EP.8 OPEN ACCESS, OPEN MIC WITH DR JUDITH FEINBERG

Welcome back for another episode of Open Access Open Mic with the Apt Foundation. On today's episode, we are joined by Apt CEO and President Lynn Madden and our very special guest, Dr. Judith Feinberg. Now, Judith is the professor of behavioral medicine and psychiatry and the professor of medicine and infectious diseases at West Virginia University. Now, to list all of her accolades and career achievements, we'll probably take an episode in itself, but her work spans infectious diseases,

Thank you.

Welcome to Open Access Open Mic the podcast........ thank you for having me let's kickstart this one with, can you tell me a little bit about what originally drew you to diseases as a specialty?

Thank you for having me.

Well, it's like solving a mystery and I love mysteries. I like reading mystery novels, you know, so you get these cases where people have bizarre symptoms and you have to figure it out. So it's really like following all the clues. It's totally not like other parts of internal medicine where you poke needles into people and biopsy things or snake catheters into them and do things to their heart. It's all...

It's all mental, guess one way to put it, but it's all like solving a problem. And I just like that. And then because I started my training at the outset of the AIDS epidemic, of course I got sucked into HIV, which was the most puzzling puzzle of that time, the early eighties.

Yeah, for sure. was quite a time. And I know we were talking earlier before we started recording, you know, that your work in that field is quite pioneering. Lynn, would you like to jump in there?

Yeah, thank you and thank you so much Judith for agreeing to join us today. I will just say that yes, my understanding of Dr. Feinberg's work is that it was quite pioneering and then after that, what would have been a full career track for many people, Dr. Feinberg made the decision to begin to think about the intersection of

substance use disorders and HIV and other infectious diseases. Particularly there in West Virginia, which I'm sure she'd like to speak to, you know, this is a way of understanding the HIV epidemic and the harms of substance use disorders that is relatively unique, making that overlap and understanding the intersection and treating people

Thank

and systems in ways that allow both of those ⁓ sets of processes to be identified and to help individual people, but also to just have a huge impact on overall public health.

You've done some incredible things, Judith, incredible things. But I'm just wondering this, was there a defining moment in your career that kind of shaped your focus on public health and harm reduction?

Well, the public health piece started with HIV because it was stigmatized really physicians had to be patient advocates in order to get anything in the system to move, including getting the federal government to devote resources to investigating it.

but also just to be able to keep your patients from being thrown out of their apartments and being fired from their jobs. I mean, it was a really pretty terrible time. So the public health aspect's been there from the very beginning. And I think it's kind of telling that, right, infectious diseases, what's like the beginning of public health, right? Finding that you could, you know, ⁓ typhoid Mary, right?

and the water pump in London. mean, it's been a central piece of public health from the very beginning. The harm reduction part came more recently when I was a faculty at the University of Cincinnati and started seeing too many cases of endocarditis, which is this terrible heart infection that can be fatal.

too many cases. so that was unusual in itself. And quite unusual was the fact that these were individuals who were transferred from small, outlying community hospitals in Appalachian, Ohio to the University of Cincinnati. Because if you have endocarditis, you need to be cared for in a place that can do cardiac surgery. You might need an emergency valve replacement.

You can't do that in a 20 bed rural hospital. And that was weird. At that point, I'd been in Cincinnati for 10 years and had never seen anybody transferred in from the Appalachian Southern Ohio. So Appalachia actually ends at the border of the county where Cincinnati is. So our Eastern suburbs are technically speaking in Appalachia.

And then, you you examine people and you see that they had track marks and it was clear that they got endocarditis from injecting drugs and this was really new. So the northeastern corner of Ohio where Cleveland is had had an established opioid heroin epidemic for many years, but Cincinnati, which is in the southwest corner, had never experienced this. And so I knew something was up.

And before I came to Cincinnati, I was at Johns Hopkins and Baltimore, of course, is an old center of heroin use, what I call the 20th century heroin epidemic, as opposed to the 21st century opioid epidemic. And our AIDS ward, which was 21 beds, at any given time, 10 to 20 % of the people

exchanges which had started in the early 90s to counter the HIV epidemic in places like New York and Baltimore and Cleveland, you know, was well established as a way to counter those harms. And so I started agitating for a syringe exchange project. And it was tricky because Ohio law wasn't very friendly to this. And ⁓

It took a long time. In fact, it took nine years of continued advocacy, finding local organizations and people who supported this. And it was like reliving the early years of HIV again, because drug use is just as stigmatized as HIV was.

Wow.

You know, I encountered terrible bias and, you know, unbelievable responses from people who were like, well, you know, just let them die. I'm like, no, you know, that's not the oath I took. I didn't take the just let them die oath. I took the oath. It's like, got to save as many lives and make people healthy and keep them healthy as I can. So it was a pretty uphill battle.

⁓ But we finally got by Ohio law, the local permission. And then it took another year, because this is the way the law was structured. First you needed permission from the public health authority, whoever the regional public health authority was. And then you needed permission from the regional law enforcement. And it took another year to convince the Cincinnati Police Department that this was something that

should be done and that they shouldn't arrest the people coming to and from. So it was a nine year effort, but it bore fruit and it was very exciting. And we bought an old RV, beat up RV and transformed it into a mobile syringe. Well, it was, you know, a syringe exchange, but really we did the full compliment of syringe services. So in addition to giving people sterile,

injection equipment. We gave them all the other stuff you need, know, the sterile water, alcohol swabs, male and female condoms. We signed people up for Ohio Medicaid. We did warm handoffs when people came to us and said, I need help. I can't do this anymore. We had ⁓ MOUs with local treatment organizations. We actually drove people to their appointments because we discovered

People were so freaked out that even when you called and made an appointment with them, they would not show up either because they didn't have transportation or more commonly because they were just freaked out and worried about, you know, having a being stigmatized and having a very negative reception. People who inject drugs don't really feel kindly about the health care system because the health care system isn't kind to them. So then we wound up driving them and ⁓ wound up driving them and sitting in the waiting room with them.

until their name was called so that they had that support. And it really made a difference. It was really encouraging and heartwarming to be able to do that for people. And it very much, as I said before, was parallel to the advocacy work that I had done when my sole focus was HIV. And what drew me to West Virginia was the nine-year struggle

Yes!

And then a close friend and colleague had already been at WVU for a year. And she said, you want to come here? I said, yeah. Yeah, I want to do something about this. And that's the story. That's how I wound up in West Virginia.

That is quite remarkable. You know, they say that most people run away from a burning building, but you're one of those few and you truly are a rock star who runs to it to try and be part of the solution. Kudos to you.

And some people

might say it's a bit foolish to run toward a burning building. But yeah, I guess I have that bug.

I guess in this context, you save lives by doing so. yeah, bravo to you. And it kind of leads me on, there was lots of things you just mentioned that we're going to actually come back to, stigmas, barriers, et cetera. But one of the things that you've kind of led me in beautifully too is how has your work evolved since joining West Virginia University?

Well, it's really been a fascinating ⁓ experience. You know, I'm an urban person. I'm a New Yorker by birth. I have lived and worked in many large metropolitan areas. I had never focused my work in a region that was rural. So I learned, first of all, a great deal about the obstacles and challenges of delivering healthcare.

in a rural environment, especially a rural environment that's really poor. I West Virginia is a really under-resourced, poor place. As the coal industry has crashed, there's really nothing there that took its place. And although it's very beautiful, it's a mountain from one end to the other, that's also an obstacle for doing things like laying cable. It's not like it's Iowa that's flat and it's easy to lay cable, but everything's a mountain. If you want to build

Let me put it this way, if you want to build sort of a modern strip mall in West Virginia, you have to blow off the top of a mountain because there's no flat land there. So, you know, it's very not only is it poor, but it's also very behind in terms of, you know, modern 21st century communication visits. Internet access is intermittent and sparse in some areas. It's OK in the major cities and towns.

But as you get further and further away, it's more more difficult. So people have dial-up or they don't have any access at all. So that was the first thing, was learning how to...

learning how to navigate in a rural environment and to do research in a rural environment. So all my research had always been done in a completely urban setting. Then the second thing was to, you know, the same obstacles that you would face anywhere, which was tremendous stigma. And that continues to amaze me because you really, in 11 years, I have not met.

a native West Virginian who does not know someone in their family or who lives next door who's been caught up in the 21st century opioid epidemic. It is so widespread that it's an experience that everybody has. And you would think, given that these are people's family and neighbors, that there would be more empathy.

I guess the word, but more understanding at least of how difficult the problem is. But there is tremendous stigma there as there is everywhere else. you know, that's another obstacle that you have to overcome. And then,

Other kinds of obstacles are that, for example, when you talk to people who have substance use disorder from injecting drugs and talk to them about, you know, are they interested in medication to prevent getting HIV, the uniform response is, are you saying that I'm gay? And I say, no, no. You know, did you know that you can get HIV from injecting drugs and sharing the equipment or the drug?

Nope, people don't know that. So, you know, even the population at risk that we're trying to reach and help, one of the obstacles is they're not well informed. you know, and that's been another piece of the puzzle that you have to deal with and figure out a way to overcome.

And Judith, I wonder if you would comment. mean, West Virginia, just from an epidemiological point of view, is really a hot spot for the issues related to the harms of opioid use. But I wonder if you would comment, apropos of your previous remarks about people not really being aware of the potential harms of injection drug use, for example.

Comment a little bit on that intersection. I think that's a phenomenon that goes throughout our healthcare system as well as the general population. You know, a person is not their diagnosis, right? And it's possible and likely that a person has multiple clinical medical issues, particularly as they move through life. But talk a little bit about that. I mean, why is it so important to think in a more

more holistic way about the person before you.

That's a great question, Lynn. So thank you. So substance use disorder is a chronic relapsing brain disease. And it's incontrovertible that that is the case. And there is just a ton of data that support that, as opposed to you're a person of poor character or a person of poor morals or a person of poor willpower or somebody who doesn't get down on their knees and pray enough.

And when people inject drugs and are vulnerable to the things that injecting drugs can risk, like hepatitis B, hepatitis C, HIV, then people acquire multiple chronic conditions that are all part and parcel. They're all hanging together. And typically in the past, these things have been sort of

dealt with in a siloed way, they're kind of separated. There are people who are addiction care specialists who deal with the substance use disorder. There are people who do deal with the infections. And really this all needs to be integrated because that person is a whole person with multiple problems. And that's really the nexus of the work that Lynn and I are doing with Rick Altice in West Virginia.

Not surprisingly, we discover that, for example, when you cure someone's hepatitis C, is miraculous that we can cure it. It's the only viral infection that you really can do that for, and you can cure it in as few as eight to 12 weeks of once a day therapy, which is even more remarkable, and with almost no side effects, which is even terribly more remarkable. And you do this and...

People come in and they get their confirmatory blood test that says they've been cured. They cry, these are grown men. They cry because it's so spectacular. But what we have learned from doing this is a couple of important things. One is that people become more committed now that something bad that could lead to liver cancer and cirrhosis and death has been fixed. They're like, ⁓ well, you know.

maybe I'll have my blood pressure checked. Maybe I'll get ⁓ a screening for cervical cancer. And people start to take better care of themselves. So that's one thing. But the second thing that I think is really terrific is the emotional meaning of this, which is that people start being treated like people again, not like their diagnosis, not like the...

they're an addict and they're a bad person. No, they're a person who has these problems. We cured one of them. We're treating the others and people become, you know, their self-efficacy and their feeling about I'm a worthy person. I'm worthy of being healthy is very, very important. And the third thing that we've learned

is that it reinforces people who are in recovery when this happens. Now we can treat people who are still injecting and we do, but people who have entered recovery and we have discovered that, you know, dealing with their other medical issues has really reinforced their commitment to sobriety. Like I got sober, my hepatitis C is gone, you know, I'm taking medicine for my HIV.

I'm gonna live to have grandchildren. So we've really seen incredible benefits that are both individual health, public health, but third, and I think from a human perspective, most important is a sense of worth as a human being. We all need that, right? You can't wake up in the morning and think, I'm a schmuck, and nobody likes me.

Absolutely.

and my family hates me and I'm a bad person and it's all because I didn't do X, Y and Z and all the negativity that comes with having the diagnosis of substance use disorder. And that is really fantastic to witness and experience and share with people. It's really what being a doctor is all about. It's not just the magic of the blood test answer. It's like the people are...

Yeah.

are encouraged and satisfied and happy. And you know, really, yeah, I mean, can't get better than that.

Nope, you're spreading hope, boosting self-esteem, self-confidence, and reminding people this is not a moral failing and treating it accordingly. Incredible. You mentioned then the work, obviously, you've been doing with Lynn and Rick. That's the Birch Project, isn't it? Is there anything you'd like to tell me a little bit about that?

So that is a project where we are working with about 15 primary care clinics across the state. Most of them are federally qualified health centers, which is how West Virginians, especially rural West Virginians access care. There isn't much private practice in these areas and FQHCs by law have to accept everybody who, as a patient who crosses their threshold. So they can't say, we're not.

We're not interested in you. You have substance use disorder. And even in these places, which are kind of the only health care in the area, still the treatment of these problems was siloed. And so we are helping them through coaching them through change projects. We are helping them learn how to integrate the care for these.

individuals and not only integrate the care but also you know the federal public health recommendations now are to screen everybody who's an adult at least once in a lifetime for HIV, hepatitis B and hepatitis C. But those recommendations are not exactly

commonly followed, and not just in rural West Virginia, but everywhere. And when we encourage and show these primary care sites that screening is a really key point of entry into care, then that's something they haven't done before. And that really improves the healthcare of people.

And then this is completely, this project is, every site deals with its own circumstances, its own situation, its own administration, its own benefits and deficits. And so what people need to do to make things better is variable. And people have approached this in different ways. Some people have started...

a treatment for substance use disorder, which they had never done before. They had outsourced it. Now it's on site. Other people have done a better job of integrating the infectious disease and substance use care. Other sites have, you know, there's just a lot of different ways to approach this and people have done this in different ways, but there's certain commonalities. And so we have these learning collaboratives twice a year where we get

the people together from all these sites and they learn from one another, which I think is actually part of the secret sauce. It's one thing to have all these experts, me with my New York accent, even though I'm at WVU and Lynn and Rick coming from Connecticut and having all these people sort of descend and say, well, try it this way. But when they hear from their peers, wow, this works.

and this worked in town X, then they think, hmm, look, work for them and we have kind of a pretty parallel problem, let's try that. And so we get this wonderful ⁓ cross-fertilization and sharing of solutions and ideas. And I think it's worked so well because it really is, it really is people facing this problem in their everyday work.

who have figured out ways to improve that work, the efficiency of it, and the number of patients that they can see, and the number of patients they retain in care. And that's really crucial. It's okay if people cross your threshold, but if you don't keep them in care, you haven't really accomplished a lot. I just think it's a better modality than having people from universities come in and say,

do this, we think it's a good idea. I think when they see that it works in their environment or a similar environment, that's it. And I mentor a younger faculty member at WVU who's a pulmonologist, and his expertise is sleep apnea. And he was so impressed by the programs that we have to teach primary care clinicians how to

take care of HIV and hep C and hep B, that he said, I'm gonna write a career development award, which he got from NIH to do this for sleep apnea. So, you know, it's not like there's that substance use disorder and infectious diseases are only the chronic problems in rural West Virginia. You know, there's a lot of...

We're number one or two for morbid obesity, which is what leads to sleep apnea and heart disease and diabetes. All these things are tied into sleep apnea. And now, you know, we've expanding that model outside of just the area that Lynn and Rick and I work in. So I just think it's a wonderful approach. And I've learned a great deal from Rick and Lynn about how to do this, because this is not something I had previously done.

Yeah, I think it's just to piggyback on that. I think it's so critical to keep in mind how hard it is for a person with a drug use problem to come and tell someone. Right? So that is a really stigmatizing place to be both for yourself, because many people with drug use problems tell us that they're ashamed of themselves or that they don't feel worthy.

as Dr. Feinberg has said, but also systems and organizations often treat individuals with drug use problems in ways that reinforce that. So if we try to consider the human aspect of how difficult it really is to take that first step, then purposefully looking at that touch point, wherever that turns out to be, so we're talking primary care in the moment in rural environment.

This exists all over the United States. If you've made that first step, we should find ways of making sure that your other healthcare needs are addressed, that you understand that they exist, you know, through mechanisms like screening or easy access, right? That you're valuable, you matter. And by the way, there's some other things going on.

⁓ in this ⁓ constellation of drug use that it might be useful for us to ⁓ really check out with you, right? So I think it's ⁓ a, as well as being clinically appropriate, it goes back to Dr. Feinberg's point about what it's really like to be treated as a person of value, right? We are, we know.

We know things, we know that it's likely that you've been exposed to an infectious disease if you are in fact injecting drugs in your lifetime, even if that's not recent. So this is an attempt to sort of re-engineer not only the system, but the thinking of the people who work with system. Like this, it's not hard to do the screening. It's just not been typical, right? So this...

Bye.

idea that they, in fact, can contribute to the outcomes, the better health outcomes of not only the individual but the community at large through pretty simple shifts in clinical practice, I think is part of the whole resonance of the work. And what's coming out of Birch is easily replicated.

in other primary care settings all across our country, which I think is terrific.

Right, don't think, I mean, we have focused on West Virginia and it is a rural state whose healthcare problems, as I said, are exacerbated by the lack of resources in very poor rural areas. But there's nothing that says this wouldn't work in urban environments too, where people are also sometimes disadvantaged and healthcare access is not easy.

And I agree, I think the work that we're doing is broadly, broadly applicable. you know, right, over 100,000 overdose deaths a few years ago, I mean, we have a tremendous, tremendous problem in this country that is now sadly being complicated by not only more potent, synthetic,

opioids all the time, right? You can't even get heroin anymore in West Virginia. It's like, forget it. But now also the infiltration of amphetamines, which complicates things because they're not as, methamphetamine use disorder is not as treatable as opioid use disorder. We have medications for opioid use disorder. We don't really have yet targeted medications for.

people who struggle with a stimulant use disorder. So, you know, the fact that this is broadly applicable, I think it's just really important. It's important at a public health level nationwide.

I couldn't agree more. And it's really interesting that the change in what we're dealing with and trying to keep ahead of the curve is it sometimes feels like a never ending battle. that kind of brings me on to perhaps the biggest challenge I've found within this work, which has been the work we've been doing with Apt is the barriers to care and specifically the stigma around it. How does that or has that presented for you and what are you trying to do to overcome it?

You know, are some of the biggest, I guess, misconceptions people have about harm reduction strategies?

Well, I think there is this enduring misperception that substance use disorder is a personal failing and therefore that individual's fault as opposed to the fact that for whatever reason when they first tried this, which, you know, a lot of young people experiment with a lot of things. This is not a...

unusual or rare event, right? Your brain isn't fully mature till your late 20s. So, you know, anything before that risk taking is kind of like, hey, why not? It's just once. And it's very hard to overcome that and have people see that it very rapidly for some people, not everybody, thank God, but for some people this really

becomes a chronic disease, it becomes substance use disorder. We are sadly a very moralistic country and lots of other first world well-resourced countries don't really deal with substance use disorder the way we do here in the United States. We have a very moralistic

kind of Puritan concept of individual responsibility for disease and...

And on some level, a lack of empathy, a lack of sympathy. And you know what? It's like there but for the grace of God, go most of us, right? In any sort of difficult moment in your life, if you had made a bad choice, that could be you or someone that you really love. And that's, I think, an enduring problem. How to fix that, how to overcome that?

You know, I've been thinking about that for the 40 years since I started in HIV, and I don't really, I wish I had a clear answer. I mean, you want to say that education makes a difference, but...

that hasn't proven to be the secret ingredient. And as I said, you you can't meet a West Virginian who doesn't know someone who has struggled and you think that that personal connection would convey empathy and it might convey empathy for that person that they know, that it doesn't necessarily convey empathy for all of the people who are struggling with substance use disorder.

I mean, let's face it, substance use disorder is a difficult, difficult problem that leads to a lot of social misbehavior so that people can get access to the drugs that they physiologically now need to keep from going into withdrawal, which is very uncomfortable and which people avoid at all costs. you know, families have been burnt by...

family members who have taken advantage of them. So, you know, it's not easy. I don't know if Lynn's got a better answer than I do, I've been thinking about, I think about this all the time and, you know, I don't have a clear pathway to fixing that problem.

You

Yeah, think stigma is so difficult and it manifests in so many ways. It manifests structurally. It's hard to get into treatment. Sometimes it's hard to find a treating provider, for example, who's even nice to you. It can manifest in ideas about, you know, that you don't care about yourself, that you don't care about others, that it's ⁓ a disease where it's okay.

to actually abandon the people that you care about and love. I think we, stigma has its roots in lots of places as Dr. Feinberg was saying, but one of those places I think is fear. That people are afraid that it will happen to them or that somehow they are, you know, that they're not strong enough or you should be stronger or.

I mean, so there are all kinds of, I think at some level, of uniquely Western ideas about how people should behave. So stigma isn't equal, right? There's more stigma, for example, against women with substance use disorders. There's more stigma against women with children who have substance use disorders, right? So stigma is not equal and it has to do at some level with what we perceive.

about deservedness in our culture. it is really complicated and that one of the ways of thinking about how to mitigate it is simply identifying how the structures of our society that we intend to help people may in fact be creating barriers for them. So that's a way that

One can think about how to mitigate structural stigma and eventually change people's minds. And I can give a quick example of this. We used to be in a space where if we made an appointment for a person with a substance use disorder to come in and be evaluated. And those appointments average about 30 days across our country out into space. So if I call today, I can go sometime in May.

⁓ And if I don't show up for that appointment, generally speaking, it used to be believed that I wasn't ready, that somehow I would have made it to that appointment. But the reality is that I'm too sick. If I have a substance use issue and I can't see someone to help me for 30 days, then I'm going to keep using drugs. And as I keep using drugs, I'm still experiencing

those deficits that go along with using drugs that include poor organizational skills, for example, lack of motivation, which is a symptom of a substance use disorder. What we learned when we shrunk time to treatment, and we've seen this in a number of places that Dr. Feinberg and I have been coaching, when you shrink time to treatment, people actually show up.

Right? So that, so you can measure this idea that somehow it was about motivation by shrinking the barrier and it works. So when you shrink time to care, people come because they can hang on to their motivation for that short amount of time, but also because it sends a message to them that they are valuable, that their problem is worth your time. Right? So I think that there are ways of thinking about stigma.

.

that go beyond trying to understand it and really try to mitigate it in these structural types of approaches.

Well, at both federal and state levels, access to health insurance that pays for treatment is quite critical, and the current administration has really damaged that safety net so that

By rates, West Virginia has the highest proportion of people in the country who are Medicaid dependent. And as Medicaid support, federal support, is weakened, that means that there's people just not going to have access to care.

So, I mean, think that is, know, access to care, think is a very key thing. I also see in West Virginia and scattered throughout the country, because this is pretty variable by state and area, a real retreat from the principles of harm reduction so that

You know, four or five years ago, we had 16 syringe exchanges, some of which were syringe service programs that did more than just give people sterile syringes. Now we have six or seven. Then there was a bill this session to outlaw it. So we're moving in the wrong direction because

Everything you do to criminalize this disease makes it harder for the people who struggle with it, with this disease, you know, to get care. And it's a disease, how can you criminalize a disease? Would we throw everybody in jail with diabetes because they went to McDonald's, you know, and got French fries and then, you know, ice cream afterwards? I mean, there's something about this that is such a...

logical disconnect for me. The concept that you criminalize something that is a diagnosis just seems strange. I'll tell you, my first level of training is an internist. And there are people you admit and readmit and readmit to the ICU for chest pain after chest pain and heart attack after heart attack or diabetic coma after diabetic coma.

And we never say to these people, you're a bad person. We say, you you should eat better. You should take better care of yourself. But we never say, you know, you're bad. What you're doing is wrong. You're bad. And you know what? We're not going to take care of you anymore. We never say that. I just bizarre to me that substance use disorder somehow is in this different universe where we can say, you're bad for having this disease.

and we're gonna punish you for it as opposed to we're gonna help you with it. I mean, those are the kinds of, yeah, those are the kinds of policy things.

not bizarre. It's infuriating.

It's not bizarre. It's absolutely infuriating. It kind of leads me on nicely to the last couple of questions from me. And this one's perfect. It's just planned this way, honestly. But what keeps you motivated in such a challenging field?

It's maddening.

Well, you know, I love seeing people get better. You know, it's the primary, I think, motivation to become a physician, right, is to keep people healthy or get them healthy. And it's so rewarding to, you know, my God, curing hepatitis C, really? These are people, a proportion of which would have gone on to get cirrhosis and liver cancer and die from it. So, you know.

seeing people get better is so rewarding. I have to tell you that, I mean, at a personal level, it's really a thrill. It's really a good thing. At a public health level, when you realize that this is something that affects society and a great many people, not the people just sitting across from you as your patient, but when you think about society as your patient, it's rewarding there as well.

These are diseases that are passed from human to human. If we could stop giving hepatitis C and HIV to one another, they would go away. You don't get this from animals or toilet seats or mosquito bites. Along that path, there's improvement in individual health, but ultimately you could really make.

you know, the world a much better place. And I think that's at the heart of it.

You're full of hope. It's fabulous and it's not ebbed in any way. And I was just kind of thinking, I'm going to tack this one on for good measure, but what advice would you give to medical students or young professionals in the field who are interested in public health?

It's so rewarding. I want more and more people to either to do one of two things to either formally get trained in public health and enter public health as a career. you know, certainly most people who go to medical school want to people, know, want to be healers. And it is really, really critical to see that

There's the patient across from you, and then there's every connection that patient has in their family and in their community that treating them as human beings and offering them the care that they need, you know, has a ripple effect and just, you know, improves our world, the world around us to a great extent. So I would like to see that medical students

and nursing students and other health professionals actually have contact with the people that Lynn and I help take care of and see that these are human beings in need of their care as opposed to some sort of abstract concept. I would love to see that happen as part of their early training so that they leave their training ready to

to provide the assistance that's desperately needed in this country. I mean, if you think about that right, over 100,000 people died from injecting opioids a couple of years ago. That's a lot of human beings.

We could do better. We should do better. We must do better.

I can't think of a better way to end the podcast. That's like probably the best sound bite you're ever going to get. Judith, it's been an absolute privilege. Lynn told me you were a rock star and she had a little bit of a hero thing going on. And I 100 % can see why. You're inspirational, pioneering, and you've saved a lot of lives and you're making changes that are going to help the next generation. I'm, well, very rarely, but I've got not a lot to say. Lynn Madden, anything?

Thank you.

Well, thank you very much. I'm trying.

Thank you so much, Judith. She also gardens clear. mean, amongst her many other wonderful characteristics. She has a new greenhouse, about a year old, right, Dr. Feinberg? You're about a year out from that.

You

Right. And

I got all kinds of baby plants growing now, ready to go into the garden and to share with friends and family. You know, all these baby tomatoes and herbs and flowers.

You're remarkable. I mean, I can't

get my head around it. I mean, I struggle to get out of bed in the morning and do a day's work. But I also hear you're a dog lover. I'm not very green thumbed, I have to be honest, but I hear that you're also a dog lover. yes.

Yes, I've

had a dog since I was three. I can't conceive of life without a dog. I've had a dog since I was three years old. And I don't want to tell you how old I am now, but it's a fair number of dogs. But I put her outside so she wouldn't.

⁓ That's another way to tell

our age, right? I'm X dogs old. I love that idea.

I'm, yeah! I'm seven dogs old.

Right? Right? And I have a very

lovely, I have a very lovely toy poodle now, but I put her outside so she wouldn't bark or interrupt our recording.

I've got to confess,

I've got quite a thing about poodles. I may have to ask you privately on email, send me a picture so that I can be gag, gag, goo goo over your dog. I've got a cockapoo, which is a spaniel and a poodle. So the next step for me will be full poodle. So we can be team poodle together, Judith. It's been an absolute privilege. Thank you.

Thank you. All right, sounds good to me.

All right. Thank you both so much.

Yes, I really appreciate you, Dr. Feinberg. I appreciate your time. Thank you. And Claire, you're awesome as always. Yeah, right. We'll talk soon. Yeah.

Always a pleasure, never a chore.