Dr. Gary Slutkin has provided counsel and advice to elected leaders and health leaders across the United States regarding COVID-19. He has advised Mayor Ron Nirenberg and other Texas mayors. He has proven that epidemiological methods for disease reduction work and they work on things like violence. This was a fascinating discussion with a very interesting guest.

Transcript:

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Justin Hill: Hello, in Bienvenidos San Antonio. Welcome to the Alamo Hour discussing the people, places, and passion that make our city. My name is Justin Hill, a local attorney, a proud San Antonian, and keeper of chickens and bees. On the Alamo Hour, you'll get to hear from the people that make San Antonio great and unique and the best-kept secret in Texas. We're glad that you're here.

All right. Welcome to today's episode of the Alamo Hour. My guest today is Dr. Slutkin. Dr. Slutkin is a medical doctor and epidemiologist. I'm stealing from your TED Talk bio a little bit. You're an innovator in violence reduction which we're going to talk about. Currently, founder and executive director of Cure Violence. Also, consigliere of sorts to some Metro health and mayors and city officials who are seeking your guidance on COVID.

Dr. Slutkin previously served as a medical director for the San Francisco Health Department. He's worked for the World Health Organization. He's worked on epidemics all over Africa which we will discuss. Importantly, he is a well sought after epidemiologist on using data and science to cure issues and specifically, issues that people probably didn't think could be cured that way. Dr. Slutkin, thank you for being here.

Dr. Slutkin: I'm happy to be with you, Justin.

Justin: You're in Chicago, right?

Dr. Slutkin: Yes.

Justin: All right. You are my first non-San Antonio local or someone who's lived here for some amount of time but our show tries to have a real connection with San Antonio and Dr. Lesch, a previous guest and Mayor Nirenberg, also previously a guest have discussed COVID with you. I know you've provided some guidance and counsel. Talk to me about what you're doing right now in your role as providing some guidance to cities and leaders including our very own Mayor Ron Nirenberg.

Dr. Slutkin: Well, I'm aware that the US has not really seen anything like this before, that's to say an epidemic of this nature that's so fast, so contagious, so lethal and many other parts of the world have. I had the opportunity to be helpful with World Health and some of the others. Although I myself have largely been working on reducing violence in this country and in other places recently, I had to quickly switch into a role of helping, supporting, guiding and training where there were needs, which is basically wherever you look and how to manage this because it's not clear.

Besides the fact that it's new, a lot of behaviors need to be changed. People don't like to change behaviors, people don't want to change behaviors and there's so much misinformation as well. I've been talking with mayors and governors and the Mayor's Associations and the Governors Associations and trying to help understand what needs to be understood here. Which is that you can't tell who's infectious and who isn't, which is a really counter-intuitive thing that someone you know or someone who looks well, could be carrying it. That it's really that serious.

That you can get it even just by talking and screaming or talking loud or it doesn't require coughing and that the results are really quite bad. For policymakers, they need to really make this so serious, and whenever we don't, we see the consequences and that has to do with the fact that the virus jumps when given a chance. Opening up, it means opening up for the virus and that's what everybody saw but not everybody knew it. Then also what the people themselves have to do. I've been guiding and training in this arena since late February, early March.

Justin: We've all seen what's in the news and we know what we're told in the news but San Antonio did really good at first and we were all very excited and we were patting ourselves on the back. Then our state opened up fast for which San Antonio had to follow lead because mayors like Mayor Nirenberg had very limited authority to out step what the mayor says. Did you see that across the board throughout mayors and policymakers who you consult with at cities that opened faster had the bigger problem or are there still some unknowns to how it's spreading or why it's exploding in certain areas?

Dr. Slutkin: There may still be some unknowns but the main things are known and just weren't paid attention to enough or taken seriously enough or confused intentionally or unintentionally. What you said about San Antonio and probably for other cities too, but San Antonio, I seem to know better because I've been talking with the mayor and other people there, is that it's exactly true. San Antonio was doing terrific, amazing actually. The rates and numbers were exceedingly low and Mayor Nirenberg and the city responded extremely fast.

They're aware of this in January. They called a health emergency in February. Restrictions in late February and early March. It seems they were being followed on the number of cases. It was maybe even the lowest of big cities in the country. Certainly one of the lowest. Contact tracing was getting going.

It seems that there was a reversal that the mayor and other mayors were not able to manage so well because of the conflicting communication and conflicting orders. It's an exceptional tragedy. I have a lot of confidence in Mayor Nirenberg and the other mayor, several whom I met just last night that they're going to get on this, of stopping the spread now but they are behind. It's clear as to why--

Justin: When Mayor Nirenberg was on the show, it really opened my eyes because they started sending San Antonio some of the people from overseas that were Americans like the cruise ship. People that were infected that were Americans got brought to San Antonio and as a normal person who lives here and some of our electeds were very unhappy this was happening. Ron pointed out this allowed us to get ready. We already had people in our backyard that we knew had it. It allowed us to get ready for this coming wave. He credits a lot of that with why they were able to jump on it so fast which I thought was great.

Dr. Slutkin: Well, there's so many things that need to be done right. They all were being done right. In terms of anticipation of visitors and in terms of tracing and in terms of restrictions. You have to do them all and they were all being done. The good news about this is if you do them all, as San Antonio was able to do, you really do control the virus and you can stop its spread. [crosstalk]

Justin: Proof is in the pudding. I hate to 101 with you but I think it's really important for our listeners to understand who you are and your history and epidemiology. Honestly, we're in an era of social media science and social media experts. Talk to me generally about what an epidemiologist's real focus is and how you yourself got into it.

Dr. Slutkin: I'll tell you that. Let me just say there are-- My story is basically this. I'm a physician and I'm an infectious disease physician first, and then an epidemiologist, and then I have been working on epidemics full time for about 40 years. First, I was asked to run the tuberculosis control program for San Francisco in the early '80s' when they had the worst epidemic in the country of tuberculosis. I then moved to Somalia to do tuberculosis among a million refugees in 40 camps, and then we got confronted with a cholera epidemic in Somalia when I was living in Somalia.

I left that country when it was moving into civil war and got picked up by the World Health Organization and got assigned the management of the global program on AIDS which Central and East Africa, the 13 countries in Central and East Africa, Uganda, Rwanda, Burundi, and the countries around there. I co-led the cholera epidemic in Somalia. I led the TB efforts in Somali refugees. I led the efforts in Central and East Africa on AIDS. I just want to say for almost all of these things, these were problems in which behavior was all we had.

From 1980 to 1995, there was no treatment at all for AIDS and 30% of the populations in some of these cities were already infected. We had a community spread. We had a contagious virus. You couldn't tell who was infected and all you had is behavior. We got 70%, 75% drops by behavior change, and not an easy behavior which was sexual behavior. Not an easy thing to change.

To your point about what an epidemiologist is, I want to say there's many people who are now using this phrase, some are from biologists, and some are from our clinicians, and care for patients, and so on. The management of an epidemic, epidemic management is a subspecialty of epidemiology. We're not the people who are doing projections or models, we're managing epidemics, and we have to succeed at reducing them. It's a subspecialty of epidemiology, which is epidemic management and control. That's what I've been doing.

Justin: I listened to your TED Talk when you said you were going to Somalia that your boss said you made the worst decision that you could make to go over there. What was the impetus from saying, "I'm living in San Francisco and I've got a nice job managing something and learning, but I want to go to Somalia," which at the time was not a nice place to be is my understanding?

Dr. Slutkin: I was asked to consult in one refugee camp, the Boho refugee camp because other people from San Francisco General, including close friends and colleagues, were working there in the refugee situation. I went there to consult and I got really excited about the people and the situation. I was then commuting between San Francisco and Mogadishu even more upcountry for a few years, and then myself and my colleague Sandy Gove, we decided to move there.

There's over 1 million refugees in 40 camps, and there were only 6 doctors. I felt that the TB program in San Francisco was pretty much under control at the time or most of what had to be done was done. I was younger and I took it as a challenge and a necessity. We did the math as to how many cases, there were 25, 000 to 50,000 I thought. We had about 500 in San Francisco and I thought we had it managed. It was like, I felt I had to do it, that's the way I grew up.

Justin: You then got into the World Health Organization and you had some incredible successes specifically in Uganda in addressing the AIDS epidemic. Can you talk to us about how that was approached differently or how you were able to get more success in Uganda than maybe some of the other countries?

Dr. Slutkin: These are such great questions. I'm lucky. I got picked up by World Health. Sandy and I were working on our own in a way in Somalia. I've been working at San Francisco General with a great team, now I'm back at a great team at the World Health Organization with the best epidemiologist in the world. My boss and mentor is Daniel Tarantola who had eradicated smallpox from Bangladesh, right down the hall was, all these superstars and I'm young. I'm in my 30s.

They gave me a very big assignment. They gave me the epicenter, the 13 countries in Central and East Africa. They were the hardest hit. I went at it and they gave me a team. I built a team. What did we do? We had to first find out how big the problem was by testing. We had to do a bunch of testing to find out where it was, how fast it was moving because it's invisible without the test, and then we had to set up infrastructures and networks.

We saw that we had to do training and that we had to figure out a strategy. It was a brand new disease. What are we going to do? We landed on public education, information, and behavior change. Uganda is the best example because it did the best implementation public education to scale, billboards, leaflets, flyers, pamphlets, media, spokespersons, ministers, clergy, refugee situations, military, everybody trained in very, very visible public education on sticking to one partner and then on condom use.

Then we had outreach workers who can help people understand why they need to change their behavior. Now, you can recognize what's missing here for COVID because we need very, very strong, very visible public education, on wear our mask, keep your distance, no gatherings, and wash your hands. This needs to be repetitive over and over and over and over again and we need outreach workers to reach people who might not get it, who needs it explained.

Justin: We have our own cultural pushback in America for whatever reasons are those reasons, but what was the cultural pushback you were getting in Uganda because you're talking about sex, which every country has its own cultural hangups or different views on discussing that publicly. How were you able to overcome those, I'm sure there's some cultural conservatism in those countries about those issues? Was it government was just fully on board or y'all had carte blanche, or how were you able to overcome those cultural hurdles?

Dr. Slutkin: You never have carte blanche in anybody's mind. Everybody's mind is their own, but to a certain extent, it isn't their own because they are influenced and they're influenced by others and they're particularly influenced by their friends and what they think their friends are doing and what's acceptable. We used that. There's a science behind behavior change, just like there's a science behind the contagion of a virus or of a behavior. This is really interesting, this question about culture.

Everywhere I would go in Africa or in Asia, they would say, "Condom is against our culture or this isn't our culture. We're different than that place." That was basically overcome by allowing everybody to really understand the way this is transmitted. We underestimate how important it is for people to really understand transmission itself. I

n that particular case, it was that because they thought it was other things but in this particular case, people need to know that it's in someone else's mouth and you can't tell that whose mouth it is. Then that goes into the air around them when they're just talking to you and you just, by simply inhaling that and breathing that stuff, can get that, and it can go right into your lungs. Then you're checking into the hospital a week or two weeks later, even though everything seemed fine, and he looked fine.

The mask blocks that and that the distance blocks that, and people need to fundamentally get transmission. That's part of it. Then the other thing is that what they need to get is the messaging over and over, and then beginning to see that their friends are doing it. We need to actually hire friends locally. Now, in this COVID-- I'm switching from Uganda to COVID because people need to know there's certain things we all need to get.

The young people who aren't getting this, other young people are people who are acceptable, and credible, and trusted by them need to begin to talk to them, and get them, and show them that they're wearing and say, "Listen. We can't be gathering like this. It is time for us to be wearing the mask. We don't want to get it ourselves." I don't know if people know that half of the x-rays among asymptomatic people show something wrong and there is healthy people who are making mistakes.

One of whom I heard as he was dying said, "I made a mistake," but basically, he was at what was called a COVID party. Then his last words to a nurse, he's 30 years old was, "It looks like I made a mistake." People need to understand this transmission, and so the public education to scale, and the peer-- This is what we did in Uganda, and we got enormous success and the countries and places that didn't, were lagging or they didn't.

Justin: From that perspective of public education and getting friends to do it, it almost sounds like a little bit of a peer pressure feeling. How important were the leaders in those countries because I think just generally, those cultural boundaries and how they were overcome should give us some education on how we overcome. Were the leaders that important in that role, or was it more a neighborhood approach?

Dr. Slutkin: You get benefit from all of this. The leadership in Uganda was particularly good from President Museveni. He made sure he talked about it all the time and he made sure there was training done. We at World Health had a very good partner and they mobilized their population for the education and the training. Leadership in some other countries wasn't so good.

With good local leadership, with a good mayor like Mayor Nirenberg or the other the mayors who I met from Austin, Houston, Laredo, Brownsville, and other places, they are able to and from what I can see, are standing up and speaking, communicating, educating, and showing the data, and showing where things aren't going right and what we all need to do.

In the more that everybody, these multiple channels is really important. A leader can't do it on his own. The behaviors themselves need to be done by the population themselves. It was the population of Uganda that got rid of its AIDS, and it is the population of San Antonio that we'll get rid of it's COVID.

Justin: I saw elected representative recently even encouraging the Freemasons and if you're a part of a membership, all of you pass resolutions encouraging your membership to sign on that you'll wear masks and that you'll avoid gatherings. I hadn't really thought about that but we are all really part of a group of probably 30 in our day-to-day life. I thought that was a really smart leadership role for one of our electeds to take.

After you left Africa, you came back to Chicago is my understanding. Then based on your TED Talk, it sounded like you almost stumbled into this idea of applying infectious disease principles to address the violence in Chicago. Can you talk to me a little bit about how that came about and what your framework was?

Dr. Slutkin: Yes. That's really my day job is I run Cure Violence Global, which is a global NGO nonprofit, which reduces violence. It's doing this in the US and Latin America and to a certain extent in the Middle East and some other places. We are listed as the ninth-best NGO in the world now. What we do is our workers and our partners apply epidemiology and infectious disease methods to reducing violence.

We see violence, exactly like any other epidemic disease. In other words, there's one case which leads to more cases which leads to more cases but the interruption of the transmission of it is what controls it, and you need outreach workers just like we were talking about COVID, you need outreach workers and we call them violence interrupters.

These are specialists for stopping a shooting from happening and stopping the spread, and if there is a shooting or if there is a COVID case, to prevent it from leading to more COVID cases or more shootings depending on which epidemic you're working on. We've been doing this for 20 years. There have been between 40% and 70% drops in shootings and...