a huge sort of local political career, which gave me the sense, I guess, like in retrospect that like, if she can do it, I probably can too.

Harlan Krumholz: But how did you come to apply to Yale at that point? I mean, what was the thing that made you think, “I’m going to apply to Yale”?

Gregg Gonsalves: So I was sitting in South Africa in my apartment in Cape Town, and I’d been doing this work for 25 years, and I loved it. I mean, the job I had then was really dealing with the Thabo Mbeki administration in South Africa and their refusal to supply oral therapy to people in the country, but also to sort of go into countries around the region with my colleagues at the Treatment Action Campaign and teach people about the virology, immunology of HIV, about clinical trials and all this stuff. I realized I could do this forever, or I could take a break and try to do something else. I was looking around the internet for programs that would take older undergraduates. I saw the Yale one and I said, “Oh, I’ll just apply.” And I said, “If I get in, I’ll go. If not, I’ll just keep doing what I’m doing.” One day I got a letter in Cape Town and decided to get on a plane and come back to the U.S.

Harlan Krumholz: Wow.

Howie Forman: And the rest is history. I just want to ask you know, I think for some of our listeners, we’re now 41 years into the HIV/AIDS epidemic right now. There was that window of time for the first 15, 18 years where it was not only just lethal, but it was filled with misinformation. Just filled with it. I think for a lot of people going through the COVID pandemic right now, there’s this expectation that after two years we should know everything. I think back—even now, we’re learning so much about HIV, and we’ve had several guests talk about this already, but I think back to that period of time where the information flow was so high for so long and so many myths were being dispelled. What is the role for activists during... I mean, right now in the COVID pandemic, what’s the role for people to be pushing back against misinformation, to be defending stigmatized populations? How do you see that looking back on that period in time?

Gregg Gonsalves: So, it’s interesting. Misinformation on the AIDS epidemic started in the beginning, and the idea that HIV didn’t cause AIDS was propounded by Peter Duesberg who was a National Academy of Medicine member. Kary Mullis, who was a Nobel Prize winner, who sort of discovered or developed PCR. And it’s being propagated around the country, was turbocharged by Thabo Mbeki in South Africa, and around 2000, a group of us set up something called AIDSTruth. It was clinicians. It was basic geneticists and biologists, and it was AIDS activists. We basically deconstructed all the sort of myths, put up all the sort of scientific evidence and did it in a simple, engaging format so people could understand what was going on. With COVID-19, everything is just sort of nuclear-scale misinformation. And for 2020, lots of it was coming out of the White House.

We were talking about people like Jay Bhattacharya, John Ioannidis, and Scott Atlas and others. We have people within our own institutions now who are propelling misinformation forward. Myocarditis in young children and vaccines. The scale of the misinformation now is really, really, really, really pervasive and coming from the highest levels of government. The governor of Florida for instance is a pretty strong proponent of not giving vaccines to children, has made comments about the state of the pandemic, and his own state surgeon general has been a problematic figure in terms of passing misinformation.

We need to speak out. We’re not just clinicians and scientists. We are citizens in a country that we need to supply back to. And part of that is sort of setting the record straight about what’s true and what’s not true. What’s science and what’s myth and fabrication.

Howie Forman: Your work with HIV, and now your commentary work with monkeypox, in one of the articles, you’ve mentioned something, or quoted as saying something about how “we have to become more comfortable talking about sex.” Here we are at a time where the LGBTQ community is being further marginalized in large parts of the country right now where we’re taking steps backward in terms of freedoms and particularly women’s agency, but really the agency of anybody with regard to reproductive health and sexual health.

How do we move the needle in a way that’s productive for society? Monkeypox is not anywhere near the level of concern that COVID was, but there is concern and you’ve raised this sort of weight between us being able to contain it versus just mitigating it, which would be a failure.

Harlan Krumholz: By the way, should we still be saying “monkeypox” or is there a new name yet for it?

Gregg Gonsalves: Well, I think the new names are going to be around the Congo and West African variants. But this is not COVID. There’s a real chance that this virus could establish itself among gay men, bisexual men. And that’s a choice, right? A few weeks ago I wrote a piece that talked about a thousand cases worldwide. Now, we have 3,000 cases worldwide in 41 countries. It’s spread by close physical contact in the context of the current outbreak, outside of its endemic regions, it’s happening among many intersections with men. And while it’s not a sexually transmitted disease, it’s happening in the context of social and sexual networks.

So, many of us have been very careful to not stigmatize gay men or to stigmatize sex or to turn into sort of modern-day Nancy Reagans and “just say no” to sex and gay pride. But we do have to say that this virus is now spreading quietly and broadly among the gay community. We have 21 cases in New York now. And it’s going to have to talk very frankly about safe sex, safe socializing over the next few months until we can get it under control.

We’re on the cusp of potentially having this sort of sustained in the gay community over the next few months and years, which would be a shame, because we have the tools. We have a vaccine to stamp it out. We have the ability to treat it. But if we keep making the same mistakes as COVID and HIV, we’re going to be in a situation where we’re dealing with another sort of persistent virus among gay men.

Harlan Krumholz: Do you want to maybe just take a second for listeners... many people may have been sort of paying a little bit of attention to this, but not as much. What are the things you think from a public health point of view that people should know about monkeypox? And who’s at risk and what they’re at risk for? I mean what do you wish that everybody knew?

Gregg Gonsalves: So one is, it’s a disease that’s been around for a long time, endemic in Western Central Africa, and we’ve ignored it because we ignored diseases that affect poor people in foreign countries. That’s basically why we have neglected tropical diseases, because they’re neglected by us. The context of this pandemic, its outbreak? It has been initially seen in a cohort of gay men who are part of raves in the Canary Islands and in Portugal, but has now spread to 41 countries largely among men, bisexual men, but not exclusively. Again, it’s spread by close physical contact. It’s not about safer sex at all. It’s about refraining from sexual contact, sharing of clothing, other objects.

Harlan Krumholz: How about a handshake?

Gregg Gonsalves: If you have a lesion on your hand, you’re going to shake somebody’s hand, touch your eye, you’re going to have monkeypox.

Harlan Krumholz: So, potentially.

Gregg Gonsalves: Potentially, there’s some idea that the presentation of this in this outbreak has been around sort of the inter-genital region, but it’s not exactly the case. There’s been disseminated sort of lesions across the body and you’re highly infectious until those lesions scab up and fall off. So this is why people are so panic that this is going to entrench itself—

Harlan Krumholz: What’s the biggest harm of it? What can it do at its extreme?

Gregg Gonsalves: At its extreme, this strain has not been responsible for that many deaths at all in West Africa. The Congolese version, which will soon be renamed, has a higher fatality rate. And right now we haven’t had any deaths from it. If it gets into immunocompromised populations, it gets into children, we don’t know what’ll happen. A colleague of mine, Demetre Daskalakis, who’s at the Centers for Disease Control, has said, “Think of this like MRSA. It’s in the gay community now, but MRSA went from the gay community to health clinics.”

Harlan Krumholz: And MRSA, just for definition, for, you want to just—Methicillin-resistant...

Gregg Gonsalves: Methicillin-resistant Staphylococcus aureus. It’s a bacterial infection of the skin that’s drug-resistant. There’s an outbreak in gay men, and then it showed up in health clubs. And so just because it’s now limited to the gay community and a subsection of the gay community, it doesn’t mean it’s not going to sort of emerge in large-population temperatures like New York and others in other populations. And then it’s hard to know if it’ll sustain itself.

The big fear is that it gets into people who potentially are HIV-positive but don’t know their status. There’s lots of reasons why you might see a more severe presentation even though right now we’ve had no deaths really among most of the cases that are circulating around the world. At least outside of its endemic region.

Howie Forman: Well, one of the things we haven’t talked about, that you’re enormously prolific and productive in writing lay pieces not just for the scientific literature, but pieces in political science magazines, in Washington Post and The New York Times and so on, how do you pick and choose for that and what you’re going to decide to write for the public? Because public health communications I think is so important, but there’s only so much time you have for that, and you’ve done a lot of it.

Gregg Gonsalves: Well, I mean, Harlan and Joe and a bunch of us have written a lot on FDA stuff. So there’s things I care about, drug regulation and the regulatory state, particularly the regulation of drugs and devices and biologics. So I’ve written a lot about that. A lot on COVID. A friend of mine, Zain Rizvi, who was at the Law School a few years ago and who’s now at Public Citizen in D.C., are writing a piece on monkeypox vaccines right now.

I got a gig as The Nation’s public health correspondent last year, and my editor sort of tends to poke me on certain issues but gives me wide latitude to write what I want. I mean, after COVID, it’s hard to think about if I’ll sustain that level of sort of commitment to public writing. The more episodic work I’ve done over the past is probably more of a template for what I think I’ll do in the future.

Harlan Krumholz: Any parting words for students coming up and who look at a career like yours, nonlinear, highly impactful, to supply them courage, to be able to supply them the ability to make choices, not that others expect of them, but ones that they really can follow their hearts and what they really want to do? We appreciate you being on today, but that’s one of the things I think about you is that it’s an inspiring path in one where you did have the courage, the bravery to move forward in ways that maybe were a little unconventional, but highly impactful.

Gregg Gonsalves: I mean, people make lots of spectacular achievements going from A to B, but I’ll never forget when Gerry Friedland, who’s a colleague of all of ours, gave a lecture to the medical students a few years ago and drew a squiggling line on the board and didn’t tell anybody what it was. And then he talked about his life. Gerry was going to be a sociology PhD, went off to the Peace Corps, met Allan Rosenfield, who became the dean of the School of Public Health at Columbia. But as the doctor of record for the Black Panthers.

So there’s lots of people we know that are among us who’ve taken sort of circuitous routes to where they are today. And I think it’s, trust your gut. A lot of Yale undergraduates when I was here were so afraid of sort of stepping off the well-trodden path of success that they’d had in high school and that they assumed they were going to go to Yale, go to medical school and go to law school. There’s a very strong pressure to conform, which despite the creativity and innovation at this place can weigh down young people.

And I’d say, trust your gut, because in the end you have to live with yourself, not your parents or your professors or your peers. And so I don’t think I would do things differently if I had to do it all over again, even though it was a little bit of a wild ride of a life.

Howie Forman: I do want to say one thing in parting words, we haven’t mentioned before, but you’ve alluded to it, you have been an incredible mentor and collaborator with our students on campus and some of whom have graduated from campus. And when I talk to students that have graduated from here, some of whom are already faculty members, many of them will still say like the paper they’re most proud of is the paper they did with you. So I just want to thank you on behalf of them and our listeners for what you’ve been able to do to help develop careers.

Harlan Krumholz: Yeah. Thank you, Gregg. And thanks for joining.

Gregg Gonsalves: Thank you for having me. No, thanks for having me in, Harlan and Howie.

Harlan Krumholz: Howie, that was great. So let’s move on to the next segment where we can hear what’s keeping you up or are occupying your attention these days.

Howie Forman: Yeah. So you had a great thread on Twitter this week about the horrible financial impact that healthcare has on a relatively large chunk of society based on a Kaiser Health News article by Noam Levey. It indicated that over 100 million people, almost one in every three in America, are saddled with medical debt, and that’s not new. Even in the decade after Obamacare, which was supposed to be the “affordable healthcare act,” out-of-pocket health spending is very high. It’s enormously impactful to even upper-income groups. All it takes is one catastrophic illness or condition and you could be saddled with lifelong debt or worse, including bankruptcy.

So I wanted to pivot from that thread, which I thought was a very important story, but to the other end of the spectrum, our recent guest Dean Sherry Glied of the Wagner School at NYU just published a paper in Health Affairs that confirms that our two-decade experiment with health savings accounts or HSAs has mostly failed. These are the accounts that people have combined with a high-deductible health plan, and we may call them consumer-directed health plans.

A lot of people have them now. They bring no efficiency gains. In other words, these plans—of which by the way 30% of what most employees are choosing now, so it’s a large part of the population—do not lead you to spend money more wisely. They just allow for a tax break primarily for higher-income individuals. It’s a regressive policy. And full disclosure: I, along with tens of millions of others, benefit from this policy.

I’ve used an HSA or prior to that, a flexible spending account for a while. Our government, in a purported effort to make healthcare spending more efficient, has instead just codified another means for an individual to reduce their federal tax obligations. And in this case, it’s to the tune of about $12 billion per year, which is not chump change. So at the very same time that so many lower-income individuals struggle to pay off healthcare debt, we are lavishing more tax breaks on the better-off with no seeming policy reason other than a lower tax burden. And Sherry Glied, Dean Glied thinks this policy should be undone, and I agree.

Harlan Krumholz: You know, that’s a really interesting point, and I’m glad you raised it. I’ll get back to the Twitter stream that I put together, the reflection on that article. Look, I’m always impressed by the studies that show that about half of America doesn’t even have $500 to manage a financial emergency. And our healthcare system imposes such profound financial harm on people. Leading people to avoid care, leading people who need care to be saddled with debt. It’s a side effect of our system.

Look, what I said was, no matter what, we should identify this as a major problem. Whether you’re for or against universal healthcare, whether you’re for, against a particular solution, then tell me what your solution is, because we can’t have a country where getting sick leads you to have your house foreclosed on, for your inability to put food on the table, for you to have anxiety, for you to have such worries.

I mean, it’s just simply not the kind of society that we should want to live in. And for the richest nation, the world, to have a record like this? We doctors are imposing harm every day because every bit of care for people who can’t afford, it leaves them weaker and in a position where they’re struggling as a result of this. We can promote health, but actually we’re not promoting well-being because they’re in these disastrous situations. And for some people it’s devastating.

Howie Forman: Yeah, it’s so frustrating.

Harlan Krumholz: I think I want a culmination. What is the solution? I mean, so universal healthcare is one solution. The government actually takes on the responsibility. That’s what happens in most advanced societies. If we’re unprepared to do that, then what are we prepared to do? But this status quo can’t continue.

Howie Forman: Yeah. No, I agree. And look, it’s taken me... It’s a long evolution for me because I was very... In the 1990s, when I finished business school, I was extremely pro-market. I really thought the market could solve most problems. And now I’ve come pretty much 180 degrees where I feel like we’ve given the market every possible opportunity to fix some of these big problems, and it’s not able to. But on the other hand, I’m also much more aware now than ever before that the political realities to fixing this are so challenging.

So I personally think that we as professionals within healthcare systems have to help reshape the way we deliver care even if our government institutions aren’t able to do it.

Harlan Krumholz: And people are afraid for change, but they have to realize the harm imposed by the status quo. And so we have... It’s true things can always get worse, but they’re not great now for a vast majority of Americans who are saddled with debt as a result of receiving healthcare. So we need to be able to fix that.

Howie Forman: Yep.

Harlan Krumholz: You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howie Forman: So how did we do? To supply us your feedback or to keep the conversation going, you can find us on Twitter.

Harlan Krumholz: I’m @hmkyale. That’s H-M-K Yale.

Howie Forman: And I’m @thehowie. That’s at T-H-E-H-O-W-I-E. Aside from Twitter and our podcast, I’m fortunate to be the faculty director of the health care track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs, or you can check out our website at som.yale.edu/emba.

Harlan Krumholz: How many people do you think have gotten an MBA under your auspices about since the whole time you’ve been at Yale?

Howie Forman: Oh, hundreds and hundreds.

Harlan Krumholz: Hundreds.

Howie Forman: And a few hundred physicians alone. Yeah.

Harlan Krumholz: Yeah, that’s amazing. Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Jenny Tan, and to our producer, Miranda Shafer. Talk to you soon, Howie.

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

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