Public health played an indispensable role during the pandemic. And will again if, or when, the next one comes. But COVID gutted the profession. Cathy Bradley’s job, at least in part, is to help it recover.
Bradley is the Dean of the Colorado School of Public Health, which is comprised of CU, CSU, and UNC. She’s also deputy director of the University of Colorado Cancer Center and a health economist.
Read the interview
Editor’s note: This interview transcript has been edited for length and clarity.
This interview has been edited for clarity and brevity.
Ryan Warner: Public health in Colorado and nationwide is still bruised after almost five years of the pandemic. Where do you see that in Colorado?
Cathy Bradley: Oh, gosh. We've had a 40 percent exodus from our public health workforce. Burnout is something I hear often from our community.
Warner: What do you think is the source of the burnout? There were certainly political attacks on public health. There was absolutely the relentlessness of care during the pandemic. What are the sources, do you think?
Bradley: I think it's the burden that was placed on them and the amount of work they had to do when information was changing and changing quickly. The evidence that was coming out and how do they implement scientific findings and do what's best for the population, all at a time when things were being so divisive at the same time. We were talking about vaccines, not a political decision, but it became a political one and this is a workforce that's all about making the world a better place.
Warner: The pace of change of information during the pandemic was remarkable. Certainly, when you learn something about a new virus, you change behavior based on that. But there were any number of people who interpreted the pace of change of information and the changing understanding of protocols and things. They seemed to think that showed that the system didn't know what it was doing or was misguided or couldn't be trusted. Can you speak to that a little bit for me, Dean?
Bradley: Oh, of course. We want things to be a hundred percent certain, and then once we make a scientific proclamation, we want it to hold up. But over time, and then during the pandemic, it was a compressed amount of time, we changed practice based on scientific evidence. We were fortunate during that time that we had rapidly evolving evidence and had better outcomes. But you got to see it happen in such a compressed amount of time that it felt more like uncertainty rather than improving practice.
Warner: How do you think that affects decisions right now, for instance, over whether to get the new COVID shot?
Bradley: Oh, the way it probably affects decisions is that people may take a wait-and-see approach. Because they saw scientific evidence rapidly evolve and recommendations change over time, so one approach might be to be hesitant and say, "Well, let's see what happens." But I think we have moved past that point where we've been able to show efficacy and improvement and the benefit of being able to take a vaccine and feel pretty sure that it's going to help you.
Warner: I want to go back to the burnout. You said 40 percent of the public health workforce is gone, essentially. Where do they go? I mean, you say they're mission-driven, they want to change the world. Can you bring them back? Or is this a question of making sure that young people choose this career path?
Bradley: Yes, I would like to make sure that young people choose the career path because of the reward that comes with it. In terms of where they go, most likely they went into private nonprofit groups, they went into health systems. They went into areas that didn't have that public-facing component of what they do in the public health workforce.
Warner: Can you draw them back?
Bradley: I hope so. I think that opportunity always exists, and by creating a community and creating those supports, I think we can, and to draw new students.
Warner: Is there that interest in young people?
Bradley: There is that interest, but it's evolved as well. They're thinking about things like climate change and health, these emerging problems that are right in our backyard around wildfires, things that they can see. They want to change what's happening. And the health impacts that those environmental changes and climate change are having on individuals, they want to get in there and do part of it.
Warner: This is fascinating because if I see a fire burning, my thought is to put it out, right? But you're saying that there are young people whose lenses say this is a health issue.
Bradley: Right. Who say they can't go for a run today, who's thinking about long-term what that impact has on respiratory systems. Now, they may be mostly thinking, "I can't go for a run today, but boy, that might affect me long-term as well," and they're connecting those dots.
Warner: You, in fact, have mounted a climate health program under public health. No?
Bradley: We have. It is a one-of-its-kind PhD program that we launched this year with our first cohort of students and now taking applications for the second round.
Warner: What have you learned in getting that up and running, about public health?
Bradley: I'm an economist … and there's huge economic impacts, of course, of climate change. We think about human migration, we think about jobs, industries. But no, that wasn't something at the time that I went through my training that was top of mind. But now, in this next generation, that's one of the first and foremost things that they're thinking about. You asked what it is that I learned in that process, what I learned is, the demand is really out there. This is a brand-new program. It received the most hits of anything on our website.
Warner: It's fascinating that the School of Medicine, which is also on the Anschutz campus, has mounted a climate health program as well. So that tells me that this is a direction any number of institutions are headed. You wrote a piece recently for the Colorado Sun. It was titled Prevailing Myths About Public Health Hinder Advancements That Could Help Colorado. Where are we getting in our own way?
Bradley: I think where we're getting in our own way is not telling the stories, the compelling stories about the change that we make in public health and how we create environments for people to thrive.
Warner: So public health has a PR problem?
Bradley: Oh, for sure.
Warner: No hesitation there.
Bradley: No.
Warner: But if that's based on myths, what's a myth?
Bradley: I think there's a myth around the trade-off of personal freedoms for the good of public health, and not understanding what you're getting back and how you benefit so many other people. There was a time when putting on a seatbelt was seen as an infringement. That was our own decision. We could jump in our cars and take off. Whether or not we put a seatbelt on was up to us.
Warner: Helmet laws strike me this way too.
Bradley: Oh, gosh. Great example. And we have helmet recommendations around bike riding, motorcycles, seat belts. All of those actions, they're individual safety precautions, they're public health measures, but have a huge impact on whether or not you survive an accident, whether or not your child survives an accident. There was a time when little kids used to stand on the front seat in between their parents, and slamming on brakes would mean that they were likely to go through the windshield. We don't have that anymore. That's a big difference, and that's a generational change that comes with understanding the implications of your own actions. And then there are a lot of things that public health does that are invisible, as I wrote in that article as well, and those are things around your clean water. So that would be another myth that we're only around when it breaks. We're around keeping it working.
Warner: I suppose, to some extent, public health is taken for granted when it's doing its job.
Bradley: Absolutely. It is taken for granted, because it's not something that's in front of you at all times. You're not thinking that when you turned on your tap water and filled your coffee pot to get ready for the morning cup of joe, you're not questioning whether your water is safe or not because you assume those things are being cared for.
Warner: How does that affect funding for public health and, frankly, for schools of public health? One, the kind of invisibility to some extent, and two, any hurt feelings or sore spots after the pandemic.
Bradley: Yeah. Public health has historically been underfunded. We all know that if we put more money into prevention, we're going to get a bigger benefit, and yet we still seem to be a treatment-focused society. After the pandemic where there's some distrust, that infrastructure eroded I think further. We built up an infrastructure during the pandemic. We created data systems, so we could figure out where the virus was taking off in some places and other places under control. We've let that infrastructure slip. So the fact that we catch up to it two weeks later, is not as beneficial as if we have real-time information that we're able to track it.
Warner: You're the deputy director of the University of Colorado Cancer Center. Personally, I feel like I can't open Facebook or chat with a friend without hearing a personal cancer story these days. Certainly, on this program, we've covered the rise in colon cancer among young people. What would you like Coloradans to understand about cancer?
Bradley: First, there are many things you can do to prevent cancer, and colonoscopy is one of them, where you can detect polyps at a precancerous stage and effectively remove them. You can avoid the use of tobacco products, which we know is highly linked with the probability of developing cancer over the course of your lifespan. Sunscreen, exercise, your eating habits, those can all change. But there's also the entire impact on your life. So when you get a young person diagnosed with cancer, they're diagnosed during their working years, cancer now is an extremely expensive, if not the most expensive, disease to treat.
Warner: Oh, I'm hearing the health economist in you come out here.
Bradley: Oh, yes, you are.
Warner: But it's this notion of cancer, isn't it like the leading cause of medical bankruptcy these days?
Bradley: It is. It is the leading cause of medical bankruptcy, and that is on insured people. And that's something many people don't understand, that you can be insured and still file for medical bankruptcy, especially with a disease like cancer. That's because so many health insurance plans are high deductible plans, and nobody knows what their health insurance covers until they get sick. And that's true across the board. Suddenly you're diagnosed with this disease. It's going to require surgery, it's going to require chemotherapy. It may even require radiation. It may require an oral, new oral targeted therapy that you take for a long period of time. The cost of those drugs are astronomical. If you're in a high deductible plan, you're going to be paying a lot out of pocket.
Warner: And it may be over years.
Bradley: It may be over years. And your working age, you're employed, now you're diagnosed. Are you going to leave your job and risk losing your health insurance? No, absolutely not. You'll miss your chemotherapy before you jeopardize your job, because that's your health insurance. That's your source of health insurance as well as your income. And it has a downstream effect on your family, on those you insure with your employer-based policy, and the amount of money that you have to pay out for treatment. Families continue to be at an economic disadvantage six years later. So it's not just a treatment episode that sets a family on a path of having economic hardship long-term. It may be what determines whether your kids go to college or not.
This is also public health, by the way. These kinds of economic impacts and policies around health insurance, about the ability of a person to be able to work, what kind of workplace accommodations need to be in place, what kinds of insurance coverage we need and make sense in order to keep a healthy workforce going. Being able to detect cancer and treat it at an early stage is a wonderful advancement. It has changed the course, but if you can't pay for it, if you can't access it, what good has it done to you?
Warner: Wow. I've never looked at cancer through this lens before. You invoked tobacco use, a key driver of cancer for sure. Cigarette smoking is the leading cause of preventable death in the United States and in Colorado. In recent years, the industry has pivoted, they might say innovated, to other delivery systems like vaping. Now we have a sharp rise in this Zyn brand from Philip Morris of nicotine pouches that go between the gum and upper lip and absorb nicotine into the bloodstream. Industry maintains these newer products are safer than smoking and market them as helping adults quit. Now there's this idea of a Zyn plant in the works in Aurora, receiving government incentives to build there with the promise of jobs. Untangle that for us.
Bradley: This is a very short-term way of thinking. You're going to create some jobs and also set up a new generation of addicts by bringing kids in, because they can do it undetected, right? They can use these products undetected as opposed to if they were smoking. And that's something you can see and you can smell and parents can find out. This is a product that will draw in, I think, youth use and create a whole new generation of addicts.
Warner: You don't buy this sort of step down idea that this is a product that helps wean people.
Bradley: I don't know. In all fairness, I don't know whether that works or not. To me, the bigger concern is, let's not get them started to begin with, then we don't have to worry about step down. Let's not bring them into a new generation of people addicted to nicotine.
Warner: But I think there's a point that the front-end and the short-term economics versus the long-term economics you've laid out of a cancer diagnosis. I'm not sure I hear that as much in the public debate. I suspect you'd like it to be more prominent in these conversations publicly.
Bradley: Absolutely. People need to understand when they think about a cancer diagnosis, it's a long term (thing), it's a long way away, as opposed to something that can happen to you while you're working. And that while you're working and getting treatment, you're not going to be able to leave. You're going to trade off your health for your health insurance. And it's such a short-term way of thinking. The impact to society of all the jobs that will be lost, all the days that will be missed, all of the people that will be out of the workforce because of addiction to tobacco and getting a cancer diagnosis is not worth the short-term benefit of those that will be employed. There are other ways to employ people that enhance their health and public health and well-being.
