On April 1, 2020, the Buckley Program hosted a public lecture with Howard Forman on the topic “Assessing Trump’s China Strategy. Dr. Forman is a Professor of Radiology and Biomedical Imaging, Public Health (Health Policy), Management, and Economics at Yale. He teaches healthcare economics at Yale College as well as directs the Health Care management program at the Yale School of Public Health. He is the founder and director of the MD/MBA program. In addition, Dr. Forman is the faculty director of the healthcare focus area in the School of Management’s MBA for Executives program. As a practicing emergency/trauma radiologist, he is actively involved in patient care and issues related to financial administration, healthcare compliance, and contracting. The transcript of this interview has been lightly edited for clarity.
Bobby Badiey: Thank you for talking to us today. I really enjoyed the discussion. Do you think the way we have a marketplace of state governments responding to this crisis on their own terms is an effective national strategy from a healthcare perspective?
Howard Forman: There are so many times where the argument for federalism is powerful. Quite honestly, this is not a counter argument for federalism but it does point out how important it is to have strong leadership at the federal level. Other than perhaps the Defense Production Act, which quite frankly never had to have been put in place if you would have had a sort of war team put in the White House that was on the phone every day with every manufacturer saying, “this is what I’m going to need in March and you better deliver for me because I don’t want to have to put the defense production act into place of course.” The rhetoric, the leadership, the communication, the transparency of a president – and it’s not just the president, but it’s the whole apparatus around our executive branch – can do everything we wanted it to do. I don’t even see this as a failure of our government, it may be in retrospect in fact a failure of our leadership.
BB: Have you seen a cohesive public and private sector collaboration in this issue? Do you think going forward the relationship between public and private sector health coordination, especially with respect to the research university, will be different?
HF: Some of this is opaque. I’ve heard some people saying the governor’s office in Massachusetts and Connecticut have been working very closely with the labs trying to get this and trying to get that set up. I may be naïve in this, however I really believe that effective public leadership can get private partners to the table to do what is right in these moments in time. I know for instance that our governor is in touch with our hospital executives every day, and what I would expect is that our president is in touch with the American Hospital association on a federal level, and that our President is in touch with Lab Corp of America, and Questcorp, and with the companies that manufacture the reagents. It’s not the President himself that has to be on the phone with these people, but you would imagine that the President through his staff would be sourcing information from the governors, culling that together and figuring out “okay here are the needs we have to take care of today, I’m putting these staff over here on figuring out why we don’t have reagents in every lab we need them in, and I’m even going to put them in touch with American Airlines and JetBlue because they have a lot of idled aircraft, and if their aircraft could help us logistically move the materials we need to move across the nation, then that’s something we should be able to do.” Think about how inexpensive it is when you have idled capital sitting on a tarmac, and then deploying it at a relatively low cost to do something socially valuable. I don’t ever want to be president, I don’t aspire to these positions, so I’m not pretending to think it’s easy. But this is what you need when you’re dealing with a national emergency of this magnitude.
BB: How are private hospitals financing the response to this crisis? Especially for people who can’t afford the expensive ICU treatments, especially for extended periods of time.
HF: Most hospitals that I’m familiar with, Academic Medical Centers, even before legislation had passed. Partly because of EMTALA, partly because of compassion, take all covers and deal with the money on the back end. This makes it a little easier to have things immediately forgiven, we still don’t forgive treatment costs for a lot of patients but are taking care of the testing costs. Generally, I’m not sympathetic to the hospital industry, because I think a lot of hospitals in this country make considerable amounts of money, but the hospitals are without a doubt, as compared to any other single industry, are probably absorbing the single biggest hit. A lot of other companies can quickly downsize their workforce, or rightsize. They can cut overtime hours and everything else. Hospitals are simultaneously being asked to staff up and get paid substantially less.
BB: Do you see that stress reflected in healthcare professionals you’re in contact with currently?
HF: Not about the money issues because they’re really opaque to that, but the stress on the healthcare workers is very very high. It’s not unexpectedly high.
BB: To shift gears a little bit, I recently took a look at your twitter account and how you’ve been using that as a tool for public health advocacy. On the flip side of that, social media is notoriously susceptible to misinformation. Do you see social media platforms being useful for public health information dissemination in the future?
HF: What got me involved in twitter was mostly fun before this. It was an opportunity to express my opinions and I had established myself for the most part as a centrist democrat, and when the moment struck me I could troll the President, I could troll Lindsay Graham, those were my favorite people to sort of attack at any given moment, and I’m very honest about that. I made an enormous pivot that was not purposefully starting at the end of February when I started to use the platform to purely talk about coronavirus. I went from 90, or 95% political twitter to being 90-95% coronavirus twitter. I get a few political things in there, but you’d be hard pressed at times to recognize politics nowadays in most of my tweets because I’m as apt to attack the state of Connecticut and California as I am to attack Oklahoma and Florida right now. Although, I do have a particular amount of venom towards Florida lately, but that a different issue. I have found the community of people with respect to Coronavirus – really a few dozen of us – that are deeply invested in this one thing and therefore there are a lot of people that follow us. I doubled my twitter following because of coronavirus. I had 20k followers and now have 40k followers. I tried very very hard not to spread misinformation. I’ve made very very rare mistakes. I have made some mistakes, however when I do I correct them. Sometimes people misperceive what I’m saying, and those things I clarify, but I don’t perceive those as mistakes. I am impressed by how many people come to me, it’s overwhelming at times, either through direct messages or through replies to tweets asking me if something is correct or what I think of it. Very often my answer is that we don’t have enough information to answer these questions and I think that’s useful. I think that’s part of my role, and you should be proud of this campus. I’m very proud of our school, there are so many good faith actors on this campus using Twitter for the right purpose.
BB: To a more personally interesting question. I read a piece you wrote for the WSJ on artificial intelligence in radiology – what broader role do you think AI has to play in medicine in the future?
HF: I’m a huge fan of AI, and I think that most of the energy is directed in efficiency, in my field its within efficiency and productivity. I think those are where the commercial applications are – the lowest hanging fruit. But I can give you some examples of how artificial intelligence can just get us answers faster than anybody else. When we do lab tests, for instance, we know that there is a range, between low normal and high normal for potassium for example, let’s say between 3.4 and 5.3. Some people run high, some people run low, some people run middle. Almost every lab test is like that, almost everyone runs differently. We don’t capture that information, only data points do. Nobody pays attention to these differences, nobody can say to you right now that if you had a particular type of cancer that maybe your responsiveness to a particular type of chemotherapy would depend on whether your potassium level, your calcium level, or your ALT level in your liver was variant. I’m blown away by those thoughts, when I read a brain CT I interpret it for simple binary findings – but I don’t comment on things like – “is the cisterna magna bigger than normal (we actually do sometimes call it a giant cisterna magna, though some people don’t comment on it), its smaller than normal, why do some people have calcium in their basal ganglia, why do people deposit calcium inside their falx, why do some people have bigger orbits and smaller orbits, why do people have larger aeration of the mastoids or smaller aeration of the mastoids, what about sinuses?
There are a million things that are effectively ignored on every exam because they mean basically nothing to us right now, but think about how much information is embedded in that and how those types of information could correlate with prognosis, how we treat things, with the choices of therapies we have and how we think they’ll pan out. That to me is going to eventually become a hot topic in AI, and we’re not doing anything there right now.
BB: What long lasting impacts do you think this crisis will have on medical research and the research economy. How much do you think things will shift?
HF: You’re too young to know how much our world changed on 911, it was the biggest change in my life. We went from a time when I was a child and was able to walk my grandmother onto the plane to see her off at the airport, and all of a sudden, we’re now at a point where you’re not allowed to go past security unless you’re getting on that plane. Our lives changed immeasurably after 911, and I think this is going to change our lives immeasurably as well. I think that social distancing is going to be more permanent in our lives, I think people will hug less, shake hands less, and embrace more meetings like this in the future. I was very reticent to do anything online in the past. I hated doing zoom meetings, I had done a few of them before but had never chosen to do them most of the time and would just do it on my phone as opposed to doing it face to face as we’re doing here. But I’ve come to realize if I don’t do this it becomes even less personal. It’s important for you to see my expressions, but we can do it with a window instead of in person. I think that our public health apparatus is going to forever be different. Not because we failed, but because we’re going to augment the processes that are in place even without the president acting in the future. I would imagine that even if the president were in a coma, our CDC will do a better job in the future about activating everybody.
Just like the Special Intelligence Committee is briefing the Senate, or rather that our intelligence community briefs the senate through the special intelligence committee I think we’re going to have an apparatus where the state department briefs the senate regularly. I think we’re going to have the CDC and emergent microbial disease as something that becomes part of our national connection between the legislative and executive branch. That sort of heightened attention to it will not be left to Chris Murphy and others that sent aggressive letters, I think it’s going to become a bigger part of our general practice and I don’t think it’ll be as partisan as it is right now. Now I think republicans are understandably trying to be as quiet as they can without criticizing the president because it doesn’t seem to serve them that much, and democrats seem to be the only ones holding up the piece of paper saying “look I did this three months ago and nobody listened to me.” I think we’re going to see a huge change. I think meetings will be more like this, I think our world will be a very different world after this. I am worried that whole industries may be destroyed – I wonder about the movie industry, will we go back to seeing movies in the way we did? I enjoy going to movies, but now that they’re gone, will we ever go back? That’s not a small thing. Concerts, I imagine we’ll go back to them, but once we got through a 6-9 month gap without concerts there are some people that will probably say “I can listen to music, I can watch it online, I can watch a live show online, maybe I don’t have to go to a concert?” I think we’re going to be very changed.
BB: Recently a lot of people have been writing about how in some countries sometimes unsavory governments, for example in Hungary, have been using this crisis to quickly coalesce power. Do you see this being a problem in the United states?
HF: I worry about it, but I tend to be so naïve about this stuff that I follow rather than lead on this topic. I know about Orban in Hungary, and the situation in the Philippines—which has had a very bad outbreak—where an authoritarian leader can use this as an excuse to consolidate power. Russia now has a much bigger outbreak than they did a short while ago. I worry about that, and I worry about it in the United States, but at the end of the day, I’m a doctor from Brooklyn and a public health person, this is more of what I get from other people other than my own understanding.
BB: Do you think the atmosphere around scientific collaboration will change?
HF: This has been one of the best moments for the medical and healthcare research community. The amount of back and forth collaboration, the desire for us to learn from Italy, China, South Korea, and for them to be learning from us, I think is doing very well right now. There are always going to be concerns about how much we share with other countries that may not be our allies and things like that, but I think that’s one of the shining moments we have going on right now.
BB: Thank you so much for your time, I know this week was extremely busy for you, and I’m looking forward to future talks you may give back in New Haven.
HF: Thanks very much, good luck, take care.