United States Public Health Service Offers Unique Ways to Tackle Public Health

Christina Madison, PharmD, BCACP, AAHIVP: Hello, everyone, and welcome to another episode of Public Health Matters with me, your host, Dr. Christina Madison, also known as the Public Health Pharmacist. We're so excited today to have another incredible guest as part of the Pharmacy Times Pharmacy Focus podcast series. So, I could not be more excited to get this incredible, award winning, incredible credentials, amazing pharmacist. As you can see, I'm like, basically verklempt because this person is someone who I admire and am so grateful for her time because she is off saving the world. And as you can see, she is in her—would this be considered your full uniform today, Dr. Lind?

Cmdr. Jennifer N. Lind, PharmD, MPH, MBA: Yep, exactly.

Christina Madison, PharmD, BCACP, AAHIVP: So, again, as this is Women's History Month, I am thrilled to bring Dr. Jennifer Lind in all the way from the CDC. And we are going to dive into some questions, but before that, I'm going to go ahead and let Dr. Lind introduce herself.

Cmdr. Jennifer N. Lind, PharmD, MPH, MBA: Hello, hello. And thank you so much. It is an honor to be on the podcast with you, Dr. Madison. You know, [I feel] likewise and admire so much of the work that you do. And so, it's really great to be able to come and talk. But as you mentioned, I'm Commander Jennifer Lind, I'm a pharmacist in the United States Public Health Service Commissioned Corps, and I'm currently assigned to the Centers for Disease Control and Prevention.

Christina Madison, PharmD, BCACP, AAHIVP: Oh, man. So, you have had a very interesting few years down there at the CDC, I imagine. So, as you mentioned, your full title is Commander, so I was wondering, could you just talk a little bit about specifically what your role is right now within the CDC? Because, obviously, within the Corps there are commissioned officer positions, there are civilian positions. But I don't know if you want to maybe just talk through that a little bit. Because I don't know if some people realize that they are different, and because of that, you know, you could do military service, but you're not. But that is sort of part of what you're what you're doing.

Cmdr. Jennifer N. Lind, PharmD, MPH, MBA: Sure. So, I guess probably the easiest thing first is I'll explain, you know, the United States Public Health Service. And then, as I mentioned, my duty station is CDC, and so I can talk a little bit more about the role that I do there. But so, the United States Commissioned Corps is the United States Public Health Service Commissioned Corps [and] is one of the 8 uniformed services. And we're the only one dedicated solely to protecting and advancing America's public health. And so, as America's public health responders, we are the first ones on the line of defense in terms of the nation's public health against threats large and small. And so, we are technically housed under the US Department of Health and Human Services. Most of the officers are assigned to one of those different agencies within HHS, which is Department of Health and Human Services. But, you know, as I mentioned, we are not military, but we are one of the 8. And so, when I say 8, you know, most people recognize Army, Navy, Air Force, Marines, Coast Guard, National Oceanic and Atmospheric Administration, the Space Force, and then the United States Public Health Service. So, we are one of those 8 services, but as a public health one.

Christina Madison, PharmD, BCACP, AAHIVP: The most importantone, by the way, the most important one.

Cmdr. Jennifer N. Lind, PharmD, MPH, MBA: Well, we definitely have a very key role in terms of protecting the nation's health. And so as public health service officers, we actually serve throughout the federal government, and we are providing essential health care services to underserved and vulnerable populations. We deploy for public health and global emergencies. So, I think, you know, COVID-19 definitely raised the level of attention for most people and, you know, there were a couple of opportunities where public health service officers were seen online or in the media, in terms of the work that we were doing. We lead public health programs and policy development, and then also advance innovation science. And so Commissioned Corps officers and being in the Commissioned Corps provides health care professionals with the opportunity to really work in diverse assignments and to serve underserved and vulnerable populations. And so, it really is an honor to be able to wear the uniform and to serve the nation. And so, for me, being a pharmacist in the Commission Corps, my duty station currently is actually CDC. I've had a couple of different roles at CDC since I commissioned in 2012, but I'm currently in CDC’s Medication Safety Program. And most of our work in the Medication Safety Program works around reducing the harms from the use of medications in the United States. And so, we do this by tracking adverse drug events nationally, and we use these data to then improve medication safety through targeted and collaborative interventions.

Christina Madison, PharmD, BCACP, AAHIVP: Wow. So, I'm assuming—and probably this might not be correct—but were you involved in the V-Safe Program? Or is it more on the side? Because obviously, when we think medications, that includes vaccinations and specialty drugs, injectable medication. So, was that something that you were a part of? Because it was so unique, because as someone who's been working in public health since 2004, because that's when I graduated and did my residency, you know, vaccinations are something that really has evolved as far as pharmacists’ role. I just saw a report yesterday that said that pharmacists administer more vaccinations than primary care providers, which I thought were primary care physicians. So, I was like, okay, damn, right? So, we definitely need to lean into that as being the vaccination experts. But before that, you know, really, we were relying on theirs to report adverse effects. So, it was just a super unique thing where we were doing real-time surveillance. So, I don't know if you want to talk a little bit about that and what your involvement was, but it's been such a successful program, I'm hoping that we can see more of that in the future.

Cmdr. Jennifer N. Lind, PharmD, MPH, MBA: Exactly. It has been a very successful program, and actually I was not directly involved in that. And so, one of the great things about CDC, and especially when there are large public health emergencies and things like that, we stand up an Emergency Operations Center. And so, that is like our command center for all of the work that we do in terms of addressing public health emergencies, and in that we had several different task forces. And so, there was actually an entire vaccine safety task force, and so a lot of that work was done there. Even within CDC, we have a couple of different programs. And so, we have a Vaccine Safety Division, or Immunization Safety Division, that kind of focuses on that work, we have other groups that work on it, as well. And so, you know, they definitely did that more day-to-day. So as a part of the COVID-19 response, though, I was involved a little bit in terms of similar work that we do in the Medication Safety Program.

And so, we ended up standing up a unit called the Adverse Event Monitoring Unit during COVID-19. So early on in the pandemic, you'll recall that there weren't any authorized therapies and things like that. And there were a lot of things that were being proposed and tried, and all of that in terms of how do we treat them and maintain and provide care to people, our patients who have COVID-19. And so, you know, we were like, “Wait, somebody needs to track this.” There was no good surveillance system to monitor what was going on. And so, this particular unit that I was involved in, we stood that up and we were tracking the different things that were being used, and we were using a variety of different data sources. So, we were using Poison Control Center data, we were using our own particular data, NEISS, which is a data set or a surveillance system that is a national electronic injury surveillance system. And we collect data, and it's nationally representative from different emergency departments around the country. And so, when someone takes a medication and they go to their emergency department, and they have an adverse drug event, this is something that our surveillance system catches. We were also using another data set that collects information related to retail pharmacies and things like that. And so, we were looking at tracking prescriptions to see, you know, related to some of the therapies that were being proposed, were there any large spikes? And so, one of the things that we were able to find in those data were related to ivermectin, when that was being heavily used in proposed efforts treatment for COVID-19.

Christina Madison, PharmD, BCACP, AAHIVP: Remember the ivermectin and the hydroxychloroquine days?

Cmdr. Jennifer N. Lind, PharmD, MPH, MBA: Exactly. So, we were tracking all of those things. And we saw, you know, alarming spikes. And whenever we got reports related to adverse events related to that, we were trying to push out information to clinicians and to the public to let them know that these particular medications had not been approved or authorized for the treatment of COVID-19, and then here are some options. And so that was more of what I was involved in, in terms of COVID-19. However, there were lots of people here at CDC who were doing great work related to vaccine safety and vaccines in general. And, you know, some of it was an extension of the work that we have been doing historically at the agency, but definitely, you know, programs like V-safe that came up as a part of the pandemic has been very successful. And there were lots of people doing really great work related to that.

Christina Madison, PharmD, BCACP, AAHIVP: Yeah, it's so cool. I always think about people who work for the CDC as these just like amazing, like, crime fighters, right? Because, basically, you're being asked to deal with these huge societal challenges, and oftentimes it's reactive because of an outbreak. But so much of the work that you guys do is preventative. So, I always say, like public health, you know, now that everybody knows about it because it's this big sexy thing, because we have this big issue, AKA the pandemic, but we are doing our best when you don't know we're here, because then that means we've done our job, right? So, it's like, everything is good. Nobody's sick, no one's getting infections, right? There are no issues with food safety or outbreaks. I feel like I see a HAN every other moment. Which, by the way, if people don't know what a HAN is, this is the Health Alert Network that the CDC does. So, I would highly recommend, if you haven't already done so, go to the CDC website. This is me like giving you guys like a little go to the website and sign up for their email alerts, because I rely on those. Like, that's one of the things I so appreciate. And I know that there were some challenges with issues around the media, around maybe the CDC not being as transparent during the pandemic, but really, we only knew what we knew at the time, right? So, understanding the way that data flows, in particular through the federal government, it has to be vetted, and the federal government does not put any information out that hasn't been vetted and gone through, like, 6 levels of approval.

But oh, man, I remember following your LinkedIn and just going through and being like, “Oh, my gosh, that's so cool. She got to do this today or that today.” And so, I just really appreciate not just the work that you're doing, but also as a woman of color, you know, being a messenger that looks and sounds like the communities that they serve. And so, I know that that's something that's super important to me. And I'm just curious, like, what's one of the most exciting things that you've been asked to do as a public health pharmacist? Obviously, you know, I'm geeking out and I'm a nerd, and I'm thinking everything is exciting. But I'm just curious what you think is like the coolest thing or the most exciting thing you've been able to do as a public health pharmacist, being that you've been doing this since 2012. So, happy 10-, now, almost 11-year anniversary.

Cmdr. Jennifer N. Lind, PharmD, MPH, MBA: Time goes fast, you know. For those who are earlier in their career who are listening, the time goes by really quickly. And it's hard to believe that it has been already, you know, almost 11 years. But one of the things you said earlier, and kind of the great things about kind of my introduction into public health and into CDC, was I came in through the Epidemic Intelligence Service Program or the EIS Program. And so, what this program is, is like the world's premier program to train what is called the disease detectives. And so literally, like what we do, and it's a 2-year service, and it's the only applied epidemiology training program of its kind. And so really, honestly and truly, the 2 years that I spent in EIS, I was in the class of 2012, and when I was accepted into that class and graduated, I actually became the seventh pharmacist to actually graduate from the program since 1951. And so, you know, I really, truly felt honored to be able to go through the program and get that experience, but it was by far, and most people who have done EIS will tell you this, it has by far been the best 2 years of my career so far. It's an amazing experience. I would say, if I can think back, let's see some of the different experiences that I got during that time period.

So, if most who have been around or in pharmacy for a while remember back to the 2012 multi-state fungal meningitis outbreak. I was a fresh EIS officer then when that happened, and so I was able to assist the activated CDC Emergency Operations Center, and they had a call center then. We were literally trying to track down and contact all 14,000 patients who may have gotten this contaminated steroid that had been shipped out and distributed to several states. And so, we were calling them trying to track them down checking to see what symptoms they may have had, if they might need additional care and things like that. And so that was kind of like my first big activation. And I think every EIS program and every EIS class, they will typically have something big that defines your class. So that was the thing class of 2012. During those 2 years, I was also able to travel to Pakistan, and I was able to provide oversight and technical assistance to the Ministry of Health of Kyrgyzstan, and the United Nations Children's Fund related to planning and implementation of a national survey of nutritional status and children 6 to 29 months of age. And so, that was a really great opportunity for me.

I wanted to be able to work in global public health because most of my experience prior to that had all been domestic, but then also to be able to work on the process of the protocol development questionnaire, develop it, and then go over to Kurdistan and be there for a month and travel around with the survey teams as they were doing blood collection to see if there were any benefits from the micronutrient supplementation program that had been set up in the country. And so, they were checking to see if there were improvements in, like, stunting and wasting anemia and some of the different conditions that you typically will see from malnutrition. And so, that was a really rewarding and fulfilling experience for me.

And then I would say a third really exciting thing that I was able to do during my time at EIS was I was able to lead a multi-dose disciplinary team during an Epi-Aid, which is kind of like our field investigations that we do as EIS officers. And we went to the field, we went to Florida, and it was related to neonatal abstinence syndrome. And so, for those, again, who have been in public health for a while, you will remember the opioid epidemic, which is still a major problem. Now, we'd only started to realize it was a problem around 2012, and at that time, the epidemic was very much a prescription drug, you know, so a lot of it was based off of prescription opioids. And there were a couple of states where, you know, they were kind of the epicenter, there were lots of pill mills, as they were called, where large volumes of opioids were being dispensed. And there were issues. And so, one of the things that was noticed was that there were a large number of babies being born, going through withdrawal at birth. And so that's what neonatal abstinence syndrome was. And they needed a way to track this and do a better job of surveillance once they realized that it was an issue. And so, I was very fortunate to be able to go and help them do that, and be able to do some medical record extraction, charge abstraction, and data analysis to see are there better ways, are there ways that we can capture these data and track these babies to see how big the problem was? And as a result of that investigation, Florida actually did change and make a neonatal abstinence syndrome a reportable condition. And so that was a great opportunity for me to see how we can take data and public health and the work that we do and how that can inform policy, and things like that. And so, I would say, you know, there were other highlights—the friendships that I was able to build, and other great experiences from the 2 years, but those I would have to say are probably 3 major highlights from that 2-year period.

Christina Madison, PharmD, BCACP, AAHIVP: What q legacy you have created, my dear, like, it is incredible. I mean, I thought I knew all of the amazing things that you've done, but I had no idea that you had gone to Kurdistan. Wow, that is just mind blowing. And I think, again, really just wanting people to understand that, you know, when you help one, you can help many. And that's the difference between public health versus doing, say, primary care, or disease state management that's really like chronic disease-focused, is that when we help people within public health, it's all about the health of the money versus the health of the one. And so, your one intervention could really have a ripple effect that impacts entire communities, and sort of this concept around population health and how that relates to how societies work better, how you can get create more opportunity, education, wellness, I mean, everything is connected. If you're not healthy and well, and you live in a place that is polluted or has lack of access to services, or you don't have a sidewalk so that you can walk to public transportation, so that you can get to a job, so that you can make the money, so that you can support your children, so that you can feed them, all of these things are all public health. And I don't think we realize how much of our day-to-day, even the fact that you wear a seatbelt in your car is public health. Right? Like nobody thinks about all of those little things that is like how our society functions and works, that literally keep us healthy and well on a daily basis. So, thank you, thank you so much for the work that you're doing. And that's incredible. I really liked the fact that you emphasize that data and being able to have clear data, right? So, like, it's not just data, but being able to clearly interpret and craft that message and craft that story can actually impact policy change and meaningful and lasting change for our community. So, you know, with everything that you've done and all the exciting things that you've been involved in, what would you tell health care professionals about why they should be involved in public health or why they should even think about seeking a career in public health?

Cmdr. Jennifer N. Lind, PharmD, MPH, MBA: Yeah, absolutely. And I think a lot of that goes back to what you already said. So much of our day-to-day, and especially as pharmacists, so much of our work that we do and what we're trained to do touches on public health. And I don't think we always necessarily put the pieces together. I mean, when we're doing vaccinations and things like that, that's public health. You know, a lot of all of the disease states and things, most of them if they are therapy-related and we're dispensing medications for them, you know, we're doing work towards public health and interventions. And so, you know, we're already working in it. And so, I would say, for those who are interested in working at a broader level, at a population level, I think there's definitely always a need and a role for direct patient care. So, we're always going to need the boots on the ground, you know, those individuals who are willing to be there and to serve the one. But then we also need those of us who are working more at the population level, and so more on the national and global level, and still doing that same type of work, still using the knowledge that we learned in pharmacy school, the training that we learned, the expertise that we have in medications, but then applying it to larger groups of people. And so, I definitely say, for anyone, not just pharmacists, any health care professionals who have that passion and desire to make an impact on communities as a whole, public health definitely is a rewarding and fulfilling space to work in. And like you say, when we do our job well, no one knows about us. We're kind of the unsung heroes when we're doing our job well and everything is running as it should be, you know, and all of that, that's what we go for. We don't want to be known, we want to prevent that outbreak from happening, so that we never have to hear about it. And so, I think there's something to be said for people who have a heart for service, and a heart to help those who are vulnerable and help those communities who can be impacted and help prevent some of the things. And so, there's a role for all of us across the spectrum, but there's definitely a role and, I think, a lot of opportunities for pharmacists and other health care professionals to start working in that public health space, because you're already doing it probably and you just not calling it public. Obviously, you're just not calling it that, but you're doing it. And you know, we appreciate that work.

Because, for example, as disease detectives, we do our research and our analyses and we find out, okay, these particular interventions can help prevent whatever disease or condition, or this particular medication is effective for that—we need those individuals who are doing the direct patient care to implement that. The implementation piece is also very important. And so, I just think it's all interconnected. And it is such a great opportunity to give back in a broader way. And so, yeah, I definitely encourage it. If you're thinking about it, definitely go for it. And a master's in public health. Not all pharmacists who work at CDC, for example, not all pharmacists who work at CDC have an MPH. However, you know, if you think you want to do public health long term and you definitely see yourself kind of working in this space, an MPH definitely helps. It's not the end all be all, but it can be helpful. And I think of it as a way—just because our teams are so multidisciplinary—having an MPH is almost like learning another language. And so, it allows you to communicate the information and expertise that you have, in a way that everybody is kind of speaking the same language. And so, an MPH is helpful in that and to also get more specialized training related to public health. But, you know, like I said, there are also very many roles that you could probably serve in and work in, in public health and not have a master's in public health as well.

Christina Madison, PharmD, BCACP, AAHIVP: Yeah, no, I agree. The one time that I was able to do direct work, I worked on the 3HP project. I don't know if you remember that, when we were doing that. So, it was the implementation of the short course therapy for tuberculosis (TB) treatment. So, I was I was part of that CDC workgroup that was implementing it into TB clinics. Because at the time, I was the pharmacist for our county health department. And so, we were one of the sites that they had implementing the 3HP program for the weekly rifapentine once weekly dose. And so, I remember going to that work group and thinking, first of all, there's so many veterinarians that work for them. So that was number one, that was like my number 1 revelation. And the number 2, it's alphabet soup. So, like they talk in acronyms all the time. So, I highly recommend, if you are going to work anything related to the CDC or the federal government, you’ve got to learn how to speak the same language. So, I love that you said that about the translation. But it was so funny when I was there. I was like, “Who talks like this?”

Cmdr. Jennifer N. Lind, PharmD, MPH, MBA: You get so ingrained, and you forget, and so I always have to try and go back. You know, like, okay, like breaking it down. Okay, what does that mean and all of that, I would say. But you learn, it's a learning curve, but you get acclimated to it. You know, it takes a couple of weeks, but you learn the language. But it is helpful to be able to communicate because our teams are so multidisciplinary. And I think that's kind of the beauty of it because you are bringing expertise. You know, you have nurses and veterinarians and physicians and pharmacists and scientists and data, you know. IT folks and informatics is now a big area. And so, it's really amazing to be able to work with such brilliant people from so many different backgrounds.

Christina Madison, PharmD, BCACP, AAHIVP: Yeah, I mean, you're basically the A team's A team. So, one last question for you, because I know your time is so valuable and I'm so grateful for this conversation. I've just enjoyed myself so much. If you could just kind of like sum up, where do you see the future of public health and pharmacists’ role in public health? You know, you've seen so much growth, so much change in the last decade. Where do you kind of see our trajectory moving forward?

Cmdr. Jennifer N. Lind, PharmD, MPH, MBA: That's a great question. I mean, I think—and we've talked about this a lot—but pharmacists, we bring a unique perspective and medication expertise to the table. And so just as we're key members of health care teams that we're on, we also are key members of the agencies and programs that we work for, for those of us who are doing more on the programmatic side. And so, I think moving forward, I see more pharmacists working in areas beyond what has historically been viewed as traditional settings for pharmacists. I think there's much more awareness as I interact with students. I know you work with a lot of students as well, and I do. There is more of a hunger earlier on to be able to learn what other opportunities do I have out there. I don't necessarily want to do what has always been the traditional. And I think, you know, that is amazing. And I always tell students who are fortunate to be able to do, for example, their clinical rotations with CDC, like you're already ahead of the game. You know, public health is already on your radar before you're winning, which is amazing. And so, I love that excitement that I'm seeing kind of in the next generation of pharmacists coming up in terms of exploring other opportunities and other pathways that are out there. And I really do feel like the sky is the limit. And I just encourage anyone, regardless of where you are in your career, like, don't be afraid if you don't see someone doing exactly what you want to do. I don't have a lot of people, and that's one of the things that I've had to do and get comfortable with in my career is I haven't had a lot of people doing exactly what it is that I do. And so, I literally have felt many of the times like I'm building the plane as I'm flying it. Because, you know, there aren't a lot of people to model my career after. But once I got comfortable with that, and leaned into the discomfort, it was somewhat liberating, because there's no one that tells me I'm doing it wrong.

Christina Madison, PharmD, BCACP, AAHIVP: You know, it's your own trail, I love it.

Cmdr. Jennifer N. Lind, PharmD, MPH, MBA: I'm able to blaze my own trail. And so, I really encourage pharmacists and pharmacy students and those who are coming up, you know, to chart a new path. There may not be a name for exactly what you want to do and what you're gifted to do. But I would say, you know, lean into that, and explore that and go for it. Because more than likely, you're addressing a need that is needed out there. And whatever you make, skills and gifts and talents that you have will fill that gap. And so, I'm just excited to see moving forward in the future more pharmacists doing that, more pathways. I don't want, you know, for those of us like you and I who are kind of like the exception right now, I want it to be more of a norm, that it would be a normal thing to see pharmacists in all of these different areas. Because really, our skills are so transferable and apply to so many different areas. I really do feel like we have a lot to bring to a variety of areas. And I'm excited to see that happen more and more in the future.

Christina Madison, PharmD, BCACP, AAHIVP: Well, thank you so much. This has been such a delightful conversation. If people want to find you or ask you questions, if they have interest—I know that the EIS program, the application process is starting up again—if they want to know more? I mean, I'm an avid follower on LinkedIn, but if there's a way that people can maybe get in touch with you, or if they want to know more about what you're doing, what would be the best way for people to get in touch with you?

Cmdr. Jennifer N. Lind, PharmD, MPH, MBA: Absolutely. So, in terms of learning more about the EIS program—and yes, the application is actually just opened March 1, so this is perfect timing—for those who are interested in EIS, it's a postdoctoral training program, but different disciplines that physicians, scientists, veterinarians, nurses, pharmacists, are all eligible to apply. So definitely go to CDC.gov/EIS to learn more about that and the application process. And in terms of the Medication Safety Program, you can also go to CDC.gov and learn more about that. To learn about our Up and Away Initiative, we have upandaway.org. And so that is about keeping medications up and away and out of sight and reach of young children. And then, you know, I try to be pretty active on LinkedIn. And so, you know, you can follow me, Dr. Jennifer Lind, on LinkedIn, as well.

Christina Madison, PharmD, BCACP, AAHIVP: Awesome. Well, thank you so much again for your time. And I will make sure that we get all of those links that you mentioned in the show notes so that people can refer to those. And again, my name is Dr. Christina Madison. I am your host for Public Health Matters, part of the Pharmacy Times Pharmacy Focus podcast series. And remember: Public Health Matters.