Unveiling the Path to Health Equity: Dr. Hussain Lalani on Affordable Prescription Drugs, Health Policies, and Grassroots Advocacy

interview by queen balina

HHPR Executive Content Editor Queen Balina interviewed Dr. Hussain Lalani, MD, MPH. Dr. Hussain Lalani is a board-certified internist at Brigham and Women's Hospital, Fellow at the Program On Regulation, Therapeutics, And Law (PORTAL) and Harvard Medical School, and a student in the Master of Science in Health Policy at the Harvard T.H. Chan School of Public Health. He is a first-generation Muslim-American, born and raised in Dallas. His research focuses on understanding the challenges and inequities patients face in accessing affordable prescription drugs and evaluating the impact of health policies and interventions. He is the Co-Founder of This Is Our Shot and VacunateYa, two national grassroots organizations that elevates the voices of trusted medical professionals to build healthier communities and combat health misinformation on social media.

To ensure clarity, the interview below has been minimally edited.

Queen Balina (QB): Okay, so for our very first question. Thank you very much for taking time to speak with me and of course, HPPR. I really want to get to know more about you and your work, so any readers who aren’t familiar with what you’ve done so far can be caught up to speed. So first of all, what motivated you to become both a physician and a health policy researcher? And how does your practice of each really affect your perspective on the other and your work as a whole?

Dr. Hussain Lalani (HL): Great question! I grew up in a low-income family to two hard working parents as a first-generation Muslim-American in Dallas. My dad grew up in Pakistan and my mom in East Africa. Community service was a big part of my life growing up, and service to others is a core tenet of our family and religious beliefs.

I first got interested in medicine because of my grandmother and her health. She was my primary caretaker, and her lung doctor was phenomenal. He built this beautiful, compassionate relationship with her and our family as she struggled with chronic lung disease, or COPD. And, I got very intrigued by his work and also the people who were caring for her when she was admitted to the hospital. I remember sitting in the chair next to my grandmother’s hospital bed watching TV, doing homework, and eating strawberry jell-o and graham crackers, and being like, “Who are all these people like in scrubs and white coats who are helping my grandmother, and why does she keep coming back here like every month or two?” That really caught my attention! Over the next couple years, I started exploring the field of medicine in high school and in college.

I was at Duke for undergrad and studied neuroscience and global health. It wasn't until I lived in Kenya and experienced extreme poverty in a different way that I started to understand that many of the drivers of health were things that I could not control – that no single person can really control in our healthcare system. And that made me wonder, ‘Well, how can we actually fix these problems?’ Medications, surgeries, counseling, these are helpful, but they do not address the root cause. That led me on a journey to public health, and I studied public health formally at Johns Hopkins, which changed my life forever.

It was then that I began to realize that policy undergirds the way in which we live our lives. And it wasn't something that I was fully aware of until I went on this journey. Being a primary care physician is the most fulfilling work I do because I get to serve people when they are in need, and during challenging times in life. I also get to learn and understand how broken our health care system is, because I struggle to provide high-quality care, even though I'm trying really hard! And this struggle, over the last decade across different hospitals and settings, has helped me to see the problems in healthcare, in healthcare delivery, and how we pay for healthcare. Listening to the stories my patients tell me about their lives, and what's important to them, help me to then think “How can we use health policy and delivery system reforms to make their lives better?” Currently, I’m specifically focused on drug pricing policy, as a lens into the struggles of the broader healthcare system, and I'm interested in health care affordability, access, and equity.

QB: Thank you so much for that very thoughtful response. I know a lot of our readers can relate to both the personal side of struggling with family members who have chronic diseases, but also the practitioner side of having to deal with helping people in such cases. Could you touch a bit more on the interplay between your health policy work and your practice? And I wonder what challenges you've encountered in making sure that one facet of your work doesn't overshadow and defeat the other but rather work together to help achieve a goal of more equitable health care?

HL: Absolutely. When I was in medical school at Duke, I started to notice that a fair number of patients were experiencing complications because of unaffordable medications. And it shocked me to see people in the emergency room who were there because they ran out of their medicine, or they couldn't afford their medicine. This could be insulin, or a medicine for heart failure, or an inhaler. One patient was prescribed a new inhaler, and he couldn't afford it because it was too expensive, and he ended up in the emergency room huffing and puffing with significant shortness of breath.

And there I was, seeing him in the emergency room. He was ultimately admitted to the hospital. And I thought “wow, this is so bizarre. Patients are trying to follow their doctors’ recommendations, they just can't do it because it's too expensive. Like, why is that happening?” And this led me to explore drug pricing as a lens into what's broken in our health care system.

I use the stories that my patients tell me to help inform my research and education efforts. I'll share a quick example. During the pandemic, I was a frontline health care worker in Dallas, Texas at Parkland Hospital, which is our county hospital that serves predominantly low-income Black and Latino people, and I was taking care of patients with COVID-19 while also seeing others who were high risk for COVID-19 in primary care clinic. Many of my patients were asking me questions about what they were reading on social media about the vaccine: whether it was safe, whether it could cause them to become infertile, whether Bill Gates was spying on them. And I was really taken aback by these questions and stories. Meanwhile, I was caring for patients with Covid-19 whose families were unable to visit them, during the early days of the pandemic.

These stories helped me to inform a different aspect of work that I do, which is trying to help spread accurate health information on social media. And that my colleagues and I to start a grassroots movement and organization (ThisIsOurShot and VacunateYa) to help empower medical professionals to do that. And that was all based on real life clinical experience!

I think that having a healthy balance of clinical work and research helps to prevent some of the overshadowing, but I could see why – like for clinicians who are primarily researchers – it can be hard, because you're spending most of your time doing research, and a lot less time with clinical work. I personally think spending time in your community and really getting to know the stories of the patients when you see them or the people you serve can help make your career a lot more fulfilling.

QB: Yeah, absolutely. First of all, your work is definitely really appreciated in terms of your work in the hospital, and all the research work that you do. I really liked the sentiment you had about using drug pricing as a lens to guide your work in the clinic and your research. And I was wondering, as someone who spends time in the hospital dealing with patients – can you talk about why you incorporate social determinants of health and health equity work into your definition of holistic, full-bodied care, and why you think advocacy is so important? Can you please elaborate on that facet of your work?

HL: We have a health care system that is not focused on producing health. And when I think of health, I think of two things primarily: people living longer lives and people living happier, higher quality lives. And a lot of what we know from research, is that these two health outcomes are driven by factors like our income, our education, our access to healthy foods, transportation, a strong community with social connection, and mental health. Often times, these factors are not addressed or even discussed during visits in the healthcare system, which is a huge disservice because patients spend about 15 to 30 minutes with a clinician and then they leave the clinic or the hospital, and they enter the real world, where they're dealing with a whole host of problems and confronted with real decisions: “What am I going to eat today, will I cook or buy? Can I afford this new shirt that I want? Who can I find to care for my child? Or am I going to spend that money on my healthcare, whether that's for a medicine or a procedure, an exam fee, or whatever that may be?”

Understanding the drivers of health for my patients helps me to provide better care for them. I can make targeted recommendations. And I can connect them with community-based resources or programs and services that may be able to help them. First, you have to ask and inquire, and then you can better understand and help and connect patients with those resources.

In terms of advocacy, advocacy is critical to improving the health of patients and our country. The US has a health care system with a lot of for-profit components, in which many major stakeholders have financial interests that can conflict with what is best for patients. As a physician, I believe that serving all patients with the highest quality, affordable health care should be our guiding light and top priority. This is much easier said than done given the many challenges we face in health care. To me, there is both individual patient-level advocacy in the clinics and hospitals and population-level advocacy outside the hospital with policymakers and legislators.

I often find myself running into roadblocks when trying to help my patients access the services they need. These include long waiting times to get a sleep study or to see a specialist, difficulty find a lab testing facility near a patient’s home, and delays in coordinating care across the health system with a multidisciplinary team. It’s frustrating and it negatively impacts the health of patients and their experience with the healthcare system. But unfortunately, I cannot do everything, so I have to pick and choose when to push.

Outside the hospital, I’m part of Doctors For America’s Drug Affordability Team and advocate for affordable access to healthcare for all, and putting patients over profits. This allows me to unite our voices together and advocate for what the people. Because together we're a lot stronger. And being part of a larger coalition of organizations pursuing shared goals has been a great learning experience and vehicle for changemaking.

QB: Yeah, thank you. I really appreciate that. And I think it can offer a lot of insight to the readers of HPPR, particularly those who maybe want to learn about global health or health equity work. Delving deeper into your career as someone who very well could have gone the more traditional medical route and only focused on practicing medicine, what led you to focusing primarily on health equity and affordability, but also, to an extent health communication? I'd also love to hear more about, like the intent behind your initiatives. ThisIsOurShot and VacunateYa. Those seem really interesting.

HL: Thanks Queen, lots of big questions. I thought growing up, when I was going through high school and even college, that I would be a full-time physician. That was my vision for how I thought I wanted to serve people. And then, going through the training process and the different stops along the way, I realized that I was struggling to provide the care I wanted to be able to provide in the clinic and hospital setting. I wasn't actually helping that many people, and there was a limit to what I could do one-on-one and that led me to explore public health and policy, where more sustainable population-level change is possible.

I'm really focused on health impact and meaningfully improving people's lives. And I think we can help many more people in the long run if we build an integrated community health system with public health and policy that serves people's needs, much more so than we can help one person at a time in a hospital or clinic. Particularly right now when our current healthcare system is perpetuating burnout among medical professionals. This realization took me a while to get to, but once I got there, I realized that I enjoy the healthy balance of being able to serve people part of the time through medical care and then serving them in other ways through public health and policy work and using research to understand what's going on and how we are doing to make things better.

Regarding communication, health care is complicated. And it's hard to boil down complex topics into something that’s relatable. Most doctors speak medical jargon. We're taught that, and we communicate via medical jargon with each other too, but most everyday people do not understand that, and they're forced to look it up, and then they go to Dr. Google. It's much better when medical professionals can communicate in a way that patients can understand; it just makes life and health so much better and easier. But it can be really hard to do when you don't have the training or understanding about key structural elements of communication. So, I've tried to invest some time in that.

And I think the growth of social media has been one way in which people have been able to share health information rapidly. There are lots of great medical influencers that do that. And so with ThisIsOurShot, and VacunateYa, our goal is to empower medical professionals (doctors, nurses, pharmacists) to use their voice in their community on social media to build trust and spread accurate health information. Because unfortunately, we know that false information spreads much faster on social media, and it can have damaging effects on our health and how we act. We saw this during the COVID-19 pandemic with vaccine misinformation and disinformation and unfortunately, the vast majority of Americans who died were unvaccinated. Our organization does a few of things. We monitor misinformation actively on social media. This helps us to understand what's spreading on social media because we're all siloed in our digital networks, and it’s important to have a broader picture of what themes are spreading. So, we try to understand what is spreading, and we educate medical professionals about how to communicate effectively on social media and in their communities. Initially, our work began due to a pressing need and lots of confusion around the COVID-19 vaccine, and we developed messaging tools, trainings, and social media content. Unfortunately, this challenge extends far beyond COVID-19 and affects many different parts of health and society.

We believe that engaging with community members and leveraging digital to local by pairing trusted medical professionals with trusted local leaders is a powerful way to share health information. That includes partnering with religious leaders, community organizers, among other local leaders. It’s important that the trusted messengers are culturally sensitive and aware of the communities they are speaking with because that impacts how the information is received. So yeah, that's a little bit about our work. VacunateYa is the one of the largest groups of Latino and Latina health professionals on social media working with Latino community-based organizations. We found that although Spanish is the second most spoken language in the US, we don't really have great health information in Spanish. It was particularly lacking around the vaccine rollout. And, so we decided to focus on that with a great team of nurses and doctors, who are all Spanish speaking.

QB: Okay, thank you so much for that. I know that in light of the pandemic, a lot of people are focusing a lot more on communication, on the importance of making sure that jargon isn't used to speak with the masses. So thank you for your work in that realm. But moving on, how have your experiences shaped your personal views of the healthcare system and health equity? Particularly your experiences as both a first-generation American and a healthcare practitioner. What changes do you believe need to be made to our healthcare insurance and healthcare delivery systems? Please feel free to highlight your past responses again.

HL: For starters, we need universal access to affordable healthcare for every single American. But, health care itself is not enough. Because healthcare these days is really focused on what Don Berwick calls “the repair shop”. We're fixing problems after they've already happened. Instead, what we need is a robust national and local strategy to sustainably invest in population health through social policy paired with sound health policy. And that includes things like eliminating poverty, improving access to healthy foods, fresh fruits and vegetables, affordable housing, and transportation. These are some of the basic building blocks of what I call an integrated community health system: where we have hospitals and clinics, but they're very much intertwined with public health agencies, social services, local community-based organizations, that collectively focus on producing health. Medical care itself accounts for only about 20% of health outcomes, and yet we invest most of our money there.

Recently, organizations participating in alternative payment models and health systems part of accountable care organizations are making investments to address the social drivers of health locally. While these efforts are pursued with good intent, I have found them to be inefficient, inadequate, and fragmented in practice. It’s like charging an electric car that has multiple flat tires. If we don’t fix the flat tires, we’re not going to get very far.

The high cost of health care is debilitating for patients and families and is consistently the #1 reason for bankruptcy. Our research group, the Program On Regulation, Therapeutics, And Law (PORTAL), uses a multidisciplinary approach to study the prescription drug market, which is a major component of the care delivered to patients and an important part of the cost equation in health care. There are 4 main reasons why drug prices are expensive in the US. First is government granted monopolies: drug companies set the price at whatever they want, because they get protection from direct competition from the government. The second reason is we don't utilize the collective negotiation power as an entire country when purchasing prescription drugs. And that's not just Medicare, it's all 330 million Americans. The third reason is there are anti-competitive practices, or gaming, where pharmaceutical manufacturers try to skirt the rules to limit competition coming into our market. When there's less competition in our market-based system, prices are high and that means costs to patients are also high. And finally, we have an inefficient pharmaceutical supply chain that lacks transparency and has some perverse incentives that support raising drug prices. That includes manufacturers, wholesalers, pharmacy benefit managers, pharmacies, and insurance companies. We are starting to see some of the benefits of the Inflation Reduction Act, which is specific to Medicare recipients, and I think there's a lot more we can do to ensure that all Americans be able to afford their medicines.

QB: For our last formal question, what does it mean to search for untraditional solutions to health equity and healthcare access issues, and why is it important to you that drug pricing specifically is included in such conversations? Please feel free to summarize some of your earlier responses.

HL: What is the point of discovering novel medications and therapies if they are priced out of reach for patients who could benefit from them? Medicines do not work if they are unaffordable. 1 in 4 Americans cannot afford their medicines—they report in surveys that they have been forced to ration or not fill their prescription. I believe that all people should have a fair opportunity to attain the highest level of health irrespective of any demographic or socioeconomic factors. To me, that also includes pharmacoequity – that all people have affordable access to prescription drugs to achieve optimal health. Striving for these goals means that we need to think creatively and outside the typical bounds of medicine and healthcare. We need to address the root causes of health inequities – poverty, discrimination, inadequate access to education, housing, healthy foods, transportation, and health insurance. We must also reckon with decades of distrust between low-income minoritized populations and the medical establishment.