- [Announcer] Live from your public media studios, WVIA presents "Keystone Edition Health," a public affairs program that goes beyond the headlines to address issues in Northeastern and Central Pennsylvania.

This is "Keystone Edition Health."

And now, moderator Tonyehn Verkitus.

- Good evening and welcome to "Keystone Edition Health."

I'm Tonyehn Verkitus.

Thank you for joining us tonight.

The challenges facing public health are as diverse as they are complex, demanding innovative solutions and steadfast dedication.

Its importance transcends individual boundaries, weaving together the threads of epidemiology, policy and community engagement to safeguard the vitality of populations.

From preventing infectious diseases to promoting mental wellness, public health endeavors to cultivate environments where individuals thrive and flourish.

But first, WVIA's Tom Reese has more.

(icon whooshes) - [Tom] Public health is the cornerstone of societal wellbeing.

It prevents disease, promotes healthy lifestyles and protects communities.

And it encompasses a broad array of initiatives like vaccination campaigns, improvements to sanitation, health education, and policy advocacy.

"To get community input for public health, you must build trust, enlist new resources and allies, and create better communication to improve overall health outcomes."

That's according to an article from William Patterson University.

Public health professionals want to create conditions where all individuals can thrive, to address social, environmental, and behavioral determinants of health.

For "Keystone Edition Health," I'm Tom Reese, WVIA News.

- Joining us tonight, we have Dr. Pragya Dhaubhadel, a Specialist of Infectious diseases at Geisinger.

Henry Radulski, Director of the Wilkes-Barre City Health Department, and Dr. Shubhra Shetty, Infectious Disease Consultant and Medical Director for Wyoming Valley AIDS Council Clinic.

Thank you all for joining us.

Well, I think first for starters, it would probably be helpful for people to just understand what we mean by public health.

Henry, could you help define public health for people?

- Yeah, public health is actually a science.

It's a science of protection and improving the health of the community, and that's all community members, And obviously the very aspects of it ranging from environmental to preventative health to communicable disease to public health preparedness.

And I think the important thing is prevention is the key.

How we prevent illnesses, diseases, environmental factors affect those people, our residents, and all residents in our community.

That's the important aspect, and that's what we do in public health.

- And Shubhra, you've been in public health for a while.

What is your primary focus now?

- So my primary clinical focus is caring for people living with HIV/AIDS, diagnosis and treatment of sexually transmitted diseases.

And a huge part of it is prevention.

So there are new strategies for prevention of both sexually transmitted diseases, HIV, and other infectious diseases.

So that's sort of my new focus.

- Okay, Pragya, as an infectious disease physician at Geisinger, how do you feel that you're incorporating public health into the work that you do?

- Well, Tonyehn, I think this is a very good question.

Like we as a clinician, I see patients with various infectious diseases, including the ones that Shubhra's mentioned just now.

And I take care of just the patient at that time, at that moment.

But what is the background?

What is the impact in the community where the patient came from?

What is the source?

Are there more people with similar illness?

And besides the, you know, diagnosis of infection, what are the other factors that made this patient at risk for infection?

Like, you know, diabetes, you know, hypertension, obesity, smoking, so forth and so on.

That's very important.

So if we see, if I see anything, any unusual case, we can give an example of COVID-19, immediately, you know, I was in fact the first doctor for my healthcare facility to get the sample of COVID and immediately have a connection with the local as well as Department of Health and get them involved if we, you see anything unusual.

At the same time, if there is increase in number of infections, like last year we saw some cases increase in Legionella, what's happening in the community?

Is there something that, you know, public health officials should know to stop it or like, you know, educate and let the community know about it?

So it's kind of a bridging from bed to the patient's home to the community and you know, the society.

- Oh, that's interesting.

So when we're talking about things that are happening at home with this potentially includes social determinants of health, and then how, Henry, would you track that?

Would your office track that?

- Right.

Well, that's actually where we come in.

Obviously at the hospital, doctor's office, it's diagnosed with communicable disease.

So there's a system in Pennsylvania called Pennsylvania NEDSS, which is the nationally electronic disease surveillance system.

So what happens is when a person is positive with a communicable disease such at a hospital or a doctor's office or laboratory, that comes to us electronically.

If the person lives in Wilkes-Barre, it comes to us.

And now it becomes the prevention aspect, which we talked about already, how important that is.

So our what our responsibility is, obviously we interview them and we want to prevent that from spreading to other people.

So once again, you can hear the word prevention over and over again, but that's, you know, our relationship with any, whether it's hospital or healthcare, where we get those reportable diseases and we, obviously there's an investigation that goes on for all factors as far as not having contact with other people, quarantine, things like that.

So it's, we work together on combating all communicable diseases.

- I'm just outta curiosity, all states have a Department of Health, but how might Pennsylvania differ from other states?

- Well, in every state, the public health system is set up differently.

In Pennsylvania, we have the Pennsylvania Department of Health who has their main office in Harrisburg.

In addition to that, they have six regional offices.

The closest regional office is the Northeast District Office, which is in Scranton.

That office covers 10 counties.

And they have 10 clinic sites, one in each county.

In addition to that, there's what's called the CMHDs or Community, City Municipal Health Departments.

Wilkes-Barre is be fortunate to be one of those.

There are seven county health departments, four city health departments, and that we're functioned partially from the Pennsylvania Department of Health.

Not only function, not only financed, but partially by them.

But we have to do everything that they do, plus we have additional responsibilities.

And then after that, so those CMHDs cover 45% of the state and the state covers the other 55%.

In addition to that, there are some small municipalities may have like a board of health with one person or two people, and basically limits maybe environmental and resident inspection, things like that.

So when you go to other places, everyone has a different setup.

That's how it is in Pennsylvania.

- Okay.

And when we're talking about STIs, what is the prevalence right now?

I mean, I think most of us don't think about that often unless you've been diagnosed.

So what are we seeing out there today?

- Yeah, you know, it's a really important question to bring up because what we are seeing nationally is an increase in all sexually transmitted diseases.

So for instance, syphilis, we've seen an increase of 200% in the number of cases in syphilis.

You know, I say this to my learners sometimes that for my first 18, 20 years of practice, I would see an occasional case of syphilis.

In the last three to five years, the number of cases I'm seeing personally in my own practice has escalated tremendously.

There were more than 3,500 cases of congenital syphilis in America in 2022.

Congenital syphilis should, we should not be seeing a single case.

- And can you explain what that is, to people?

- Yeah.

So congenital syphilis is basically babies being born with syphilis.

And I think to the points that were made earlier by Pragya and Henry, it's a reflection of their mothers not getting the care they needed, people not getting diagnosed and treated in time.

So babies are getting born with congenital syphilis, which can be a killer.

You know, significant deformities can occur and it can be a killer.

Similarly, we've seen an increase in gonorrhea cases as well as chlamydia.

And this is just sort of the traditional STIs.

Interestingly, HIV cases are finally dropping in the country.

So on average, the number of cases were stuck at about 50,000 new cases a year for the longest time.

But in the last, I would say five to six years, finally, we're starting to see a decrease.

So the numbers are still unacceptably high, but it's about 30,000 new cases as opposed to what it had been.

And I think it's with some of the strategies that have come out.

You know, I wanted to make other, another point that's related and I think was brought up by my colleagues.

When you see a patient or a person coming in with syphilis, gonorrhea, chlamydia, HIV, or really any disease, any infectious disease, it's really important to think about what caused it.

What are the psychosocial factors?

What was missing in terms of prevention and care that the person should not have gotten sick?

What's going on in their social context, their social networks?

Because that tells us where to go looking for other cases that may not have ended up in care or maybe didn't get that sick.

And I think that's where public health comes in, in a big way.

You know, most physician offices, most hospital-type care, it's sort of, you know, you have, you take care of the patient who's in front of you and maybe a little more.

So for instance, in HIV care, we have case management services, we have surround services.

But lot of other diseases, that doesn't exist.

And there is a need to go delving to see why somebody got sick and how can it be prevented from spreading.

And that's happening in our communities.

You know, it's sort of the tip of the iceberg is what we end up seeing and caring for.

- Go ahead.

- I just want to add, and, you know, kind of piggyback to the context that you brought in.

So, how can we address that?

And there comes the equity from public health.

You know, equality does not serve everyone.

You need to address the equity.

So what's the difference between equality and equity?

Equity is like, you know, getting all the opportunity that the patient needs to lead a healthiest life.

Keeping in mind there are some people who may need some extra resources who are underprivileged who do not have access to care.

And that is where the crust of the, you know, the STD cases, and not only that, like mental health issues, opioid issues, obesity, smoking, all these things are there.

So I think this is where public health plays a big role.

And Henry, you can, you know, add on this if you- - Yeah, I was actually gonna ask, I'm glad you brought up health equity because I was curious to know for you, when you have patients coming in with infectious diseases that aren't necessarily common, do you find that there is that commonality maybe that these are folks who have not been seeking medical care on a regular basis?

- I mean, definitely.

I can give an example of like, you know, foot infection on people who have uncontrolled diabetes.

We see this patient and especially after the pandemic, we are seeing more and more infection of foot, even like requiring amputation that is, you know, removal.

Resecting the foot.

Why?

Because, you know, they did not have access to care for care of their diabetes, you know, smoking, obesity, or just to have a, you know, regular primary care provider's care.

So this is one of the biggest area where public health I know is like focusing and equity is very important.

- Henry, oh, go ahead.

- Yeah, and obviously we wish we could do everything, but we all have our limits.

But the important thing is to know when you get the patient and they need assistance, where do we, where do they go?

- [Tonyehn] That was gonna be my question.

- It's about knowing resources and that's very important.

And you know, we review that all the time as far as resources with our nurses and other employees.

We don't have all the answers, but if you know where to send people and even make sure they go there, I mean, we've, we've given vouchers for transportation sometimes even take, we have taken people for treatment.

So that's what we need, probably more of it.

But it's obviously it's a matter of resources that are available.

- So it's kind of a wraparound service.

We're not just thinking about prevention, but how do we affect the whole life of the person?

- Right.

- Holistic care.

I also know that you do children's immunizations and when you mentioned that, I thought a lot of people's children are going to a pediatrician.

So again, if they're coming to the Health Department for these immunizations, is this because they don't have a primary care provider or for ease?

- Either.

It's either.

We don't charge.

So if you have a lack of insurance.

Or listed on Medicaid for the children, we'll do, we do them for free.

- Okay.

And how has public health changed since you've been at the City Health Department?

- Well, I think, you know, throughout the years, I think one thing that's that's happened is obviously communication electronically.

At one time I talked about PA NEDSS as far as electronic records of communicable diseases.

I mean, that used to be done with a piece of paper and a fax machine.

Immunization records, they're all on PIERS.

Okay, so those things have made a better system of recording and analyzing.

Another thing that's happened, of course as a result of COVID, GIS, which is geographical information systems, that's expanded and we've had resources for that.

And it's amazing, just amazing what you could do.

And a lot of the hospitals have that.

We're just getting that.

So we, if someone says, you know, how many cases of RSV, how many cases of flu, how many case hospitalizations of COVID in Wilkes-Barre, we could just go into the computer, pops up graphs, gives you rates, it's really come a long way.

So I think we've progressed that way.

One negative part I think that's disappointing is the misinformation that we're getting.

And we've talked about education and prevention.

Well, to have education and prevention and competing against social media, which is another thing that's changed in my years in public health.

So you're fighting a real difficult battle, but that doesn't mean we don't stop.

We always try and convince people to do the right thing.

- I would, anyone can answer this, but do you feel like social media diminishes trust in the Health Department or physicians?

- You know, that's a loaded question.

And, I think it's changed things forever.

A little bit for the good, but a lot for the not great because everything gets amplified.

And again, you know, social networks are defined in a very different manner anymore, right?

Social networks where your neighbor, your who you went to school with and so on, and now it's your, potentially your Facebook friends or who you hang out with on TikTok or what, you know, so on.

So I think it's changed forever.

And, this is not an original thought by any means, but people are living in echo chambers, so you'll find evidence to support what you already believe much more so than before.

And I think with an erosion of trust in systems and who were previously considered trustworthy institutions, people can sort of come up with their own theories, which are not always vetted or true and they can take a life of their own.

So, I think it's been really hard.

On the other hand, some information is very readily transmitted in a good way.

And I'll share with you, you know, monkeypox, which we barely talk about anymore.

But a couple of years ago what we were, we had a huge, we we were having an epidemic and the populations that were at risk, highest risk, especially gay and bi men, really took it to heart and changed practices, got vaccinated.

And the epidemic has basically almost completely died out in the US.

So there's good and bad, but it's how it's used.

And I think what it's brought to light is just the need for trusted authorities.

Trusted institutions like public health institutions, like, you know, your local healthcare providers who you may interact with or you trust more.

I think that has become even more critical than before.

- I also wanted to ask, since we're talking about social media, if we're thinking about prevention, especially in your field especially, how are you educating people so that they understand what type of preventative measures are out there or the fact that they're highly at risk?

- Yeah.

You know, talk to patients, you build on trust that you hopefully already have because you're a provider or you interact with them in different settings.

I'll go to patient groups where they can ask me anything.

But I think a huge part of it is building on that sort of doctor patient trust and encouraging people, nudging people to do the right thing.

So for instance, acceptance of COVID vaccinations was very high in our clinics, in specialty clinics because there was already a relationship, right?

It wasn't a hundred percent by any means.

I don't, nobody reached that, I don't think.

But it was, I think it comes down to that, comes down to trust in your providers, your, you know, who you're getting information from and repetition.

You know, we have all of us probably use certain tools of, you know, cajoling convincing, educating, you know, giving evidence, give, sharing new data, making sure patients realize that, you know, that they can come to you with anything.

I think open doors for certain kind of issues really helps, but it's an ongoing fight.

You know, we, none of us I think, has all the answers, but we keep trying.

- Pragya, I'll ask you a similar question.

So if you have a patient that you feel you'd like to refer to the Department of Health, how do you build that line of communication so that they trust going someplace else as a resource?

- Oh, that's very, you know, I mean easy, again, like it's a doctor patient relationship and then bring the, not only the patient, you know, the family into the picture as well and then, you know, explain to them like why you need to, I need to transmit the information to Department of Health and certain benefits.

I'll give you an example of tuberculosis, right?

Tuberculosis, as many of us know that there is increase in the overall numbers of tuberculosis in the whole country after the pandemic.

So we have a very good way of communication with the Department of Health for tuberculosis.

Once I have a patient who I'm treating for tuberculosis diagnosed, refer the patient to Department of Health and they have this trained designated staff, they will go to the patient's house, give the treatment, it is called directly observed therapy.

Then again, you know, you need to do a workup about who are the exposed people.

So that care is, you know, what the patient needs.

So I think, you know, most of the patients are receptive.

They understand because they care for the help.

And it is part of our duty to explain why I am doing what.

And it's not only you, it's your family, your community, and whoever lives around you.

That's the benefit for the whole system and the quality of care that is provided by, you know, the organization or you know, the agency.

- Henry, you did talk about COVID for a second there.

I know that you all did a lot of vaccinations.

How many people do you think you vaccinated?

- We know obviously what we talked about, the electronic system that's entered.

So we, I think we know we did close to 20,000 people.

And the good thing about it, not the good thing but the preparation that we had, our public, we have a public health preparedness bureau and every year we actually do drive-through and walk-through clinics.

And some people thought the reason we always did those was so you get your flu shot, but actually it was practice in the event of a major event.

So that, once again we talked about prevention was also preparedness.

- Mm-hm.

- So that really helped the situation.

I did feel that we did build trust with people for the COVID vaccines 'cause they were repeat visitors and knew where to call and were comfortable with what we did.

So I think you developed that as a compassion and understanding with people and know you're doing something for them.

So yeah, it was well received.

- Just outta curiosity, are there any services that you provide that people might not think they can go to the city Health Department for?

- Well, as far as, from a clinical aspect, obviously we do a TB, STD, HIV clinics, the immunizations that we mentioned.

Obviously we have a Bureau of Environmental Health and they investigate 5,000 nuisance complaints a year.

Nuisance complaints consist of someone, they put their garbage out, there's trash, unhealthy living situations, unsanitary conditions.

In addition to that, speaking of, you know, prevention, we actually inspect 2,500 rental units each year.

So we go in there to make sure it's safe for people living in there.

So there are some of the various things that we do.

- [Tonyehn] I had no idea.

(Tonyehn laughs) - And we also were involved, obviously we talked about prevention and education.

I mean, we do other, we collaborate with other agencies.

So you know, we have a program, we do physical therapy in high rises, we have walking programs, we have falls prevention with the YMCA, we have wellness clinics, various wellness clinics, mental health clinics with subcontractors that we use.

So there's a lot of things that we do that people aren't aware of.

And some people always have the impression that health departments where restaurant inspections, which I didn't mention, because we do.

(everyone laughs) We do 600 of those a year, but, you know, they do restaurant inspections, I think they do immunizations.

And that's pretty much it.

So, you know, there is a lot in, a lot more involved in than just communicable diseases.

- Yeah.

It's holistic care for the community.

- Exactly.

- Yeah.

- Which is I think also animal bites, you know, an investigation.

So for instance, rabies, you know, I call the Health Department all the time and to Pragya's point about tuberculosis, you know, screening, contact tracing, et cetera and treatment.

But similarly, you know, again, knowing that you can call a number- - Yeah.

- And get the information.

You know, there is so much fragmentation in healthcare today that there is such a need to have almost like an anchoring with public health, you know, and filling in gaps as because gaps do exist.

So, and even for people like us who are invested in, particularly in infectious disease specialists who are probably very sensitive to psychosocial aspects of care or lack thereof, it's really important to have those partners in public health.

- I think knowing where to go for your problem is important.

And we become a referral because just say for instance, restaurant inspections.

Since we are a county municipal Health Department, and city, county municipal Health Department, we actually do our own restaurant, food establishment inspections.

If you don't have a Health Department, the Department of Agriculture does those.

Okay?

- Okay.

- If you have an animal bite, we have an animal enforcement officer, but if you don't, then you have to call the Department of Agriculture.

- Okay.

- So it's that system of public health is somewhat scattered, but as long as you know where to call to get the information, that's what it's all about.

- I'm so glad to hear that we have such holistic wraparound care in our community because I really had no idea how substantial the work is that you all do, actually.

Thank you to all of our guests for their insights and to all of you for joining us.

For more information on tonight's episode and to see other episodes, go to WVIA.org, Keystone Health.

For "Keystone Edition Health," I'm Tonyehn Verkitus.

Have a good evening.

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