Data Brew Season 4 Episode 5: Public Health: Education, Access, and Policy

For our fourth season, we focus on connected health and how data & AI augment and improve our daily health. While we’re at it, we’ll be enjoying our morning brew.

Matt Willis, Marin County Public Health Officer, shares the three pillars of public health: education, access, and policy, and the critical role data plays in addressing the COVID-19 pandemic & opioid epidemic.

See more at databricks.com/data-brew

Transcript

Denny Lee (00:09):

Welcome to Data Brew by Databricks with Denny and Brooke. The series allows us to explore various topics in the data and AI community. Whether we're talking about data engineering or data science, we'll interview subject matter experts to dive deeper into these topics.

Denny Lee (00:24):

In this season, we're going to focus on connected health and how data and AI augment and improve our daily health. And while we're at it, we'll be enjoying our morning brew. My name is Denny Lee. I'm a developer advocate here at Databricks and one half of Data Brew.

Brooke Wenig (00:39):

And hello everyone. My name is Brooke Wenig, machine learning practice lead at Databricks and the other half of Data Brew. And today, I'm thrilled to introduce Matt Willis, public health officer from Marin county, where I'm actually from, as well as an avid cyclist, assistant coach to the high school mountain biking team at Archie Williams, and has also previously worked at the CDC. Welcome Matt.

Matt Willis (00:59):

Great to be with you.

Brooke Wenig (01:00):

To kick it off, I know public health officers have been in the news a lot since the pandemic started. But what exactly is a public health officer?

Matt Willis (01:07):

Wow, that's a good way to start. So who am I? What do I do? Every county in the state of California has under health and safety codes, a requirement to have a physician health officer. So while it's true that health officers are more well known over the past two years, it's been that way for decades. And I came into this role eight years ago after having been at CDC in the Epidemic Intelligence Service, moving to Marin, working as a primary care doc. So I'm a physician epidemiologist, as are many of my colleagues across the state. Our job is to really ensure the health, wellbeing, and safety of our residents against any number of potential threats. So prior to the pandemic, my main focus was in the opioid epidemic. We had been seeing ever increasing numbers of overdose deaths, increasing rates of addiction. And that was kind of the primary focus of our work.

Matt Willis (02:10):

And then the pandemic hit. And now for the last two years, I've really been focused primarily on COVID-19. We use data. One of the most important tools for us as health officers is to have our hands on the vital signs of our community. That's how I think of it. As a physician, I use data to manage my individual patients, making sure that their lipids were okay, their blood pressures were okay, their BMI. Really taking that same philosophy of using a data driven approach to think about the science, think about the evidence, offer a prescription, offer a therapy to my individual patients and extrapolating that to the community as a whole. And so that's where data comes into play for us as health officers. And that data is epidemiology. So it's looking at the health of the community across the board, cancer rates, overdose rates, communicable disease rates, which communities are disproportionately impacted. And designing strategies to make sure that everyone is as healthy as they can be.

Brooke Wenig (03:10):

And so you had mentioned that every county in California has to have a public health officer. What about other states? Do they have the same mandate?

Matt Willis (03:17):

Yeah, it's funny in the United States, its different ways of approaching public health practice. In the state of California, it is very county focused and you'll know that from our pandemic experience. You might have one county that has a mask mandate and the next one that does not. And that's because many of those policies derived at the local level. In other states like Florida, it's much more state driven. It's centralized at the state level. So it's different in each place and there's advantages and disadvantage of each approach.

Denny Lee (03:49):

Got it. One thing related to this, what are the trends that you actually see around community vaccinations?

Matt Willis (03:56):

Yeah, this is obviously, probably, our most I and single tool when it comes to the COVID 19 pandemic and limiting hospitalizations and deaths, is vaccinations. And so this has been our most important focus since the vaccines arrived 16 months ago or so, mid-December 2020. And we've been really focusing on making sure that our vaccines rates are as high as they can be. And making sure that no community is left behind in that promise and protection that the vaccine offers.

Matt Willis (04:28):

I really look at the trends in two ways. And again, this is just always going to the data. What is our overall vaccination rate as a community? And then within that, doing a deeper dive into subsets. Smaller population, groups that might be not following up what the mainstream is able to accomplish.

Matt Willis (04:48):

In Marin county, we are really fortunate that we have some of the highest uptake of vaccines of any county in the nation. We have 250,000 residents, we've administered over 600,000 vaccines, that's individual shots. And that places us, we did an analysis a couple weeks ago, looking at across the United States, every county with more than 100,000 people, which was over 2000 counties in that category. Marin county had the highest vaccination rates of people fully vaccinated and boosted. And interestingly, the other counties in that top 10 of the most highly vaccinated and boosted are Bay area counties. Six of our Bay area counties are in the top 10 nationally for that. So that's something I think we can all feel fortunate in the Bay area that we're in a region that by and large understands the value of vaccines that has access to them.

Denny Lee (05:43):

Then interrelated with that, how are the policies of the county or of the states affecting or impacting the vaccination rates, from the data that is?

Matt Willis (05:54):

Yeah, I think it's a great question. It's one that has been, I think, particularly important and divisive, frankly, in a polarized response across the nation. The role of policy and vaccines has been important. We are very fortunate that we have been able to achieve the success we have mainly through a common understanding of the value of vaccines and understanding the benefit for us as individuals and for our friends, our neighbors, and those around us, following the science. So when I think about where I might use vaccine policies as a local public health officer, I think about our three buckets that we look at.

Matt Willis (06:37):

One is education. When it comes to promoting vaccines, it's education, it's access and its policy. And we really only get to policy, if by policy, we mean mandates as a last resort. After we've exhausted those other tools of education and access. And so it's been a very important and explicit strategy for us in Marin. And I think tracking those steps has been important for why we were able to get to over 95% of our residents fully vaccinated before we really invoked any mandates. Only in the past two months, did I use any sort of mandate for vaccinations. And that was one of the hardest decisions I had to make, but we did require that our first responders, so our ambulance drivers, people who are in and out of long-term care facilities, our jail guards, other law enforcement, we required that they be fully vaccinated to remain in the workforce, unless they had a medical religious exemption, because we were seeing preventable outbreaks, hospitalizations and deaths in those settings. And our vaccination rates were not high enough in that particular sector. But that's well less than 1% of our population.

Matt Willis (07:51):

That's an example of how we actually resorted to policy and mandates, but only as a last resort after we had done much as we could in education and making sure everyone had access to vaccines.

Brooke Wenig (08:04):

And so for those that are familiar with Marin county, they might have had the misconception that it's an anti-vax community. Could you talk a little bit more about the data behind that, potentially debunk the fact that Marin county is an anti-vax community?

Matt Willis (08:17):

Yeah, it was true. And in fact, famously in 2015, we were called out when the measles outbreak happened. If people remember back, the Disneyland measles outbreak. We in Marin county had some of the lowest vaccination rates against measles of any county in the state for children. These are required childhood vaccinations, including measles, mumps, rubella. We also had the highest rates of pertussis, whooping cough, which is a vaccine preventable disease, and some of the lowest vaccination rates against pertussis.

Matt Willis (08:54):

And so Jimmy Kimmel, I think said on his show that people in Marin county are more afraid of gluten than they are smallpox. And I was like, "touche." There was this paradox of a highly educated community, affluent. We couldn't claim lack of access as a reason not to be vaccinated. So when I became health officer, this was one of the most important priorities. I, at the CDC, had been working globally, internationally in places where low vaccination rates were due to lack of resources. And there were outbreaks of vaccine preventable diseases, including in Haiti when after the earthquake, outbreaks of diphtheria in the tent camps, because they just didn't have vaccinations. And then moving to Marin county, which is on the complete opposite end of the socioeconomic global spectrum, and finding us to be at risk for the same thing, but for a very different reason was a challenge.

Matt Willis (09:58):

And so we worked as a health department with our pediatricians, with our schools, with community members to really change our understanding of what vaccines represent for us and really reframing it as a matter of community welfare, welfare, community responsibility, and not just purely individual choice.

Matt Willis (10:18):

And over that five year period, our vaccine rates increased from about 75% to about 95% for children coming into schools. So we had been a more vaccine hesitant community. The grounds changed, I think even prior to the arrival of the COVID-19 vaccine. So when we had high uptake in Marin, I was less surprised by that than many were because I had seen how the game had changed for us in other vaccines, especially for schools. And I attribute some of that to some of our community members who chose to step forward, especially a young man named [Ret Crawit 00:10:59]. And I'll just tell you briefly about Ret. Ret was a child who had leukemia, was unable to be vaccinated, was in a public school. And this was when the measles outbreak occurred. He stepped forward and said, "It's not safe for me to be in a classroom with other children who are unvaccinated because I could die if I get infected and I cannot get the immunity from the vaccine."

Matt Willis (11:27):

And that became a very compelling story for us, to really put a face to that concept of herd immunity, or community immunity and community responsibility. So that's just one example of the kinds of messages that really, I think, changed our cultural understanding of vaccines in Marin.

Brooke Wenig (11:44):

Yeah. That's so powerful, putting a face and a voice to that. And so as a follow-up, how do you communicate with the community, particularly with those that have very polarized or very different views to what the public health officer or public health community believes is best?

Matt Willis (12:04):

Yeah. I mean, at the end of the day, vaccination is a choice, right? So we need to find a where people trust us. I think ultimately so much of this comes down to trust. And how do you build trust between public health and the community?

Matt Willis (12:24):

I think one of the key strategies for us was to be as transparent as we can, in terms of what we know and what we don't know. To have a lot of open communication and maintain open dialogue. In that first bucket, education, access and policy, that education is importantly bidirectional. The default idea of education would be that you as a public health officer have your pulpit or whatever, and you talk about the safety and efficacy of vaccines and show data. That doesn't work very well, actually.

Matt Willis (12:57):

For some, it's certainly necessary, but it's not sufficient. What we really need is to listen as much as we talk, I think, and to hear people's concerns and to demonstrate that we can relate to the dilemmas in people's everyday lives around these decisions and meet them where they are. So that's, I think one of the critical elements of education is that we are educating ourselves as healthcare providers and as public health at the same time as we are offering education to our community.

Matt Willis (13:30):

And that act of listening both builds trust in itself, but it also allows us to be more precise in our messaging, because our messaging is actually aligned with what people are actually concerned about. And then, I think it's probably the most important, that's the most important strategy for dealing with the polarization. It's just getting not condescending to people, not shaming people, not making people feel defensive. Because they will never change their hearts or minds when that's their attitude.

Denny Lee (14:03):

Do you feel that politicians... What role should politicians play in public health? Because perhaps the fact that politicians did get involved tended to make it more polarized and so people were less apathetic? I'm curious, especially from you were sitting in the middle of it.

Matt Willis (14:21):

Yeah. We're fortunate. We were in a bubble in some ways. And when I was looking at what was happening back east and other parts of the country, I mean, not that it was easy here, but we were really fortunate in that our politicians, by and large, we're supportive of public health practice and leadership. I do think that there are important roles for politicians. The answer is not for politicians to simply step aside. Politicians are elected to represent the people. There are some checks and balances there. I think when we get into trouble, it's when politicians are using a superficial understanding of the science and then making recommendations or declarations or laws that don't actually agree with what scientific reality would determine. Face covering is an example, vaccinations are an example.

Matt Willis (15:18):

These are tools that are important for protecting our residents. And the fact that space got politicized, I think it really set us back. I'd love our politicians to be much more active in ensuring that we have the resources we need. Testing, we didn't have enough testing. Early on there was lack of vaccinations. We're fortunate locally to have our political leaders really help support access to those resources. But I think we needed more advocacy, more resources, federally at the state and the local level for the infrastructure, for the public health infrastructure to respond.

Brooke Wenig (16:01):

And so I know that there's a lot of policies around mask mandates, vaccination status, and all of that's changing right now in part because of the low COVID numbers. But I know a lot of people are doing at home tests, a lot of things aren't getting reported. And so I'm just curious how you're planning to make upcoming decisions with new surges, new waves, with a lack of access to data.

Matt Willis (16:20):

Yeah, that's a great question. As the pandemic evolves, the data sources we need to look to also change. I was just talking with our epidemiologist this morning. We are seeing a greater fraction of our cases now coming in through antigen testing, that's performed at home than through PCR testing that's performed in laboratories. So the basic idea of just how active is a virus in our community. Up until very recently was PCR tests coming from laboratories. And we had these data streams that were coming in. I could look at the numbers each day and say, "Okay, this is how active the virus is." That's really no longer the case because a smaller and smaller fraction of people are actually going to the clinic to get that PCR test, going to a lab and then sending the results to public health.

Matt Willis (17:08):

We're looking to other sources to answer that question of how active is the virus. Wastewater is a really promising new tool for us. In Marin, we had been really active in using wastewater early on, and we were able to really see and validate that the wastewater levels really correspond very well to case counts, when we knew the case counts were more accurately capturing true transmission rates.

Matt Willis (17:35):

And so knowing that, now we can continue to use wastewater moving forward, knowing that the window around case counts is actually less precise. So we have four sites in Marin and all across the nation, there's more and more infrastructure using wastewater. The joke on my team is that poop don't lie. It's everybody, the poop don't lie. It's upstream, so to speak. It's an entire catchment, a whole community that might have a certain, like a sewer shed, they call them. And you measure the amount of virus particles actually, as a matter of concentration within that sewage. And it really accurately tells you how much transmission is happening, how many people are infected, not necessarily numerically, how many people. What is the burden, the viral burden within that community? And it tracks closely, again, to case counts.

Brooke Wenig (18:29):

That's super interesting, finding that correlation between wastewater and COVID cases. And so I'm curious now as the next step, are we entering in the endemic stage of the pandemic?

Matt Willis (18:41):

Yeah, I think it's important not to get too hung up in the semantics there. Because at the end of the day, we have a virus that is traveling through our community. I think we recognize that whether or not you call it pandemic or endemic, it's going to be present. Endemic diseases don't necessarily mean they're benign. They're common. But like flu is an endemic disease, but causes 30,000 deaths approximately, annually in the United States. Worse, more in a bad year. So calling it an endemic disease doesn't necessarily mean that we can abandon the measures we use to control and protect ourselves.

Matt Willis (19:31):

I think to me, the value of that shift would be to have a new, psychological relationship with the virus to understand that this is part of the world that we live in now. And feel reassured that we have tools to manage risk in our own individual lives and at the community level. And that we'll track using the data, we track the transmission rates. And we can flex into those tools depending on what's happening at any given time, from a more ongoing, sustainable endemic relationship with SARS-COV-2. But I sometimes hear when people say endemic, it feels synonymous with over. And I think that's an oversimplification, unfortunately. I think this is a virus that's going to be with us forever more.

Denny Lee (20:18):

This is really interesting, Matt. I did want to actually ask the question though. What do you think about the dropping of the mass mandates for air travel and transit that just actually recently happened? Just curious for your opinion as a public health officer.

Matt Willis (20:31):

Yeah. Well, first off my personal opinion, if I were traveling, I would continue to cover my face. And my mother-in-law's coming out for our son's high school graduation and definitely counseling her to continue to cover her face, she's 80 years old. I think it's clear that transmission, that there will be increased risk associated with travel if everyone around us is not covering their face. So if you a picture a six hour transcontinental flight where you're sitting shoulder to shoulder with people, and their face is not covered. If that person is infected and they're not covering their face, and you're not covering yours, your risk is higher than it would've been if both of you were covering their faces. So it's important to acknowledge that this decision does increase risk.

Matt Willis (21:24):

I think it's also being done, this question we just talked about in terms of pandemic or endemic. We also know from a quality of life standpoint that we don't want to be covering our faces forever into the future. And that there is a point at which it's no longer necessary to mandate that. My opinion is that this is premature in terms of that point. We are seeing with the BA2 variant, we're seeing more transmission. I think the coming week will really show us in the Bay area and probably across the nation that BA2 is really getting a foothold. We're seeing pretty dramatic increases in cases, fortunately not hospitalization yet, but we are seeing cases. The timing of this I think is unfortunate.

Matt Willis (22:17):

But I understand what's behind it. I think it's also part of what we talked about in terms of the politicization of this whole pandemic response. We issued a statement as soon as the federal judge came across. And then that it was clear that the state of California was trying to determine what their ruling is for the state. And right now, it's ambiguous from a legal standpoint right now what the state of California can or cannot do given that this is a federal ruling. So that's where we are right now. But in that ambiguity, I wanted to be clear with our residents, that we still recommend that people cover their faces, even if they're not obliged to, in the course of travel. And that stands, especially for people who are at higher risk for severe illness and death if they're infected.

Matt Willis (23:07):

Wearing a KN95 mask that protects the wearer more than just the surgical mask, I think is an important step to take for our older residents who are traveling. And we want people to be able to have that experience of travel. I took a trip recently and loved the fact that I was able to step out of the COVID cave for a little while and be renewed. And travel's important, but I also think there are ways to do it safely. And covering your face isn't that big a deal, really if it comes down to it. It's a relatively simple intervention that you can take. And it does have some protection, not as much as vaccines, mind you. If we can pick one thing, it's vaccinations. But masks are also an added layer of protection. And why not take that measure?

Denny Lee (24:00):

Makes sense. And related to that, do you find from the data that the boosters are actually helping with these new variants as well?

Matt Willis (24:09):

Yeah. The booster dose, the first booster is important. It's gotten more confusing for the public as we roll out more different phases of the vaccine. We have the second booster dose now for people age 50 and above with chronic conditions. Now we're talking about the first booster dose for children, age five to 11 will be coming on board. And then the first vaccine for zero to four. So there's all these different cohorts and groups in different stages. But for the forest for the trees, really moving from being fully unvaccinated to vaccinated is the most important single step. If you are not vaccinated, getting vaccinate with that first series is by far the biggest benefit. And then for people who are fully vaccinated, getting that first booster is also important because that does boost your immunity.

Matt Willis (24:57):

I think if we look back, if we'd had more time in operation warp speed, where we moved remarkably quickly to getting these vaccines out into the world. If they had actually done studies where they did three vaccines versus two, it probably would've been a three dose regimen actually. So I think about that first booster as being really important to full protection. I think the second booster for people above age 50 is more up to the individual, talk to your doctor. It may be right for you, especially if you're at higher risk for a bad outcome. But we're not recommending it nearly as strongly as we are that first booster dose, because it does have protection against the emerging variants.

Brooke Wenig (25:48):

And so in the midst of the COVID pandemic, one thing that often didn't get enough attention was all of the opioid epidemic, as well as opioid and drug overdose related deaths. Can you talk a little bit more about what the data has behind that, what your outlook is? I know you've co-founded Safe RX Marin to actually help with the opioid epidemic locally. But can you talk about it both locally and nationally?

Matt Willis (26:10):

Yeah. I think when we talk about moving from pandemic to endemic, to me, this is one of the benefits of claiming this as an endemic, ongoing challenge for us, SARS-COV-2. Because it will allow us to move out of that pandemic emergency frame and see it as being next to other public health challenges.

Matt Willis (26:34):

And the opioid epidemic is something that has been neglected because of COVID-19, and necessarily so. We really did need to focus on saving lives with this new virus. But it's important to change back now to really see a more holistic understanding of all the public health threats. And that's where I see opioids as really being an important priority for us moving forward. Looking at the data, in Marin county, I just did this analysis last week and was really alarmed to see... I had a sense that this occurred, but not to the degree to which opioids were really continuing to harm our community.

Matt Willis (27:10):

In Marin county, anyone under age 60, over the past two years, 10 times more likely to have died from an overdose than from COVID-19, anyone under age 60. And if you think about all the work hours, the time the societal interest and focus on COVID-19 compared to overdoses, there's really a mismatch there. And so I think this is an invitation for us to refocus on things that the data tells us are in fact, as pressing in the next stage.

Matt Willis (27:49):

We're fortunate that we've had this coalition going in Marin. There's a variety of coalitions like it across the state. They bring together law enforcement, educators, our school community, public health, healthcare providers, elected officials. Really, it's a complex overdose. And the opioid epidemic is a very complex problem. And it requires strategies that cross sectors to come together to really design a single solution. And that's what those coalitions are designed to do. They're designed to create infrastructure for people who normally don't talk to each other, but are facing the same challenges to come up with common strategies.

Denny Lee (28:32):

Perfect. Well, okay. We're going to switch gears just a little bit to make things a little bit lighter. But as an epidemiologist, I'm just curious, what are some of the coolest or the funnest analysis that you've done, actually?

Matt Willis (28:43):

Yeah, I mean public health I think is the funnest application of data. We get to use data to really change things and save lives. And so I love having my hands on data that it can immediately turn around into strategies that protects people. And that's what we do. And there's been a few chapters, I think in my career that it really stood out. One was in Haiti after the earthquake, where there was hundreds of thousands of people who were displaced from their homes in Port-au-Prince, Haiti after the earthquake. And they moved into tent camps. Basically, all the structures there are these concrete cylinder blocks, not seismic in any way. And almost all just collapsed.

Matt Willis (29:35):

So people, that night, if they had survived, and more than a hundred thousand did not. We had very quick early mortality. But the rest needed to find places to live. And so they set up these makeshift tent camps in any open field across the region. And those places became obviously at high risk for outbreaks of communicable diseases, because there was not plumbing, there wasn't proper hygiene. And so we moved. Clinics, doctors without borders and other organizations moved into those sites.

Matt Willis (30:10):

And I was able to go down to Port-au-Prince and help establish a surveillance system for outbreaks of diseases in the tent camps, working with the medical providers in those camps where they would send us each day just basic data of hash marks of different diseases they were seeing, respiratory illness, malaria, diarrhea illness at each camp. And then we would crunch the numbers at the embassy in the evening to try and determine where outbreaks were occurring so that we could intervene. And it was that system that ultimately detected the cholera outbreak that occurred in Port-au-Prince after the earthquake. And in malaria, we were able to get antimalarials out to places where malaria is more active. And it was just a really clean and direct application of using data for public health. I think that was my favorite initiative.

Brooke Wenig (31:00):

And how does the data get stored or transmitted across these various agencies as well? Because I imagine when you're crunching the numbers, you might be running something locally, maybe on Excel, but then how do you report that data back out elsewhere?

Matt Willis (31:10):

Yeah, exactly. Just the technical aspect of it was important. Just getting people to report data, I think was the first issue. Anyone who's interested in data always knows, garbage in, garbage out. You've got to start with the right stuff. And so I spent a lot of time moving around Port-au-Prince on the back of a motorcycle, going to these clinics and saying, "This is what we need." The last thing these docs wanted to do at the end of a long day of taking care of patients, was to fill out a form for the CDC.

Matt Willis (31:47):

So we needed to take a realistic approach to that. And then we're using Excel. This was very basic stuff. And then we're looking at proportional contribution of different diseases. So in a given area, it used to be only 10% was malaria. Now it's 30% of the things that are being seen in that particular setting are malaria. So we'll see that as a trigger for uptick in malaria incidents.

Matt Willis (32:14):

And then it's through communication. We had weekly meetings, all the NGOs would get together in person, at a golf course, and a clubhouse of a golf course that was a giant tent camp and review the data. And then people were on the internet. There was email and there was some informational infrastructure where we could communicate the findings and dispatch our resources to the right places.

Brooke Wenig (32:41):

Wow. That is some amazing work that you've taken part of. And so before we close out our session, I would love to ask you cyclist to cyclist. What is your favorite bike route in Marin?

Matt Willis (32:54):

Oh my gosh. That's like asking someone to pick their favorite child. I can't. I mean, it depends. I guess it depends on the day and the bike. I have a gravel bike and I have a mountain bike and I have road bike. So for road riding, I love to go out to west Marin, just that loop out to Point Reyes Station. And I stop at a bakery for the calorie neutral ride. Burn calories out there, eat a giant something. And then I like riding up Mount Tam. I live in San Anselmo, and Phoenix Lake and Eldridge road is close to where I live. And it just helps me to be at the top of town and looking out across Marin and thinking about the community that I'm serving and see everyone in their place and recognize that's the level that I'm functioning as a public health officer, is really seeing the community as a whole. And having that perspective physically actually helps me see things more clearly.

Brooke Wenig (33:58):

That's truly inspiring. I love mountain biking on Mount Tam as well, though I don't quite have that same feeling of looking over everyone that I'm protecting or looking out for as the public health officer. But I just find it's a great way to reset and clear my mind. My personal favorite loop is Alpine dam.

Matt Willis (34:14):

Oh, it's spectacular. I think we did that ride together.

Brooke Wenig (34:18):

We did. It was such a fun ride.

Brooke Wenig (34:20):

Well, Matt, I want to thank you so much for taking the time out of your very busy schedule to educate us all in public health, the role poop plays in policy, and your outlook on the pandemic and endemics.

Matt Willis (34:31):

Great talking to you.