When I was approached by the program committee to do a 90-minute lecture on this, I found every cell in my body saying, no, nobody wants to hear you talk for 90 minutes. So we devised this as a way of having those on the panel who will introduce themselves. We have a group of people who have varying degrees of experience historically and in terms of their own age, with either the AIDS and the COVID epidemic or just the COVID epidemic. And you'll see that the spread of our experience really has something to do with how we understand what we're going to be talking about today. So thank you for joining us today. I'm delighted that the group is larger than the panel itself. As the current pandemic wanes enough, and life seems to be returning to somewhat normal, we're going to be discussing the importance of psychiatry, understanding these pandemics in preparation for the next big one. And I don't mean earthquake. On a personal note, my career in psychiatry has been bookmarked, in a sense, by AIDS on one end and now COVID, not quite continuously bookmarked, but at least the tentative moment of pause in my career. I began seeing patients with AIDS in 1981 and probably even saw a patient with AIDS in 1980 as an intern here in San Francisco at Presbyterian California Pacific Medical Center at the time. And this was a patient who had a complete immune collapse, but had not yet been described as having this syndrome due to a virus that was yet to be determined. When I later learned more about the AIDS epidemic itself, in retrospect, it turned out that this particular patient fit the dynamics of the epidemic absolutely. Now, most people today living, or many people today living, have had both experience of the ravages of one or two epidemics in their lifetime. And so I want you to think carefully about your own experience, either in the experience of AIDS as a disease of the moment, or something that you learned about in your training or in terms of people that you knew. And all of you, I know, have been terribly affected by the COVID pandemic. And I would venture to say that we've yet to really understand the full meaning of that pandemic in our lives. We're just beginning to understand it biologically, really, and we are hardly fully aware of all of the ramifications of the impact it's had on our institutions. But let me remind you, we live in this biosphere of microorganisms. And we're essentially one social biosphere as well. You know, the world is really one globe in all senses of the word these days. Both air travel and now the internet, information, travel, communication, contact with people of varying cultures has been really changed dramatically over the last 50 years. I want you to remember that the bird flu epidemic of 1996 caused a great deal of concern about where would this lead? There have been two previous coronavirus epidemics, SARS in 2002, MERS in 2012. 2009 brought the swine flu and caused the slaughtering of literally millions of pigs. Out of fear that this would somehow jump into the human population. And in 2014, the Ebola outbreak that jumped the Atlantic and more recently is contained in Africa, but has had periodic episodic outbreaks among communities there. And there's a constant vigilance necessary to keep those outbreaks under control. 2015 and 16, we saw the Zika virus appear and more recently Mpox, which has been interestingly a pandemic that never got to be a pandemic. Fortunately, it was caught. People responded to it having learned so much from how it was transmitted and the possibilities of getting a handle on it before it caused major damage. I particularly am aware that in the Provincetown area, which is a very common place for GLPTQ people to travel to during the hot weather, there was a huge outbreak of Mpox. And that community that had lost a tremendous amount of its population during the AIDS crisis jumped on this and really settled it down and acted in a responsible public health way that was absolutely phenomenal. And it reminded me personally of what happened when we finally identified the AIDS pandemic. And it was the GLPTQ community and our allies, people who loved us, who rose to the occasion and took care of people when there was nothing to do but care for them. Since we had no medications, there was no way of stopping the pandemic except by changing human behaviors. RSV, respiratory syncytial virus, I don't know if any of you have been tested, but most of you probably have it lying dormant in your system. I went through a recent bout of it, although it was very, very mild, because I'm around people who had it. And the pediatric population experienced it as an explosion amongst its population. My brother, who's a pediatrician, took care of kids, and he got it because he was exposed to so many kids. Now, fortunately, they're coming out soon, I believe, working on at least a virus vaccine. And then, of course, you're all aware of viral hepatitis, smallpox, polio, all these. And COVID is nowhere out of the scene, okay? We are very quick to try to pretend that it's no longer a threat. But the true impact of these viruses and those that are about to come remain threats to life. Now, as you know, some viruses enter the CNS at the time of infection and can cause short- or long-term brain dysfunction, which I'll talk more about in a bit. But all of them have significant impacts on society, individuals, families, and institutions. It's now been 40 years since my patients have come to me with AIDS, and now they're being treated, they're surviving. But I am still processing the loss of literally hundreds of patients, some colleagues, and some friends who died of this virus that they got before they even knew it was out there to protect themselves from. My generation of gay men, about 50% were lost to the AIDS pandemic. 50% of men in my generation of gay men died from this epidemic. To most of you, well, to all of us, I think, the Spanish Flu of 1918 is but a note in history to those currently living because we didn't have any way of dealing with either the virus itself or the secondary consequences. Many of you were not around when the TB epidemic raged out of control and the threat to life and people's families. Measles, that you all take for granted, is not going to hurt you because you have a vaccine. And TB, the vaccines that have been developed to prevent secondary infections and so forth, we take for granted. But other epidemics have caused disease, death, and most important for our discussion is the healthcare inequities that have been highlighted and exacerbated by all of these pandemics. We realize this with the GLBTQ population that was sequestered off and thought to be problematic for the world because of the AIDS selectively attacking the people because of sexual transmission and then finally drug use. But these healthcare inequities really remind us of the shrinking world and the impact of zoonosis, which I'll say a little bit more about later. AIDS alone took more lives, think about this, AIDS alone took more lives than both world wars and is still taking hundreds of thousands of lives every year. This is not an ended pandemic. In examining both pandemics, there are similarities and differences that provide important knowledge about the neuropsychiatric syndromes of viral infections and cognitive and emotional responses to such threats in our world. What are those similarities? What are the differences? What has been the experience of the medical world in trying to manage and understand these pandemics as they've appeared on the scene? What's the implication for training, education during the different phases of these pandemics? For psychiatry specifically, what have we experienced as a mental health field and learned to help us really deal with pandemics continuing in less overt ways as we face the human impact and a climate change in a sense, trying to prepare for the next onslaught by the microscopic world in which we try to coexist. I'm going to recommend a book for all of you to read. It's enlightening, a little bit frightening. It's a story about the relationship of humans to microorganisms called Spillover and by David Quammen. It's a book that with your medical knowledge and training will have a lot of meaning for you to understand. You'll learn things that you didn't know. I've been studying HIV for 40 years and there are two chapters in there that I learned a great deal about AIDS. And a lot of it resonated with me in terms of what is my future obligation as a physician, as a psychiatrist about future epidemics. I currently still treat patients who have had HIV for decades. And for some of them, they're continuing to develop or just starting to develop neurocognitive sequela to having had the virus in their bodies for so many decades. The impact on brain function, as you all know, also carries with it enormous emotional responses. Each of our panelists will address their experiences with HIV and or COVID either as an experience with patients or academically. Each of them will give a very brief introduction of who they are, what the work is that they're doing, and really what these pandemics have meant to them professionally and personally. Just going down from afar, Ken has worked in the AIDS pandemic with me for a few years younger than me and has a direct experience with AIDS patients. Adjoa has a little bit more recently been involved with a lot of work around both the AIDS pandemic and its sequela, but also as an academic, really understand sort of how do we study this? What do we need to know? And Will has been graciously agreed as a medical student, who will tell you a little bit about what he's doing now. And we asked Will to join us as a medical student who has learned almost all of his medical education during the COVID pandemic. What does that mean? How do we understand what's going to happen with the next pandemic that's easily communicated? What do we have to prepare for training? As a former training director, recently former training director, I am aware that trying to understand, you know, who is it? It was Dean Gretzky who said, you don't shoot the puck to where the player is, you shoot the puck to where he's going to be. That's what we have to talk about. What should we be doing now to prepare for the future? We're going to give brief presentations and then I'm hoping to moderate a discussion amongst ourselves and hopefully you will bring up questions and topics, comments that you want to make. We really want to make this a town meeting in a sense, but we want to present some basic stuff to give us a platform on which to further the discussion. Could I ask somebody to close those back doors because it's a little distracting standing up here. So let me first, I'll ask Ken to come up and give you an introduction. So I'm Ken Ashley. I'm a CL psychiatrist at Mount Sinai Beth Israel in New York City. For the purpose of this talk, my most significant work right now is in the outpatient psych clinic and on the inpatient CL service where my outpatient panel is probably 80% patients with HIV, many of them who I've been seeing for at this point 20 years. Well, some of them, not many of them. And then some of the work I've done on the inpatient CL service during the pandemic seeing a large number of patients with COVID and what that's been like. So that being said, so I'm just going to cover some similarities, differences between HIV-AIDS from the 80s and COVID-19 in the 2020s. I actually did this presentation initially shortly after, well, not shortly after, but like in August, September of 2020. So when I was going back through the slides, it was interesting to see the changes that I had to make because of the changes that have happened since then. So no conflicts of interest. Picture the virus. Do people know which one is which? So COVID is blue, HIV is the red one. That's what they look like. So quickly, so what are some of the similarities of the virus? They're both easily communicable. They're communicable viruses. They could result in rapid death. Initially, there were no effective treatments, no vaccines for either of the viruses. They affect historically marginalized communities, and that was data that we certainly got later, certainly around COVID to see who was getting COVID and who died from COVID, more about who died from COVID, and we saw how that played out in terms of marginalized, historically marginalized communities. So they both exposed health inequities. Once again, that was significant. Once we started looking at the numbers with COVID, we kind of knew that fairly early on with HIV. There were significant fears among healthcare workers, manifesting in a variety of ways, and it may have also been tied a little bit to bias in healthcare workers about how that showed up. Healthcare workers wearing PPE. Certainly early in the HIV epidemic, there was lots of PPE and very full gown, spacesuit-y kind of things because people were very concerned about it. As we learned more about the virus, there was less of that. And then there were, of course, issues with access to care that were evident in both people with HIV, people with COVID, and the acquisition of COVID. So what are the differences? What are some of the differences? So as I mentioned earlier, the bias amongst healthcare workers, I think bias towards people with HIV was probably more significant than people with COVID, and we'll talk a little bit more about that later, about how I think that played out. The right of transmission and the ease of transmission was certainly very different. The effect on the body, we're still learning some of the effects of COVID on the body, but the effects on the body are different. And then one of the really big differences was the development of a vaccine for COVID, and there still is no vaccine for HIV, and that was certainly a topic of discussion amongst my patients with HIV, many of them who lived through the worst of the pandemic and are now going through the COVID pandemic and are kind of looking at it and wondering about, and I'll talk about it in the politics section as well, but the role of government and why did we get a vaccine for COVID and we still don't have one for HIV. The politics around COVID and HIV, and these are images from ACT UP. I think maybe it's from Grand Fury, which is one of the artistic arms of ACT UP, the AIDS Coalition to Unleash Power. Clearly the first one on your left is focusing on HIV, and then the one on the right is a riff on that, talking about COVID. what are some of the similarities? There was inaction by the government. Well, certainly there was inaction by the government early on with COVID, which kind of, as the pandemic continued, there was more activity, there was more action by the government. And certainly with HIV, there was the concern or the reality that it was related to lack of concern about the communities being most impacted. There was politicization of the virus, both situations. There's criminalization with the virus. There were travel bans put into place. Another similarity that I don't think people think about so much is that they both provided energy and support to social and health justice movements. I think HIV caused the LGBT community to rally around itself, finally realizing that there's no one that's gonna take care of us, so we're gonna have to take care of ourselves. Also, people who may have been able to be LGBTQ, but not necessarily have to share that. They could remain closeted, but once HIV came on the scene, these people were also getting infected with HIV. And so suddenly, what happened to the LGBT community became very important to them. I think with COVID, with the murder of George Flory happening at the time that it did, the fact that we've had COVID and people were not at work, it allowed them to focus on Black Lives Matter and other health equity and DEI issues. I think that certainly is one of the reasons we are seeing so much around DEI. Also, because of when people looked at the data around COVID and looked at who got it, who was unable to manage some of the things that were being recommended about how to avoid getting COVID because of the things that they needed to do because of structural inequities. I think people began to really realize that this really, DEI really is something that we do need to think about as physicians and look at structural issues. And so I think that was very, something that's kind of important that happened during COVID that might not have happened if it had not happened, if those two things didn't happen temporarily, if they didn't happen at the same time. So what are some of the differences? With COVID, we had stay-at-home orders, people were quarantined. And although there was some questioning of science around HIV, the questioning of science that was introduced in a very strange political way as a part of a political movement was not similar, was not the same with HIV. There was a lot of questioning of science, but not quite the way we have now began to question science. And now that has become so general in society that we are questioning science and authorities unlike recent history, I would say. And so then let's talk about some of the personal aspects of COVID versus HIV. So some of the similarities. So there are definitely recommended public health. Interventions to reduce risk of transmission, whether it be masks or condoms. Then of course, certainly some of these recommendations were politicized. There were shaming of behaviors that could contribute to the spread of the virus. There was very significant impact on the public psyche. And then there were mental health implications. We saw increased rates of depression and anxiety. Certainly a lot of isolation that were involved. A lot of loss, a lot of trauma. Patients of mine, both with COVID and HIV, are still talking about the loss and the trauma they experienced. Slightly different, I think, loss and trauma for healthcare providers was probably more significant during COVID than with HIV. But there was also some, if they were doing a lot of work around HIV, that was an issue. I think it was not as broad with COVID as it was because COVID impacted on so many more people in a larger way in the society. And then there are some differences. And once again, these are just some general thoughts I had and people can challenge me on any of them because as I read them and looked at them, I said, eh, some of these are a little questionable. I'm not so sure how definite they are. But HIV was associated with stigmatized groups. And I think there was more stigma associated with HIV than COVID. That may not, I don't know how, not always true, but I think in general, it's true. There may have been more discrimination against people with HIV than with COVID. But once again, not sure how strongly I am gonna put that out there. And then there was a disruption in public life, which I think was certainly more significant in a general way with HIV, I mean, with COVID than with HIV. And that is it. Just some brief ideas and thoughts. So something to think about. I'm happy to answer questions, have a discussion around some of those thoughts. Hello. So I'm Audra Smalls-Monte. I am both a physician and a scientist. I'm primarily at Columbia University and also a few other places. I have no conflicts of interest to disclose. So first I wanted with this presentation to talk to you about sort of what I did during the pandemic and then about observations I had and then how we as psychiatrists can move forward should another pandemic or other major illness come to affect us all. So as I explained before, I'm an emergency psychiatrist in New York City. I'm at Bellevue, Columbia, Boca Methodist Emergency Room. And prior to becoming a psychiatrist, I was an immunologist. I did a DPhil or PhD equivalent in pathology. And that was studying HIV. My research had vaccine implications. So I was basically looking at how the cells that typically fight bacterial infections like neutrophils, macrophages, natural killer cells, how they can be recruited by antibodies you produce to kill HIV infected cells. And this was a very novel concept at that time. About 10 years ago, this was thought to be possibly the method by which a vaccine could act based on some stage two trials of a vaccine at that time. As Ken mentioned, we don't have a vaccine right now. And that's for many reasons due to the nature of the HIV virus. But I went to medical school. I became a psychiatrist, but when the COVID pandemic hit, that really brought me back to thinking about infectious disease and how could I educate people about how to protect themselves. And when we got closer to around November, December 2020, when they were talking about a vaccine coming out and I started to hear a lot of people saying, I'm not sure I want this. And knowing I had for 10 years on research, trying to get a vaccine for a disease that I think most people would want to get a vaccine for, I thought, how can I contribute to educating the public about how helpful vaccines could be? So I approached ABC News. I worked with their medical unit as a consultant working to review their medical scripts that the anchors read and also writing several articles for them. And I still do work with them now. I also appeared as a on-air expert for Black News Channel. I did a lot of podcasts as well, talking about vaccines, their safety, their efficacy. And I think just the more and more people saw that I was writing, they would invite me to do community presentations about the vaccine, but also about the mental health effects. I would say earlier during the pandemic, I was talking about how do you get through this very stressful time? And then it became more, can you tell us more about this vaccine? Who is it helpful for? Who should avoid it? And then this culminated in me co-authoring a children's book called Anjali the Brave, all about vaccines last year, which I felt I needed to do because I had the opportunity to talk to adults, but not necessarily children. And I knew many adults that had gotten the vaccines themselves, but were nervous about giving it to their children. And I understand it's something new, but I felt that by writing this book and I hoped, and a lot of people have shared with me that it helped them feel more comfortable getting shots and the vaccine. So I want to talk to you about some of the mental health challenges I observed with the COVID pandemic and the HIV AIDS epidemic. First of all, both of these things caused fear in a lot of people when they came around. With COVID, you feared everyone. You didn't know who could make you sick. So everyone stayed at home as that was imposed by the government. There was a lot of anxiety about it. Will I get sick? Will I make somebody else sick? Especially if you were a younger person, maybe going to be around somebody that was older, that was more vulnerable. Everyone was physically isolated and this started to lead to a depression that we have seen skyrocket during this time, but was also increasing in the years prior to the COVID pandemic. So right now they estimate that about 29% of people have a lifetime episode of depression and maybe about 17% at one time in a recent Gallup poll. And the surgeon general just released an advisory about the loneliness epidemic that is also happening that further spurs depression. Michelle Obama even has disclosed during the early days of the pandemic, she felt, as she said, a little bit sad, a little bit depressed because of that isolation. It's very incredibly hard. And now we are dealing with a nationwide mental health crisis and adults, one might point to the opioid crisis, but there's also a youth mental health crisis. Again, the surgeon general put out an advisory. When it comes to HIV and AIDS, again, there was fear of others, but more so about a particular group of people. Primarily it was gay men when it was first happening because those were the individuals that were dying. There was a lot of anxiety and there was stigmatization of these individuals as well. So much so that, you know, you had a lot of isolation and one person that helped to decrease that stigma was Princess Diana, Mother Teresa, and them going out, holding hands, touching, meeting with people to help them realize, hey, this is, you don't need to isolate people. But I will say the difference between the COVID pandemic is that everyone was forced to be isolated from each other, whereas with HIV, AIDS, people were more so stigmatized, isolated as a result of fear. The incidence of depression in people that have HIV, AIDS is estimated to be about 33%, maybe more or less, depending on what continent you live on, but it doesn't correlate with a global rise in depression as the COVID pandemic did. And also with HIV, AIDS, while it did not spur a national mental health crisis, definitely a lot of people dealt with individual comorbid mental health issues. So through the COVID pandemic, HIV epidemic, the collective psyche of our world changed. The first thing I'll talk about is burnout. That was increasingly being recognized as a phenomenon, an issue with people. And I definitely heard about it a lot in the healthcare space because we were having new committees form while I was in residency in the mid 2020s, wow, or 2010s. And I was even on wellness committees advocating for wellness days. And during that time of the early COVID pandemic, about half of healthcare workers reported being burned out, but this was definitely increasing over the years. Another group of people that experienced a lot of burnout were caretakers. All of a sudden parents were being asked to be teachers, to also do their jobs, to also tend to the home where more people are there every day, all day, the place gets more messy. And so this led to a lot of stress for a lot of people. There were some people, maybe if you were single or young and didn't have too many responsibilities to other people, it was a time for you to actually take a break, to relax. But for a lot of people, their life became more stressful during this time. And as a result of that caretaker role, one group in particular that was impacted were women. There has been now a shift where people have said the pandemic almost shifted women 10 years back. And that they are leaving the workforce or left the workforce. There was a loss of jobs at 1.8 times the rate in females as opposed to males because of the nature of the jobs and because of the return to homemaker responsibilities. And also, not only was there a loss of jobs for women more so than men during this time, but also for everyone that was going through financial hardships. I think a new thing that happened in our psyche was thinking about how can I set myself up financially for future events that might completely cause disruption in my life. So you hear a lot more people talking about generational wealth, a lot of more people thinking about side hustles, entrepreneurship, whether that is starting their own practice, starting a cookie business, starting becoming social media influencers. More people are also thinking I need to have a backup in case something else happens. One good thing I do think that came out of the recognition of burnout among everyone was this idea of supporting yourself, help yourself in wellness. Lots of people were realizing they were under a lot of stress. So it was everyone should get therapy is now very common. So you have new agencies like Telkietree, Teladoc popping up that are expanding access to care. You also have more people focusing on self-care and trying to limit how and also wanting to impose more of a work-life balance. You have less people saying I'll push myself to the limit to attain this financial goal, which I think in moderation is a good thing for society and I hope continues. One thing I hope employers recognize is to be a little bit more flexible for employees during their jobs like they were during the pandemic to allow people to be able to work because I think we all figured out how to maximize our efficiency during this time. With regards to HIV AIDS, burnout was not so much of a thing thought about 30 years ago and it definitely wasn't something that we thought of universally. But it was recognized in health care workers, especially those working with patients that had HIV. The health care workers, there weren't a lot of studies that I found, but one study did show that health care workers felt a little bit more burned out, but they also felt more satisfaction and rewards with their job than their other colleagues that were not working with individuals with HIV. In the early epidemic, primarily gay men were affected with HIV and women in the LGBTQ community were offering help and resources. There wasn't so much help from the government like had mentioned you had to. That caused the community to galvanize and really help itself. And there were also financial and career consequences as a result of becoming very ill before there were medications that caused a loss of jobs. And in response to that, at least in states where I've been, there has been government support for people living with HIV that can help them with medications, housing, and other things if needed. And in terms of the psyche, I think during that time, because HIV affected only fewer people, not everyone as much, there was more of an attitude of let's help each other. So we all know the song That's What Friends Are For that was released by Dionne Warwick and Friends as a way to raise money for HIV, there was a big drive to cure AIDS and things like that. So I will say the two biggest changes is like there's more of a recognition of people are pushed to the limit. They need help. But now we're recognizing I need to help myself. I need to balance myself, whereas with HIV AIDS, it's more of a let's help each other other people, even though I may not be affected. In terms of physical health, I will mention that my residency director used to always say we are physicians. You are a physician first, meaning that if someone gets physically ill, you need to know how to stabilize them, triage them, because they will die of a physical illness before a mental one oftentimes. So when we are encountering people, I just want you to think back to the early days of the pandemic when you were still seeing patients, if you were, were you addressing protection and treatment with them at that time? I know for COVID, I would see patients in the emergency room and talk about, hey, still wear your mask here because most of the people that are here are here because they have COVID. But it's and trying to remind people of that. When we had vaccines available, again, I'm all about vaccines. I didn't remember to ask everyone, did you get a vaccine every single time that I came, they came in. But when I did and people had hesitancy, I used that as an opportunity to talk to people about the questions that they had about the vaccine. And if they were interested, try to get it for them in the hospital, but you'd be surprised by how challenging that could have, that was actually when you were admitted to the hospital. And then there are also long-term effects with COVID that we're going to be grappling with as psychiatrists in the days to come, in the years to come. There's long COVID that has been, that happens, you know, where you have symptoms four weeks after and beyond of having infection, brain fog, arthralgia, sleep disturbance. And those are things that we're going to have to learn to support our patients with. And you should also keep on your differential. When it comes to A's with the physical health and the work that I do now, I don't do too much counseling about protection. Maybe if I had young individuals that I see that are becoming sexually active pretty early, I might just check in with them, making sure that you're using protection. But it's not something that I do too much, but you should be prepared to do that as well. And then treatment, also talking to your patients that they disclosed this to you and their medical history, just encouraging them to deal with all aspects of their physical health. The long-term effects of HIV include HIV-associated neurocognitive disorders, HIV dementia. These are a little bit less common. And also AIDS. But as a physician, we definitely, while we're dealing with the mental health, you always want to check in with people that they're addressing their physical needs. And then to sum it up, there were a few things that I took away from my experience with the COVID pandemic, living through that sort of, when I was a teenager, the AIDS epidemic was really very, was at the top of people's minds, which got me to wanting to go into infectious disease research. So then seeing, kind of being in it in two different ways, there were two things that, a couple of things I took away. So one is, as a doctor, use each patient encounter to reinforce good physical health practices, even though we are mental health providers. You can always talk to people about that. And we're very well positioned to explore issues and hesitancies and fears that people might have that might prevent them from accessing treatment. The second thing is that the COVID pandemic, unlike the HIV epidemic, really affected everybody. So be sure to ask people how they're doing, I would say primarily at this time with socialization and with balance in their life. Because seriously, if there's one thing I could do as an emergency room psychiatrist, I would want to give, help people find friends, give people a hug. People are lonely out there and it just leads to so much depression, leads to them, I think sometimes coming into the hospital, seeking human connection like that really is going away in our society and the pandemic only caused that to accelerate. And then also with balance for people as well. And then the final thing I will say is that we are all doctors, very knowledgeable, very smart, and to maybe push yourself to go beyond your typical role in your clinical practice and trying to educate the public in whatever way that you feel comfortable, whether that is getting seminars to community groups, whether that is using social media, going through to traditional media and writing or appearing on TV in different ways. That we really do have a voice, things to say. Other people are saying things, sometimes correctly, sometimes incorrectly. So we should let our voices be heard. Thank you. Hey, guys, good to be here with you and I'm really excited to share this debate with my co-panelists and I'm excited and thank you all for being here today. So to kind of round off the panel, I'm going to talk about three things. I'm going to talk about my experience in medical education during the pandemic, some challenges that were kind of posed to everyone, but especially to medical students through that experience. And then lastly, where do we go from here and like opportunities as I see it and I welcome I'll lend myself to the experience of my co-panelists and open to other thoughts at the end of it. So just to kind of talk through the how I experienced the pandemic, I'm at LSU School of Medicine in New Orleans. Great place, great city. I had just moved there in 2019. I've been in Louisiana my whole life, but then I got to New Orleans. It's kind of relatively the big city in Louisiana. And so in the fall of 2019, we were still in person doing preclinicals. We had the traditional medical education that a lot of folks are probably used to, you know, going in person in classes. And then by the second semester, you stop going to class. But in the second semester, COVID hit also, and that kind of prompted a mass evacuation from traditional teaching. And New Orleans in particular, we had Mardi Gras. I don't know. Anybody been to Mardi Gras in this room? Yeah, there we go. So in most years, it's a great experience, a great cultural experience. But in a year where we have a contagious pandemic, there's not a lot of opportunity for social distancing. And so on top of the global pandemic, we had to deal with it regionally in New Orleans and had to deal with the fallout of Mardi Gras as a jump starter for the pandemic. And so there's the public health background that was the public health department was mobilizing at the time when they were sidelining us as medical students. So we were kicked out of the clinics. We had to go on to Zoom platforms for our education. And it was a really hard transition because a lot of the faculty, and LSU in particular, they had already pre-recorded a lot of lectures and stuff. So the teaching modality was preserved in many ways, but it was still hard. There was a lot of isolation. There was a lot of, you know, we had just gotten to know each other in the fall, our classmates, but then the camaraderie kind of fell down as we weren't able to convene with one another. And so that took its toll among my classmates. I think another area where this started picking up was, you know, this went through up until through my second year, and then we got the vaccines in 2021. And so that's when they started, in LSU's context, and I know this happened in many other places, they started getting medical students off the sidelines to start giving out vaccines. We were partnered with the New Orleans Department of Health and other adjacent organizations to start putting shots in arms at LSU. And so in that way, it taught me kind of a, everyone got kind of a boots on the ground knowledge of public health practice in medical school. A lot of people became very passionate about sharing the information about the vaccines, combating misinformation. There was a lot of passion amongst my classmates. I know that's typical for many other places across the country. Me and myself, we helped organize an organization called Crew to Flu, keeping with the New Orleans theme, which spread it, you know, handed out public health information, education, signing up people for vaccination appointments and stuff. And I think another thing that was coinciding that my co-panelists brought up was, you know, the murder of George Floyd and a lot of awareness of racial inequities and just kind of a lot of compounding factors that resulted in the uprisings we saw in 2020 and 2021. And so thinking about that, equity was top of mind for Crew to Flu in a lot of ways. So we started translating public health materials into Spanish, Arabic, Vietnamese and stuff, and really trying to center those things. And I think that's something that's created a sea change for medical students especially, because I think there's a greater awareness of these things in today's medical graduates than, you know, I think there's a galvanization in that regard. And I think the last thing is the role of social media became kind of apparent. There's a lot of younger physicians and a lot of medical students are very aware of how platforms like Facebook, Instagram, TikTok are catalysts for the spread of information, both misinformation and, you know, true information, like traditional health information, excuse me. And so I think that's created a lot of savviness, like Ajwa mentioned, you know, using social media as a platform through the pandemic to spread awareness and to get patients involved was one part of the important part of the experience. So what are the challenges that arose out of that? There has been dire public health, mental health effects on the public. We've seen, like Ajwa mentioned, there have been greater rates of depression that we've seen throughout both pandemics. I think, as I previously mentioned also, there's been a greater awareness of social inequities. And to kind of tie it back to the HIV pandemic, I want to quote Jonathan Mann, who was the World Health Organization researcher for HIV and AIDS back in the 80s. I was going to try and say something a little bit clever, but he said it all. He said, to put it simply, if you can identify who is marginalized, discriminated against, and stigmatized within each society today, you can predict who will be most affected by the pandemic in 10 years. It will concentrate among people who, before HIV arrived, were in a situation where their rights were less realized and their dignity less respected. And I think that's a through line between both HIV and COVID, where we saw populations who were black and brown, who were incarcerated, whose rights were less respected in today's society have faced the brunt of the pandemic. I think the social awareness of mental health is another, both a challenge and an opportunity. I think we have a lot of TikToks about neurodivergence and ADHD and these kind of things that have kind of coincided with the pandemic that I think it's up to today's psychiatrists to be on top of, to really be abreast of that and make a conversation starter. Because people are asking about it. They're asking about depression. They're asking about anxiety. And I see it, especially among medical students themselves. And to bring it into medical students themselves, there was a psychological toll. Like I mentioned, there was isolation experienced by medical students. And we were kind of the guinea pigs for how do you teach medicine and how do you teach psychiatry during a pandemic? And I think the lessons learned were that the future will be hybrid. There will be a balance between the in-person psychiatry, but also I think the rise of Zoom and these telemedicine platforms will really be a part of the future. And then another lesson we learned is that health is political. Like I mentioned earlier, like the effects of the pandemic will, pandemics typically are litmus tests for social inequality. And I think as part of medical education, we need to stop shying away from thinking that medicine is apolitical and that having a curriculum that addresses the political realities and how we can organize as a profession to address them is essential. And then lastly, a workforce, a healthy physician workforce, a healthy psychiatric workforce is pandemic preparedness. I think we see that a lot of the drivers of burnout are feeling like you don't control where you work. You feel like you're kind of being struck. You're put in a position where you can't do your best work. And I think some of these responses have been in organizing workplaces through unions. They've also been through raising awareness about the conditions of the healthcare workforce through social media and things like that. I think that's part of the future as well, is really mastering the different modalities that psychiatrists will have available to them to spread awareness of their profession and of the content of that profession they're in. That's all I got. Thank you guys for listening. I appreciate you. Okay. We've taken you through a lot of information and also I think some observations that are worth really thinking about long-term. Let me ask the panel first to, in looking at the question of what's happened, what have we learned, but what's next? Where do we go? I think you've raised several different questions about knowledge, but there are two things that strike me. One is that the role of psychiatrists as physician scientists and mental health providers is going to be increasingly important that what we need to retain as we enter psychiatric training is the medical understanding of illness, not just from a biological perspective, but from a public health perspective and a social perspective. How are we going to do all this in the short years of training? As a training director, it always seemed to me one of the crises was how do you get it all in four years and do it well so that it's not just superficial training? The other part is you've mentioned the workplace and the burnout. It is very common for institutions, there's an old saying that you can love an institution, but it doesn't love you back. Institutions do not have a moral center. They have whatever center runs them. It can be financial, it can be legal, whatever, but so much of the moral burnout, the burnout that people feel is placed on their shoulders. If you knew how to work better, if you knew how to do this, you wouldn't burn out. As opposed to thinking about burnout as a systemic problem where everybody's treated the same regardless of whether you're seeing acute psychotic patients or people in a long-term outpatient setting, we have different ways of conceptualizing diagnoses, treatment outcomes. In the COVID epidemic particularly, where there weren't enough nurses and the nurses were asked to do superhuman tasks without a recognition from the system that it would cause this kind of burnout, but you all watched that, either participated in it as an observer or working on the wards or something. How would you talk a little bit about your reaction to this moral injury that we saw in all of our healthcare providers? Let me just ask you to make some comments on that. I want you to think about questions and comments you want to make, and we'll get to those in a moment. Any thoughts? Let's take a stab at this. On both those questions? Whatever one strikes you. The one thing that I found interesting, and I know it's because of my training, I'm a NACL psychiatrist. I was co-located in an HIV clinic for many years, and so when I worked with my trainees, one of the things that we would talk about in supervision is like, oh, did you ask them if they had the vaccine? They're like, well, no. As part of your treatment of your patients, you want to be talking about all of their healthcare, all the things they're engaged in, and so you need to be asking them if they've gotten the vaccine. I mean, subsequently later, it was kind of listed in their chart, but it's like, ask them if they had the vaccine. You can look on the side and see, have they gotten the vaccine? Have they gotten their boosters? Have they gotten the bivalent? I mean, these are things you should be talking with your patients about, because they're going to be looking to you as their physician for some answers, I mean, and even though you're a psychiatrist, you can talk to them about the vaccine, and they may even want to talk to you more than they will with their other providers who have like five or ten minutes to like get them in, get them out for their medical visit, so just doing some general healthcare. I mean, once again, I ran over their hypertension, you're taking your meds, or your diabetes, you're following your diet. Just some general medical things that we as physicians should be doing, and so trying to encourage my trainees to be aware of all the health behaviors that their patients are engaging them and having discussions about them, and certainly talking about COVID was one of the ways I talked to them about that, but a whole host of other things, which I think is really important for us to do as psychiatrists, because, and once again, we probably see our patients more frequently than any of their other healthcare providers, and so they often have a more intimate or a closer bond with us than some of their other clinicians because they just see us more often, and they look to us as someone in some ways that they trust more than their other clinicians, not always so sure about that, but it was very interesting that trying to push them into that space, there was sometimes some resistance. So I don't know what people's experiences have been like or what their thoughts are about that. You know, it is our lane to be in as well. I know some people are like, oh, it's not our lane, but just thinking about what other people do that, what their experience has been like with that, and the panel as well. I'm actually curious as to people that work in an outpatient setting, how they found themselves addressing physical illnesses that their patients have, because we're both in the hospital, so it's very much in our face, but did anyone work in an outpatient clinic and find themselves reflecting or talking with their patients about it? But I'm seeing them outpatient, generally. Oh, you are? Oh, okay. Yeah, so these are my outpatients. I mean, inpatients, I think it's much more present, but I'm doing it with talking about when my residents are seeing their patients in the psych clinic or when I'm seeing my patients in the psych clinic. Oh, okay. What about the moral injury issue, which I think you all have worked so hard, and you've had to manage this whole question of watching the pandemics, watching your fellow, you know, your colleagues suffer, deal, and take care of patients without the time to really process their own responses. You know, as psychiatrists, we particularly pay attention to our countertransference and how we manage things like loss and grief. We watched patients die who we didn't expect to. We watched families trying to survive the death of people that they never thought would die of a viral infection like this. And it brings, for me at least, up a lot of unresolved, undiscussed, unmetabolized grief from patients from the HIV pandemic. You know, I had patients I lost, colleagues I lost, people I was concerned about whether they would put themselves at risk or not, and how do we carry all that and still try to find a place to take care of patients without feeling ourselves burned out by the process? So really, I don't think there's an answer to it, but I think how do we model the question of being, in some ways, more vulnerable than we are taught in medical school to be about this? And I venture to say it's the unusual faculty member who sits you down and talks to you about being vulnerable in moments of loss. I think you have to ask yourself what is the limit that you're willing to go to and recognize at certain points in our lives that we will have to go to our limits, but as long as you're going to your limit and not past it, then that is one way to maybe preempt getting to a point of exhaustion and then not being able to do anything or feeling resentment against the system. So I think for myself, I know where I worked, we had a lot of moonlighters that covered on weekends that were now lost and not able to cover on weekends because they were needed to work in their hospitals, and their hospital put a restriction on them being able to work somebody's house. So that left three of us primarily working every weekend for the first couple of months to deal with a pandemic, and that was a very exhausting time. But I think as healthcare workers, we feel like we don't want to see anyone suffer. So I knew, I think in my head, we all expected it to be a couple of months, I knew I was doing something to help people, and that was what I could do to help people be better. But you know, where I was concerned for other people, I have other family members that are in the healthcare setting, they're older, I said, hey, if you don't have to do so many of those type of shifts, I'd be okay with that, I'd be happy, because I was really concerned for their safety. I felt a little bit more secure just because of the demographics that COVID was affecting, putting myself at risk, but I think that's how I dealt with maybe having to fill in and work more than I typically would. You know, this, healthcare providers are a school to put other people first, and to take care of people, even in dangerous, it's stunning to me how in the middle of pandemics, people rush in to take care of people who are suffering. That's our moral prerogative, that's our moral stance. It comes with the notion of what does it mean to minister, to doctor, so forth. But I think what's missing is how do we get to that balance? When do we say, I need a break? When is it okay to admit that you are just human yourself? Well, I'm going to put you on the spot for a minute. Is there any talk about that in your training so far? I'll say we had a few sessions on mindfulness and checking in with ourselves and emotional well-being, and I think to summarize a collective sentiment about that is, you know, burnout is a synonym for exploitation in many cases, and I think that when you start shifting the onus on to people who are naturally caring and who make it their profession to take care of one another, when you start leveraging that to task shift on to them, all these extra burdens of grief and loss, and without helping them metabolize it, like you say, I think that that's a recipe for exploitation, and I mean, it's really leaning on people to fix the problem themselves instead of coming together, organizing to make a solution that takes the load off of everyone collectively, and I think that that's kind of where I see a lot of medical students who are going into residency thinking about it, it's like, you know, will this place take care of me, or am I going to have to take care of myself at this place, and you can lean on your colleagues, but I think when you go from like, I can lean on my colleagues to like, hey, no one deserves to have to deal with this in this situation, and the situation that, it just requires a lot of rethinking about how we organize at workplaces and stuff, but medical education does not teach you that. You know, I don't know how many of you are aware that the number of people going into psychiatry from medical school has increased by 10% each year for the last few years, and nobody really understands that completely, but there's some hypotheses that it has something to do with the lifestyle, the ability to have some time for a life. The emergency room residencies have not filled this year. That's really scary for those of us who sometimes think, what if I ended up in the emergency room, who would be there? And of course, when psychiatrists are in such short supply and great demand, it scares people to think about what kind of work can I do as a psychiatrist? Can I stay in a system that is going to potentially exploit me versus honor me for what I can do, but what I can't do is okay? There's a kind of survivor's guilt of trying to cope with things that you can survive for a while, and then the burnout is about the system just refusing to pay attention to you. Survivor's guilt is something we knew from the AIDS epidemic, patients who had survivor's guilt, and frankly, my colleagues and I talked about our own survivor's guilt at various times and how it affected the work we did with patients and whether it helped us to really hear what people were saying. Well, you said something, and Andre, you actually talked about this, too, is some of what was most important in your work, understanding, was this notion of connection, of when you started medical school, you made contact, and then it was sort of broken, and you held on to some of that belief that these people would still be part of your life. And you all know as psychiatrists that attachments, whether they're brief and momentary, you know, the hug you're talking about giving in the emergency room lasts a long time. It's not just, you know, there's a residue of attachment that stays with patients that make the statement to the patient, I matter to someone. And I don't think we give that enough credit for creating a system in which we're allowed to have that kind of, even fleeting attachments, connections with people that really help to break what has become this epidemic of loneliness and isolation in our society. The World Health Organization has called loneliness one of the major threats to mental health in this world. Loneliness. Now, that's different than being alone, okay? And we want to make sure that we think about that as psychiatrists. What does it mean to help people not feel lonely? And how do we, what's the limit? What's our capacity to enter into that? I want to thank our panel because they're here, they're going to continue to talk with us, but I want to make sure that for those of you who have thoughts or questions you want to share with us, that we start with that and we'll come back to some of these things. Don't be shy. I'll take this one. So I, in a variety of spaces, I'm working on some social determinants of mental health, doing some work around that. So actually at our institution, I don't know who uses Epic EMR, but there is a social determinants of health little thing. And so in our clinic, they have instituted, they're asking everyone to actually do certain basic needs questions. And they've actually given us material to give to patients if they score, if they have issues around certain things. Like if they talk about food insecurity, we have lists of food pantries and resources for food. If they have housing issues, we have resources for that. So this idea of things you didn't want to talk about because you just couldn't leave, there's nothing I can do. The idea of actually having maybe something to do. So bringing up the questions, having a discussion with your patients about what basic needs they have, but also having something tangible to give them. It just opens up the conversation and gives you something to give them. Hopefully they will find some benefit from it. I'm not sure that they will, but I mean, that's something that one can do so you don't feel overwhelmed by the vastness of the need. I mean, housing in San Francisco, housing in, but there are some options, at least in New York, to discuss with your patients. And so having the discussion and having some resources is a place to start. I think you're asking another kind of question, which is what's the responsibility of a healthcare system to provide services that are really an economic, social structure? And how do we get other institutions that have money and power to take some of that burden? Because otherwise, you end up carrying that sense of failing the patient if you can't, I mean, should we give them money for cab fare? Should we give them money to go buy food if they're hungry? Because I think, again, that moral injury is that we should be able to take away suffering and pain. But if they're anxious, we know how to treat anxiety. If they're hungry, what do we do as clinicians, as people who are healthcare providers? How do we get to the system to hear that message? What's our role of advocacy as clinicians? And where does it stop? Where can we say, I've done what I can do, and I can't take responsibility for a system that refuses to hear? Now, that doesn't mean that you can carry the consequences of that without a great deal of emotional vulnerability. And that's the guilt, I think, that ends up feeling like, can I stay doing what I'm doing? You know, I talked to a couple of friends who are nurses, and they say, you know, just knowing that you're going home and somebody did not get some major issue addressed makes me afraid to go back the next day. You know, when I was a resident, at that time, AIDS patients were being isolated in the hospital. People were gowning and gloving to go into their room to talk to them. Housekeeping wasn't going in to clean the rooms. They'd clean the front part of the door. The dietary people would leave trays full of food outside the door to be taken in by somebody, who? And when I went in, you know, having studied what we knew at that time, my attitude was, this is a sexually transmitted virus. All of the evidence showed it was not casually transmitted, or by the time the cases were described, there'd be millions of them, like COVID. It didn't spread like a viral infection, that it was easily communicated. So I would pick up the tray, go in to the patient's room, sit on the chair, and talk to the patient. And the gratefulness that a patient had for us to do that was the reward itself, I have to tell you. But I couldn't solve the whole process of the system, and I couldn't go around feeding, picking up all the trays and feeding all the patients. But the fear that I saw in my colleagues, which was unnecessary fear, as opposed to COVID, which was an appropriate concern and fear for one's safety, and whether there was enough PPE, personal protection equipment, to do the correct kind of care, were all these conflicts that we were facing. Larry, were you going to say something? No? Then, I mean. Okay. Other thoughts, questions? How are you feeling about what you've learned today, in terms of what does it mean for you as clinicians, providers? What about this work we do? Where should psychiatry fit into this whole pandemic question? Anybody? Panel? Audience? I don't know that there's an answer, but I'm curious about how people are processing the questions we're facing today. Well, I'll mention that as psychiatrists, when we're doing therapy with people, we're helping them to understand themselves, be introspective, and we're also providing information. And I think when another pandemic, virus, great medical illness comes along, or even health issues that people have, we can also translate that, not only from their feelings and their behaviors, but also translate that into how they act around physical illnesses as well. So that's what I feel our major role is, and that's how I felt I was talking to people, having to be mindful not to really interject my opinion so strongly, like, you have to get this vaccine, but more so, why are you nervous about it? Why don't you want to get this? And even every day when we're talking about medications that people should, we think people should take to alleviate their conditions, it's sort of really trying to understand why first, and then trying to then provide them with the best knowledge. And then you are also saying, look, in my professional opinion, I have training in this, this is what I really feel is good for you based on all the medical information and facts, which are now being discounted, but you can put that rubber stamp on it at the very end. But trying to help them work through their understanding of it, I think, is something we can do with most issues that people are dealing with, social, mental, physical. So how do we prepare for the next one? What are your thoughts about, most of us will be around, the next one's not that far off. There's inclinations that with climate change and the movement of people around the globe much more quickly now again, that once COVID is thought to be on the wane, people are sort of making up for lost time and getting to places they wanted to get to. So let's assume in two, three, four years, we're going to see a major pandemic again. We don't know how it's going to be transmitted. But it's likely it's going to be one of those routes of transmission we've talked about today. What should we be doing now individually as psychiatrists? And what should we be doing as a field of psychiatry to be prepared for what we already know is an overwhelming mental health need from these pandemics that are still in our midst? What kind of resources do you think we should look forward to? Again, thinking about Wayne Gretzky and the puck, you know, where should we be shooting? Where is the next place that we're going to find ourselves waiting for something to happen? Yeah, please. Everybody hear that at all? So there's a bill pending to increase the number of residency positions, not just in psychiatry, but across specialties. And let's say that they increase it by 20%. That's a drop in the bucket for the need that we already have, okay? What, so yeah, I think it's an indication that someone is hearing we gotta do something, but who's talking to the people on the ground asking what do you need? What should an institution be doing to prepare its current workforce? And how do we recruit into the workforce? I went to another workshop before which had to do with how do we provide culturally and racially matched providers? We're never going to have enough people of color or different ethnicities to match up patient with provider perfectly. It's never gonna be possible given how things are structured in our culture. But how do we then prepare? How do we, should we be spending more time in training and in professional CME development thinking about, instead of just neuroscience stuff, should we be thinking about how do we prepare to deal with people who are very different from ourselves? And what would that training look like? Yeah, go ahead, Will. This is something I've been thinking a lot about. In 2020, Don Berwick wrote a great piece in JAMA called The Moral Determinants of Health. I highly recommend it. Everyone go back and read it when you get a chance. He makes a really astute observation where he says modern medicine today is kind of like the repair shop of our country where we kind of take a lot of things downstream of the social determinants and then we're asked to do our best with it. I really think, to reflect on another inspirational physician, Rudolf Verkau, who said physicians are the natural advocates of the poor and the dispossessed. And so taking those two things together tells me that it's gonna require the truly pandemic-prepared healthcare workforce will have to go beyond, in some ways, its traditional hospital walls. It has to organize with patients. And it has to really, health equity is a pandemic preparedness. When you really think about who's really gonna be affected in both HIV and COVID, it's gonna be, like Robert Mann said, it's gonna be the people who are most oppressed, most marginalized. And so I think when I'm thinking about the next one, which is probably gonna be a flu virus, if my money's right, I would focus on those. I would focus on organizing with patients who don't have as much protections. And it can be hard, right? Because to your point earlier, what are we supposed to do with this? Call social work? And so it really comes down to changing the conditions, intercepting the political determinants of health that are causing the downstream structure of the social determinants of health. And that can be uncomfortable because we're not really taught that, right? We're not really, it's something that comes with, I think, hopefully comes with experience. I hope I'll find it comes with experience. But I think it's necessary to really make the kinds of changes that will be needed so that there isn't such a great and preventable loss of health and life and mental well-being. That's a great point. Would you say the source of that talk, of that information again? It was, who was it? It was Don Berwick in JAMA 2020. It was the moral determinants of health. Okay. Oh, yeah, go ahead. where is this now again South Jersey how is that funded okay so this is a grant to help support if I'm hearing you right kind of community educators who can go around and be in the community like the barefoot nurses of Africa who do a lot of the work we were talking this morning a couple of us about the need to have a peer-to-peer education for teenagers who have themselves dealt with depression and suicidality to be very present in the lives of other kids who are struggling with the same thing we're facing also another epidemic of scientific disbelief that who we are as physicians has been devalued now by politicians you know for the first time all of the gains we've made in LGBTQ rights as now suddenly educators and and physicians no longer know anything about how to take care of kids or people but legislators magically overnight developed a medical education and knowledge about how to take care of people and what we can't and shouldn't do for kids who are trans for kids who were gay and how do we combat that as a profession what is the role you know you have a you you publicly speak you write about these things should every psychiatrist be educated in how to take a position as an advocate in the political world you know because it's getting more and more split between those people who believe in science and I mean Anthony Fauci to be devalued as a scientist after a lifetime of work I I met Tony when he was in the beginning of the AIDS epidemic he was just helping out at CDC and then on my NIH he's an extraordinarily loving guy wonderful giving person who didn't deserve any of the stuff that he was thrown at him and he survived by sticking it out you know by just logging through it but nobody deserves to be treated like that with the level of knowledge and commitment that he's demonstrated year after year of the year but yeah go ahead I mean I think we've talked a little but I mean it's once again stepping outside of a role is just being physicians but also being advocates and you know whether it be speaking on TV or writing a book or going to your legislature or but all these spaces that we are able to do advocacy because once again this is we can't write a prescription for it these are things that are often systemic and we have to work on trying to change the system which sounds overwhelming and feels overwhelming at times but you know it's giving a lecture it's talking to be going to the communities talking to people it's just a lot of advocacy work in any space that one feels comfortable doing a lot of organization and APA offers advocacy trainings and so a lot of I think a lot of institutions are now learning that this is a space they need to be in I know I think a lot of medical students are calling for this now because they want to be engaged they people have seen what happened with COVID and recognizing that DEI is important and social determinants of health are important people are trying to figure out how can we get in a space that we can make some changes and it's going to involve advocacy As in they say, I should be getting help by this or that or I've tried this and it failed? From which angle? I guess I always ask people exactly what do you need done, or what do you need help with? Who do you expect to help you with that? And if people can help me identify that, then again, I'm in the emergency room, so I'm seeing you for 20, 30 minutes, and that's it. But helping people really pinpoint what is the key thing that they need, who is the key person that can help them out. I think sometimes when you talk with patients, sometimes you'll realize, yes, there is someone that can only help me with this, and I need to work with them. Sometimes patients will realize, no, I actually, or you help a patient realize that they also need to take some more initiative or responsibility for doing certain things as well. So I think it's just really trying to get to the exact specific need, because a lot of people always point to just kind of general things, but it's like, what is the one thing that's causing you not to get it? Similar to what Adwoa said, you're working with them, trying to understand what their needs are. Sometimes it helps knowing what resources are available, but also, once again, helping them take some responsibility for making some of the changes that they're looking for in their lives, if possible. Because a lot of times it's like, oh, I didn't know that, so now I'm going to give you five numbers to call. Call them. Next visit, we'll talk about the results of those phone calls, and we'll see what we can do about making some changes. Because I do think that we also have to empower people to do things. I live in New York. There are a lot of resources for people. But you have to take some initiative, because you're going to have to keep sustaining those behaviors in order to get to the end of what you want. It's not just when you come to the emergency room, you have this and that's it. So one thing where I find it kind of challenging is we'll say, oh, we found a rehab that you can go to, but literally you have to pick up the phone on the wall, and you have to call them and speak to them, because they need to hear from you. I can't just put in the referral and it's all done. And it's sad for me to even see for patients where that's almost too much for them. So I think I have to balance kind of helping giving people the resources, but in a very brief visit, trying to encourage them to take some ownership without being too condescending as well. In the early days of the AIDS pandemic, I'm talking about in the early, mid-80s, we started a clinic at Cambridge Hospital called the HIV Clinic. And it started off as a single three-hour clinic on a Friday afternoon, and within four months became five days a week of a full-day clinic. One of my former chief residents in that clinic is actually with us today. And I think what's important, we learned something very, very important. We had a waiting room that became a daycare center. The patients mobilized each other in ways that we couldn't as providers do. They began to see, while they were waiting to see their provider, that they could learn from each other how to get food, how to find housing, how to, as one of them said, beat the system. And it taught me a lot about how we tend to think that our patients are helpless, and we collude with that, because many of them have felt helpless. They have felt isolated, and they have felt incompetent to make changes in their lives. So one of our tasks, which is appropriate for us as psychotherapists, clinicians, psychiatrists, is to, how do we mobilize patients to help take care of themselves? Now, they can't go out and build apartments, obviously, but they can work together to think about, is there a way for them to live together with other people? What would it be like? Instead of trying to find a single room, can they think about sharing a room? And what would that mean psychologically for them? How do we help them process, how to break through this loneliness? Because a lot of it's the isolation and the loneliness that helps them to feel helpless. But I think it's a way to think about how we treat them. What is it that we're actually helping them learn? Go ahead, Audra. And just to go back to answer your question, what's the way that we can help prepare for the next pandemic? I think everyone has talked about it, but dealing with the social determinants of health, I think whatever we feel comfortable with doing, whether that is talking to our legislators, whether that is working with a program within our own health care system to help address those things, I think that some of those things will have to be addressed, and some of those are very economic. In the health care system, we're not trained to do that. That literally is not our job to do. And we really have to hold other people's feet to the fire about trying to find solutions for that, whether that's in Congress, state legislatures, businesses, to really help with the economic things, even in the education system, helping people to understand how they can understand their health information is important. And the second thing I think we can do to help prepare for the next pandemic is what you said about the isolation and being alone. I really see that as being one of the number one drivers for why there is so much distrust of people, the others, the loneliness that everyone feels. I'll take it a little bit biblical, but I always think of Adam, the first thing that he asked for was a partner in life. We are just humans. We're social creatures. We need other people. And what I see when people kind of give up on life and they just are completely disconnected and they're suicidal, the one thing that people always say is nobody will care if I'm gone or something. And just for me, that's when I am going to hospitalize you. It's not fear of something else happening to them. It's just that lack of connection. So I really feel that when you're connected to other people, it still motivates you even when you're in your hardest moments physically and emotionally. So we really have to figure out ways to build connections and trust among people. Thank you. Well, you've all been great in staying the whole thing and I appreciate it. We obviously have told you we don't have any answers, but we are very curious about where we go as a field from here. And we ask you to start thinking really about what you can do in your own way to contribute to the question of where should psychiatry be and what's next for us and what did we learn that we can carry forward. I want to thank our panelists, Dan, Adwoa, and Will, for providing a different perspective in each of their work lives so far. I think if you're right about the next flu vaccine, flu epidemic, maybe we should get more flu vaccines going. But that's way beyond my pay grade to talk about vaccine production. I want to thank you all again and hope that this conversation will continue wherever you are. But as I am prone to say, our time is up.

AIDS pandemic

COVID pandemic

psychiatry

future pandemics

neuropsychiatric syndromes

health equity

socio-political challenges

marginalized communities

holistic approach

public health

mental health support

pandemic preparedness