In this episode in our series on global public health, Megan and Steve explore the public health response to COVID-19 in Bosnia-Herzegovina, with Dr. Sanjin Musa, epidemiologist at the Institute for Public Health in that country.

Steve Sonnier:

Hello, everyone. Welcome back to From The Front Row, brought to you by the University of Iowa College of Public Health. My name is Steven Sonnier and I’m joined by Megan Pospisil. And if this is your first time with us, welcome. We’re a student-run podcast that talks about major issues in public health, and how they’re relevant to anyone, both in and out of the field of public health. Today, we’ll be talking with Dr. Sanjin Musa, epidemiologist at the Institute for Public Health in Bosnia and Herzegovina. Sanjin, welcome onto the show.

Sanjin Musa:

Thank you so much. It’s a pleasure to be with you.

Megan Pospisil:

Just to start us off, could you talk a little bit about the background to your career and what your current role entails now? In our introduction, one of our colleagues at the College of Public Health likened you to Dr. Fauci.

Sanjin Musa:

So, in brief, I’m a medical doctor. I started my career as a general practitioner, I worked three years as a general practitioner, and then after I started to work in the Public Health Institute of the Federation of Bosnia Herzegovina. First, I had a residency in epidemiology two years, then after I was a specialist, so epidemiologist. In parallel, I completed the Master and PhD in epidemiology. And during my PhD, I spent one semester in the University of Iowa. So I completed PhD in 2016, then after I’m also now an associate professor in epidemiology in Institute, now I’m the head of the Department of Epidemiology. So, in 10 years everything’s happened. So as I said, as a beginner to now the head of the department, and especially now in this crisis response to COVID-19, I’m also a member of the Federal Crisis Headquarters.

Steve Sonnier:

With that role that you’re talking about, handling the COVID-19 crisis, what exactly are you involved in, in the countries? What are you directing? How are you influencing how the general public is responding to the COVID-19 crisis? What does that look like on a day-to-day operations level?

Sanjin Musa:

Bosnia Herzegovina in general is a really complex state. We are organized in two entities, and we have also state level. So, I work in the Federation of Bosnia-Herzegovina, and on the federal level, we have a crisis headquarters, but we also have a crisis headquarters on the district level. Also, I would like to refer to your previous question just a bit, when you said Anthony Fauci, I want to say that he’s my great inspiration. His podcast, his interviews, I’m regularly following. But also to mention one of the public health heroes that I really like, it’s [inaudible 00:03:01] because during my career, I was also the head of the immunization department and in vaccinology he’s number one. I like his books, his interviews. I also like Laurie Garrett, epidemiologist. She wrote really nice books, especially one book is about pandemic problem and issues.

Sanjin Musa:

And now it’s really actual. And also another hero, I think it’d be interesting for your listeners. In my teaching sessions, I’m using Leon Gordis’ book, Epidemiology. He’s a classic. And I think that you are also using that in Epi 1. So these are my, I would say heroes in public health.

Sanjin Musa:

Now back to this question about how we respond. First cases we had in March. But during that whole February, we were preparing for expecting first cases. And I remember it was somewhere in the middle of February, the Chinese Embassy organized for these public health professionals from this whole region, a link with our colleagues from China. And I think after that meeting, that’s the first time they really realized the dimension of catastrophe which was approaching. It’s different when you read about it and you read some data, but when you speak with your colleagues and then they show you data and they told you their experience, then it’s different.

Sanjin Musa:

I remember that at that meeting, we were really like, “Oh, this is really, really, really big stuff.” So then we started to organize. In the beginning was really difficult, with the basic stuff like PPE, for example, because you have some reserves in your stock of PPE, but you don’t have millions of it, you know? So that was in the beginning, the issue. So I said first cases we had at the beginning of March. So it was the families who are coming back from Italy and Italy was a hotspot at that time. So we had one, two family and then we have a big meeting. And on that meeting was one guy who was positive. And then we had that huge clusters that are just approaching one, two, three, four, five, second, third generation of new cases.

Sanjin Musa:

And then we decided, it was I think 18 or 20th March to do a so-called, we start to use these words frequently, lock down. So we closed bars, schools, all this stuff. So we completely closed society because it start to spread like a fire, it couldn’t be controlled. Also what had really big impact of me in that first part of the response, that meeting with the colleague from China, and also the paper that I read, it was Imperial College U.K., the modeling that they were doing, they said that, for example, just a couple of weeks, it will increase the capacity until it’ll overburden your health system. So I remember also that paper was really influential, that big analysis, but it was circulating everywhere, but I’m not sure that it was published, but it was really interesting.

Sanjin Musa:

So that also affect how our response. So we decided to lock down for a couple of weeks and then we opened, it was maybe beginning of May that we start gradually to open. We started with some small businesses and stuff like that. And during the May, it was totally open. So in six months it was June, we were opened. Totally. And of course immediately when you are open, you start to see new cases who are coming. During the summer situation was pretty okay, but we had some outbreaks localized. And finally it was beginning of October that we start to increase number of cases. And the peak we had in the middle of November, I remember it was 272 cases per 100,000. That was the highest peak that we had in one week.

Sanjin Musa:

And after that mid November, we start to see decreasing of cases. And now we are, I would say, not so bad. We had 58 cases per 100,000 in one week. So it’s like during that summer months that we had that number of cases. It’s going good, but I would say that now we are expecting this new variant of virus. I see the region, they started to find this new variant. And I’m sure that there is a report and we will also find it here. So it’s still challenging. This winter is really challenging, I would say. So we will see how it goes further.

Steve Sonnier:

When you’re talking about the new variants coming up, because I know that’s a question that’s on many people’s minds. Why is it so important for folks to have a really a global mindset when we’re combating these issues of public health, especially when it comes to COVID-19? We’re seeing new variants come up in multiple states here in the United States, we see things happening right in Bosnia, Herzegovina and other countries. How does this need to be a coordinated global response? Why is it so important to emphasize when many folks think country-specific at times, that can kind of be their perspective?

Sanjin Musa:

I think this pandemic shows you very well how it’s a global thing. In December of 2019 you had cases in China, in February you had cases in Italy, in March, in Boston and elsewhere in the world. So for me, I was a advocate for immunization. And I remember when I speak with parents, and you have to convince them, for example, to vaccinate their children against some disease that maybe the kids, they didn’t register it in our country. For example, diphtheria. You say to them, “Look, there is some points in the world when there is still that virus or bacteria, and it can be also transmitted here.” And now you see how it’s going now. Especially in this globalized world, germs are just with human, they are traveling. It was happening also in the past, of course, so cholera, for example, when you go back and you see the army, how it’s traveling around the world, but now in this globalized world you should expect it much, much sooner.

Sanjin Musa:

In these last couple of years, we were preparing for this situation. You are never well prepared, I would say, no matter how much you are doing. Especially Ebola in 2014-15, we start to, to see importance to react faster. For example, CEPI, it’s abbreviation, “Center for Epidemiology Preparedness Innovation,” something like that. It means that it was created as a mechanism to help the world to faster response. Unfortunately, it’s going slowly. For example, with vaccines, it shows that we are not so well prepared as we would like to be.

Megan Pospisil:

How would you say educating the citizens of Bosnia Herzegovina? Do most people take it very seriously or have you had any pushback?

Sanjin Musa:

That risk communication is a really important part of your response to this pandemic. When we organized our crisis headquarter in the first part of March and April and May, we had daily press conference. And after every week, and now every two weeks, we have press conferences. So it’s always important to communicate, to explain your decisions, to explain situation and decisions with the population.

Sanjin Musa:

Because for years I was doing these vaccines, and I know how it’s really important to establish the trust between community and the public health officers and public health institution. So, especially in this crisis, it’s important that people understand your actions and the measures that you are implementing. And also what is strange, you have to convince people and you have first to convince yourself by reading data and reading tons of papers and articles.

Sanjin Musa:

I will give you just one example. So for example, with masks, universal masking. So at the beginning we were saying, “Only if you have symptoms, then you wear masks. Or if you are treating someone who has symptoms, then wear masks.” But then we change our message and we said, “You should all wear masks.” We have to clarify it. And they said, “Oh no, you’ve changed your opinion,” you know? Yeah, we changed our opinion because we collected enough data to change our opinion. On the beginning, I remember I was watching Anthony Fauci interviews in January and the beginning of February, and we were thinking there is asymptomatic transmission of the disease. So if we are not so sure, we have some just anecdotal stories that yes, it’s possible to be asymptomatic and to transmit.

Sanjin Musa:

But now we know between 30 and 50% of people are asymptomatic and capable to transmit disease. So universal masking is key in your response. Of course there’s always some people who are complaining about it. They think that the discomfort they live because they have to wear a mask, but then you have to repeat your message. And you have to always to explain why you are doing something and why you are recommending something. So the risk communication is a very important part. For example, I had maybe sometimes per day a couple of interviews, and they always wanted you like you are celebrities. I now see how the celebrities, when you always have to be in the media, that it’s really a heavy burden on your back, because also you are trained to read, to communicate, but not in such amount. You always have to be there. And so it’s also something new for us, but yeah, you have to learn step by step and to be ready to respond. That’s really important.

Steve Sonnier:

I would argue also it’s a higher burden hopefully than the celebrity status, too. You’re caring for a nation, you’re caring for all these folks in your community who you want to see succeed and live healthy lives. I think one of the big things that stuck out to me when we were going through our introductory courses in epidemiology and global health was the notion of Measles immune theory and the idea that if you had contracted measles, potentially later on you could have complications where you would have limited immune response just by contracting this virus. And having something unknown like that, that is just starting to really kind of make waves now, I reflect on that with COVID and it’s the idea that a lot of folks think, “This’ll be nothing. We won’t have any long-term consequences.”

Steve Sonnier:

And we’re seeing that now for a lot of folks who, whether through their own actions or by accident, they’ve caught COVID and there will be those long-term implications of catching the disease that we just don’t know yet. We’re so early on into it. Do you think that communicating that aspect, when we’re coming with these public health education topics, do you think communicating how much we really still don’t know about COVID-19 or at least the longterm effects of it would be helpful for folks? Is it helpful to take that approach of, “You really should be cautious because we don’t know the full scope of what we’re dealing with here”?

Sanjin Musa:

That’s really important. It’s really a good question, but you always have to declare what you, what you don’t know. You cannot speculate. That first question in risk communication, you never speculate. You just say what you know, if it’s something you don’t know, you have to say that, “I don’t know, we still don’t have enough data to clarify that.”

Sanjin Musa:

For example, I’ll give you just another, your examples of really good but that is also an aspect when you have to explain people. So 80% of people will have a really mild form of disease. Among these 80%, maybe 50, 40% will not have at all symptoms. But then you are pushing them to wear masks, you know, to stay home and stuff like that. So you have to clarify, why is that?

Sanjin Musa:

So even if you are not hardly affected by disease, you can still transmit disease. And that chain of transmission can finish with someone who will have severe form of disease. So you have to communicate that. During this day, something that I was really thinking about and preparing my strategy, how to respond, AstraZeneca vaccine. So people now are saying after they finished the third phase of clinical phase, “They didn’t have enough older adults, older person in the study group.” So now a question, should you recommend that for people over 60, even there were not enough number in the third phase of a clinical trial. So I’ll give you just some of my thoughts and my arguments. So you have first is to read the second phase, when there was safety and immunological response, and you see that there is no such a big difference among the age groups, but definitely in the third phase, there are not enough, the senior citizens who are part of the study group.

Sanjin Musa:

There is many reasons because of that, because during the third phase trials to manipulate with the dosage, they start maybe just one dose, but it didn’t work. Then you start with half dose, they start to manipulate like that. And finally they decided you needed two doses, but then you’ll shrink your group. So now you don’t have 40,000 and much of people who are older, then you just have 25,000, I think they had been in total. And then you have to now to think what to say, to check your data, so of course the most [inaudible 00:17:13] groups are the older citizens. And then you don’t have enough data now to explain that. And now it’s debate, so someone said like U.K. said, “Okay, we start to give that to first group is older than 80.” In Germany they said, “Oh, maybe we shouldn’t go above 60.”

Sanjin Musa:

So it’s always like that, it’s always, “You need the data.” In my institution, in public health it’s always driven by data. But sometimes you have to do your best on the data that you have. And sometimes to take risks, but reasonable risk when you are making your decisions.

Megan Pospisil:

Moving a little bit away from the COVID-19 topic, what would you say are other big public health challenges that you face in Bosnia and Herzegovina?

Sanjin Musa:

As you see during our discussion that now everything is COVID-19, all our full capacity. We are a totally devoted now to COVID-19. Also I said, my main scope, I’m mostly focused on communicable diseases. So in my career, I was really dealing a lot with the vaccine hesitancy. I did several studies trying to answer why parents are hesitant to vaccination. Also about some vaccine preventable disease, for example in Bosnia, we are still endemic for TB, tuberculosis, for example. So my main focus is infectious disease.

Sanjin Musa:

And I would say in the public health challenges, the biggest challenge I would say is you have to build your capacity. Workforce is also important and challenging. You have to have trained skilled workforce. You have to have strong institution who are capable to dealing with the challenges. And now as a head of department, it’s something that I’m dealing also with that management staff, how to organize the department, how to find people to [inaudible 00:19:24]. So that’s also part of that building capacity in public health, that is also an issue in these LMIC, low and middle income countries.

Steve Sonnier:

When you’re talking about building capacity for public health professionals, is there some advice that you give to early career professionals who are looking into the fields of public health and epidemiology? Are folks in these lower income countries that you’re talking about not interested in public health, or are they just not aware of the opportunities presented to them by public health?

Sanjin Musa:

There is a difference between a education system in Bosnia, for example, and in U.S. So here, if you want to be epidemiologist, you have to be medical doctor. So we are recruiting the epidemiologists from the medical, graduated in medicine. I’m not so sure that’s a good idea. For example, it’s not very popular to say, but most medical doctors would like to be surgeons, internal medicine specialist, you know. And public health is not really so much interesting. That’s also affecting the pool from where you are recruiting the candidates. So I think that we should open this wider for other professions also. And when you recruit staff, I’d say the two important things are that candidates should have, first you have to be ready to learn, continuously to learn.

Sanjin Musa:

I remember once I asked one of my mentors something in statistics. I asked question, so I said, “Where are the books that I can find the answer?”. And he told me, “You have to critically review the papers.” Critical reading of papers. So that’s important, you always have to read, read, read, read, read. So you have to be ready to learn continuously, to learn to increase your capacities. And what I see is really important in public health is teamwork. Absolutely. If you are part of good team, then your life is much easier. But to establish good team, there’s also one critical aspect. If you are surrounded with people who are devoted to their professions, who are ready to work all day, all night.

Sanjin Musa:

So when you’re continuously driven to do something, then it’s much easier when you work in that kind of group. And I think that’s the quality that people should have. And I think that’s a good path, when you are building your own path, that’s good recipe, then you will never be lost. If you are ready to work, to continuously to go further, to push your limits more and more. And if you’re lucky that you are surrounded with people who can inspire you, who are ready to show the same dedication to a job, that’s really important.

Megan Pospisil:

So our last question for you this morning is just, what is one thing that you thought you knew, but were later wrong about?

Sanjin Musa:

For example, the mask. So we were are quite sure, we were making some posters and stuff, I always like to give it to give examples. So in general, that’s the science, science is not a dogma. It’s not something that you have to believe or not to believe. You have to collect data ,and to have good high quality public health data, that’s really important. It’s a long way when you design something for your study, when you then go to collect data, to analyze data, to publish data and then people are there to read. It’s a long, long, long way, but you have to be ready to work on it. You have to be ready for that long journey. And it’s always like that.

Sanjin Musa:

For example, I’ll just give you one interesting something for reading. Just couple of months before the pandemic start, I was reading book, Vaccine Race by Meredith Wadman. And it’s about the story of how the rubella vaccine was developed. The story with Stanley Plotkin, for example, also another one, my personal hero. I had the chance to meet him during one conference and I made a one and half hour interview with him. And you can read that interview in ResearchGate, to find my profile and you can find that interview. To see, for example, how long journey is to develop vaccines. He was explaining his career and all that rubella story and poliomyelitis story. So it was really interesting, but you see now, it took him years and years to develop rubella vaccines because it’s a live attenuated vaccine.

Sanjin Musa:

And then you have to go to the cell lines to attenuate it, it takes time. I look now, in nine months, you have a vaccine for COVID, for example. But it’s also important to say, because now quite often I’m responding, “Is it developed too fast? Is that new platforms are something that should, we should be scared?”. So then you said, “It’s new, but it was not unknown. We were working on it for a couple of years before.” So you have to explain.

Sanjin Musa:

I started my story with the Stanley Plotkin, now I finished with mRNA vaccines. That that’s my main message. It’s science, you have to be ready that maybe something that you believe that you find is not as you started in the beginning. We can see that vaccine race even now for COVID. I remember in Bosnia, unfortunately we still didn’t started vaccination. We are part of this COVAX mechanism and we are expecting first doses now in the middle of February. COVAX was helping to develop working on the 10 different vaccines, so AstraZeneca for example is the one which we are expecting now. So it’s amazing challenging now in public health. So, sorry, I was just changing subject several times, my response, what was your response? What was your questions?

Megan Pospisil:

No, I think that’s fantastic to talk about. The transformation of expectations really is critical. And we’ve talked a lot about that today, whether it’s in the public health education, whether it’s in the vaccination standpoints and how that’s evolved. I think back to when this all started, on my end, I was thinking the fastest vaccine that was developed, I think was four years, right? I think it was mumps, off the top of my head. And I remember quoting that to myself and thinking, “This is going to be a long haul.” And seeing this vaccine come out so quickly, similarly I had the question of, this came out very quick, how efficacious it is, this is going to be a safe situation? And just thinking about the trials, the magnitude of what’s going on right now, we have such a different world that is so interconnected at this point.

Megan Pospisil:

And we’ve been working on this for a long time behind the scenes to be ready for this moment. And while it has all caught us off guard, we are on a very good trajectory. We’re keeping with the positive attitude here. We’re on a very good trajectory in terms of vaccination development and many candidates coming out. So it is incredibly exciting to be part of this history and see the development of these opportunities, and then also having that ability to recognize that science changes over time. I think that’s a very important public health concept, and so a very important public concept too as well, as we’ve talked about today. So I do want to be respectful of your time and thank you very much for coming on, Sanjin. It was incredibly inspiring to listen to you. You’re doing such good work for Bosnia and Herzegovina, and we really wish you the best of success in the coming months, dealing with the pandemic. Thank you so much.

Sanjin Musa:

Thank you for your invitation and thank you for having me in your program, and good luck students in their career in the future.

Steve Sonnier:

That’s it for our episode this week, big thanks to Dr. Sanjim Musa for coming on with us today. This episode was hosted and written by Steven Sonnier and Megan Pospisil. This episode was edited and produced by Steven Sonnier. You can find more about the University of Iowa College of Public Health on Facebook. Our podcast is available on Spotify, Apple Podcasts, and SoundCloud. If you enjoyed this episode, please share it with your colleagues. Or team can be reached at cph-gradambassador@uiowa.edu. This episode was brought to you by the University of Iowa College of Public Health. Keep on keeping on out there.