Clare Harrop in her office in Carrboro

CTSA Program research fellow breaks down barriers

| Marla Broadfoot

Infectious disease specialist Megan Srinivas, MD, MPH has witnessed how difficult it is for people living in rural areas to access the healthcare services they need. She has traveled down dirt roads to poverty-stricken regions of Kenya, Peru, Honduras, Brazil, and India. She has worked in inner-city Baltimore, an area beset by glaring health disparities. And, most recently, she has spoken out about the lack of PPE and COVID-19 testing in her home state of Iowa.

Along the way, Srinivas, a research fellow at the University of North Carolina at Chapel Hill, has come to believe that healthcare problems often result from flawed policies that do not take the latest evidence into account.

Her tweets to correct the science and promote science-based policy (under the handle @YourlocalIDdoc) have drawn both adoration and ire. They landed Srinivas on the pages of In Style as one of the fashion magazine's 50 Badass Women of 2020. They also incited so many death threats that the police regularly circle her house to make sure she is safe.

"I feel like my mom must have nine lives because I have used up way too many," said Srinivas.

Using the support she has received through the mentored postdoctoral program offered by the NCATS' Clinical and Translational Science Awards (CTSA) Program, Srinivas is studying how the decisions made by politicians and policy makers can impact public health. Specifically, she is looking at the effect of defunding family planning centers on the rates of sexually transmitted infections (STIs) in Iowa.

"Her work is path-breaking," said Joseph Tucker, MD, Srinivas' mentor in the program. "It is unusual, at least in the public health field, for someone to take a specific legislative change and ask what effect that change has on objective health outcomes like STIs."

A brazen approach

Srinivas has a history of forging ahead where others might falter. As a high school freshman, she secured a spot in the World Food Prize's Global Youth Institute, an exclusive event that brings together exceptional youth with Nobel Laureates to discuss food insecurity and other pressing issues. The following year, she applied for the Prize's coveted summer internship, which sends graduating seniors to remote locations all over the world. Despite only being a sophomore, Srinivas was selected for an internship in Kenya, and remains the youngest intern the program has ever had.

The experience was transformative. On the last day of her internship, Srinivas visited a woman and her four-year-old child living in a dilapidated one-room shack. The woman, named Docila, was HIV-positive. Docila had no way to seek medical treatment and was ostracized by her community because she openly admitted she had HIV. "She was just all alone, and I was desperate to help her," said Srinivas. "It was that moment, at the age of 16, that inspired me to go into public health and medicine."

She went on to Harvard, where she majored in human evolutionary biology and minored in Spanish, Latin American studies, and health policy. While taking a class on scientific writing, she drafted a grant to study the evolution of drug-resistant malaria in Peru. Srinivas became so engrossed in the idea that she continued working on the grant on and off for the next two years, cold-calling famous researchers to ask for advice. "I thought, what am I going to lose? The best-case scenario is I get to help people. The worst-case scenario is nobody calls me back," she said.

"I saw that this small idea I had as a college student could actually change outcomes..."
Megan Srinivas, MD, MPH

Her perseverance paid off. At one point, Srinivas ended up in an hour-long conversation with Trent Ruebush, a member of the President's Malaria Initiative, who connected her to people on the ground in Peru. Srinivas spent the summer riding around the country on a motorcycle with a band of nurses, testing people for the mosquito-borne illness. Her project was awarded the Hoopes Prize, the highest award for undergraduate projects at Harvard, and prompted changes in the Ministry of Health's nationwide treatment policy. "I saw that this small idea I had as a college student could actually change outcomes," said Srinivas. "It motivated me even further, that this is exactly what I want to do."

Throughout medical school, graduate school, and residency, Srinivas continued to search for ways to transform the systems that affect the public's health. One night as she was attending the annual meeting of the American Medical Association (AMA), a gunman opened fire in the Pulse nightclub in Orlando, killing 49 people. "I realized that we were putting so much trust in the hands of politicians who have no medical training or healthcare background, hoping that they get the right advice from the right people so they pass the right bill," she said. "I knew I needed to become more involved." She helped to draft an emergency resolution on behalf of the AMA calling for the repeal of the Dickey amendment, which had banned any federal funding on gun violence research. Connecticut Senator Chris Murphy read the resolution on the Senate floor the next day.

Srinivas took time off from her residency to contribute to the health policy platform for the 2016 presidential campaign. Later, she continued her lobbying efforts through the AMA, eventually helping to get the Dickey amendment repealed. She ended up running for a seat in the Iowa House of Representatives in 2018, losing by a mere 300 votes.

"My focus hasn't changed; if anything, I have gotten more immersed in the overlap between politics and healthcare," Srinivas said. "I'm trying to create that bridge where my voice can be used to create legislative change in an effective manner."

Digging up data

Tucker first met Srinivas when she interviewed for an infectious disease fellowship at UNC a few years before she received support from its CTSA, the North Carolina Translational and Clinical Sciences (NC TraCS) Institute. "Megan is a dynamo; she is super-motivated and hardworking," he said. "She occupies this interesting interface between public policy, governance, and infectious diseases, at a time when there is a huge need for public voices on infectious diseases."

Srinivas is spending her fellowship conducting research in rural areas like those in her home state, where she is investigating reproductive health restrictions in Medicaid and Title X funding and their impact on STI rates and health care access. "She is very passionate about rural Iowa," said Tucker. State legislatures often defend their decisions to pull funding from family planning health centers – which include but are not limited to Planned Parenthood – because these centers may perform or refer to abortion providers, Srinivas said. However, these sites also provide the community with valuable health services, including contraceptive counseling and STI testing. Approximately half of the people who use these clinics have no other way to get medical treatment.

"They're essentially shutting down a huge access point for all types of health care, including treatments for chronic conditions like diabetes and hypertension," she said. "That's going to result in horrible access to care, especially in rural areas where these centers are sometimes the only places that can help low-income individuals or people from marginalized groups like LGBTQ populations and racialized minorities."

Srinivas would like to reverse this trend. She has been tracking the number of STIs in counties where these centers have been shut down to see if there is a difference in gonorrhea, chlamydia, and HIV rates pre- and post-closure. To her surprise, Srinivas discovered a drastic rise in rates in Iowa just one year after closure. "I thought it would take longer for us to see a change," she said. "I plan to do a two-year analysis, and I imagine the further out we go, the worse it is going to get."

She presented her latest findings at the Infectious Disease Society of America (ISDA) meeting in October, and will conduct similar studies in Texas and Louisiana. Then Srinivas plans to use geographic information system (GIS) modeling to explore the hypothesis that these closures have created health care deserts, large stretches of land where there are no physicians or hospitals.

"The whole point of this research, and what TraCS funding is enabling me to do, is to say that this policy is not working," said Srinivas. "As a clinician, I see a lot of these gaps in care that are affecting patient's lives. Whenever I ask why they exist, the answer always comes down to politics and policy."

Pandemic preparedness

At the start of the COVID-19 pandemic, Srinivas was dismayed to hear many of her fellow Iowans presume that their state would be spared the wrath of SARS-CoV-2, as if being part of flyover country somehow meant they would be passed over by the airborne virus. It seemed like any efforts to prepare hospital systems for the influx of patients were focused on big cities like New York City, not small towns like Fort Dodge.

"To me, that has been always been a huge aggravating point, that rural areas' needs are always ignored," said Srinivas. Rural areas contain 20% of the country's population, but only 2% of the intensive care unit (ICU) beds. Srinivas took to Twitter to warn people that though they might have a lower population density, it was only a matter of time before the pandemic hit their state.

In the fall, the state's two university towns, Ames and Iowa City, became the highest hotspots of per capita infection in the world. Srinivas was part of a team that discovered that Iowa had been reporting COVID cases incorrectly, leading to the appearance of lower 14-day average positivity rates, a metric that was being used by the state to determine the safety of school re-openings. "If it's flawed data, then it can only be flawed decisions," she said.

Now Iowa has among the nation's highest coronavirus death and infection rates. In October, a White House Coronavirus Task Force report found that the virus infected and killed about twice as many people per capita in Iowa as the national average. Srinivas continues to use her voice to combat misinformation and encourage people to do the right thing to protect themselves and their fellow citizens: "FYI, sending me DMs or IMs saying you'll never wear a #mask because… (it's uncomfortable, not convenient, etc) will NOT make me stop believing in #science or advocating for #public health."

Not everyone appreciates her outspokenness. Recently, Srinivas was in the middle of a meeting that was interrupted by a phone call from her parents, who were checking to make sure she was OK. Someone had called her father's unlisted cell phone number claiming that he had already killed Srinivas and threatening to come kill them next. Her parents were reluctant to tell her the story, afraid that it might change her path.

"We don't want this to stop you," they said. "You need to keep doing what you are doing."

NC TraCS is the integrated hub of the NIH Clinical and Translational Science Awards (CTSA) Program at UNC that combines the research strengths, resources and opportunities of the UNC-Chapel Hill campus, partner institutions RTI International in the Research Triangle Park (RTP), North Carolina Agricultural and Technical State University (N.C. A&T) in Greensboro, and North Carolina State University in Raleigh.

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