Spring 2024
In My Scientific Opinion
On This Page
Five leading researchers draw from decades of experience studying diabetes, tuberculosis, health equity, and HIV/AIDS to share their unique perspectives on current events. These op-eds were written in late summer 2025.
Diabetes: A Window to Tackling Multiple Chronic Diseases in Rural Georgia
Diabetes affects over 800 million people worldwide, including more than 40 million in the United States. In Georgia, more than 12% of adults (more than 1 million people) are known to have diabetes, and a quarter million remain undiagnosed. Additionally, 34% have prediabetes, and the state experiences over 50,000 new cases of diabetes each year.
Besides the tragic human costs associated with this disease, diabetes is also financially costly. It is the leading contributor to health care costs in both the United States and in Georgia.
There is considerable variation in diabetes rates across Georgia counties, with the least healthy counties experiencing diabetes rates about seven to eight times that of healthier counties. Counties with high diabetes rates tend to be more rural, experience more socio-economic challenges, report poorer diet and physical activity levels, and have less access to a sound health care infrastructure.
Stark health disparities exist between Georgia's rural and urban communities, with rural residents facing significantly shorter lives and worse health outcomes. Rural Georgians experience a life expectancy 2.3 years lower than their urban counterparts (72.9 vs. 75.2 years), alongside substantially higher rates of preventable hospitalizations (3,408 vs. 3,145 per 100,000). Particularly concerning are the diabetes and obesity metrics, with rural counties experiencing 25.7% higher diabetes-related hospitalizations (269 vs. 214 per 100,000) and higher obesity prevalence (39.6% vs. 36.6%).
Places with high diabetes and obesity rates also tend to be those with higher rates of other chronic diseases, notably, heart disease and dementia. Diabetes and obesity are also risk factors for Alzheimer’s disease and related dementias, which disproportionately impact rural areas, with delayed diagnosis, increased nursing home utilization, and shorter survival. Thus, diabetes offers a window into tackling multiple chronic diseases and for promoting health of people in Georgia, especially in rural areas.
There is a critical need to redirect our focus toward understanding and drastically lowering chronic disease rates through innovative approaches to nutrition, physical activity, and healthy lifestyles, rather than merely managing diseases after they develop. For example, about 50% of diabetes cases and about 45% of dementia cases could potentially be delayed or prevented by improving activity and diet and other modifiable risk factors.
There is a critical need to redirect our focus toward understanding and drastically lowering chronic disease rates through innovative approaches to nutrition, physical activity, and healthy lifestyles, rather than merely managing diseases after they develop.
Multiple factors, including sparsity of primary care and specialty providers, closure of hospitals, lack of public transportation, and the absence of large grocery stores or supermarkets all lead to “health care deserts” in the rural areas of our state. As such, the health inequities in rural Georgia exist within a challenging social and economic context that demands a comprehensive, systems-based approach.
Much can be done to solve these problems. There are several innovative opportunities. By proactively detecting and diagnosing prediabetes and diabetes, several other chronic conditions (hypertension, poor lipids, subclinical cardiovascular disease, subclinical cognitive decline) can be identified early. This can be achieved through large-scale, multi-tiered, human-centric, AI-enabled health care technology.
We can thus address the health problems of rural Georgians by developing and implementing technological solutions tailored to local communities. Additional health care technologies, such as point-of-care or home-based testing for diabetes-related illnesses and mild cognitive impairment/dementia, wearable technologies, custom smartphone apps, and telemedicine platforms can also be employed.
We can leverage local infrastructure—local pharmacies, churches, community centers, local markets, and more—to promote healthy diets, physical activities, and sleep, and screen for and monitor chronic illnesses related to diabetes, such as cardiovascular disease and cognitive impairment/dementia. A decentralized detection and lifestyle promotion approach like this can also be integrated with state, federal, and private insurance programs to deliver effective health care to those who need it the most.
Given the rich academic and technology resources available across Emory University, Woodruff Health Sciences Center, Emory Healthcare, and local partners, such as Georgia Institute of Technology, improving the health of rural Georgians by pivoting diabetes, technology, and community resources is imminently feasible.
Let’s Be Clear: Public Health Language Matters
During the early days of HIV in the 1980s—when stigma, fear, and silence defined the national response—U.S. Surgeon General C. Everett Koop insisted on clarity and candor. In 1986, he issued the Surgeon General’s Report on AIDS, written in direct, nonjudgmental language that explained how HIV was and was not transmitted. Two years later, he mailed Understanding AIDS to every U.S. household, the largest public health mailing in history. Koop refused euphemism or obfuscation. He named sexual practices, described risk without moralizing, and told the truth when it was politically unpopular. His example established language transparency as a core ethical responsibility of public health leadership.
Language is as essential to health as vaccines, clean water, and safe housing. Clear communication democratizes access to information and offers actionable guidance. But we have entered a period where language itself is monitored for compliance with political edicts.
Words once central to the public health lexicon—e.g., diversity, gender, transgender, racism, oppression, underrepresented, health equity, environmental quality, social justice, pregnant people—are now flagged as “triggering” for administrative review. Entire fields of research—vaccine hesitancy, climate change, gender-affirming care—have come under scrutiny. In response, many researchers feel compelled to adjust their language to avoid surveillance, with chilling effects on science and public health.
To improve health for all, we must directly name the causes of health, the people most affected, and the solutions required. Public health cannot thrive in half-truths or surveilled language.
This linguistic adaptation carries profound ethical consequences. Pressuring researchers to omit or dilute language does not protect science. It distorts it. Euphemism and vagueness can obscure reality, mislead the public, and delay needed action. Over time, the removal of words will erase the very populations and phenomena that public health exists to serve, undermining both evidence and trust.
To improve health for all, we must directly name the causes of health, the people most affected, and the solutions required. Public health cannot thrive in half-truths or surveilled language.
Language is itself an instrument for promoting health. Words can heal by fostering comprehension and mobilizing action, or they can harm by obscuring reality and increasing misinformation. Clarity of language is not only an academic consideration, it is a public health intervention in its own right.
The Looming Global and Domestic Resurgence of Tuberculosis: Our Next Predictable Surprise?
Authors Max Bazerman and Michael Watkins aptly describe “predictable surprises” as the “disasters that you should have seen coming” and yet occur anyway due to a failure of recognition, prioritization, or mobilization. Previous drastic reductions in funding for tuberculosis (TB) programs in the U.S. were associated with the unprecedented 1985-1992 resurgence of TB in our country. This was compounded by the HIV epidemic and widespread occurrence of outbreaks of multidrug-resistant (MDR) TB.
Consistent with “what is past is prologue,” the sudden cancellation of the United States Agency for International Development (USAID) bilateral assistance programs for TB prevention and control in 24 high TB burden countries and projected disinvestments in domestic U.S. TB programs point to the next predictable surprise: a global and domestic resurgence of TB.
Regrettably, we can never recover the lives lost from preventable deaths during these failures. And ironically, recovering from such public health disasters is consistently costlier than having provided continued investments for the effective implementation of prevention and control activities. Thomas R. Frieden and colleagues estimated that New York City expenditures to address this resurgence in the 1990s “easily exceed $1 billion and may reach several times that amount.”
Those necessary expenditures for sustained response and recovery during 1993–2014 yielded remarkable benefits. Nationally, we estimated that renewed investments in the infrastructure for services and research activities averted approximately 145,000 to 319,000 new TB cases during 1995–2014, and the economic benefits of these averted TB cases saved $3.1 billion to $6.7 billion dollars, excluding deaths, and $6.7 billion to $14.5 billion, including deaths.
In March 2025, The New York Times shared an internal USAID memorandum by the acting assistant administrator for global health, projecting the impact on human health following cuts to foreign aid. That memo estimated an annual 28-32% increase in global TB incidence, and another annual 28-32% increase in global MDR TB incidence if USAID support for TB programs were to be permanently halted.
More recently, Rebecca Clark and colleagues used mathematical modelling to estimate the impact of reductions in international donor funding on TB in low-income and middle-income countries. The authors focused on 79 countries, which accounted for 91% of global TB incidence and 90% of global TB deaths in 2023.
They estimated that termination of USAID funding would lead to 1.4 million excess TB cases and 537,700 excess deaths by 2035. Another publication by Sandip Mandal and colleagues modelled the potential impact of U.S. TB funding cuts to 26 high-burden TB countries using three recovery scenarios: minimal impact (services recover within three months), moderate impact (recovery within one year), and worst-case scenario (long-term service reduction). Since the first three months have already elapsed, the data presented here are limited to the moderate impact and worst-case scenarios.
...the sudden cancellation of the United States Agency for International Development bilateral assistance programs for TB prevention and control in 24 high TB burden countries and projected disinvestments in domestic U.S. TB programs point to the next predictable surprise: a global and domestic resurgence of TB.
In all 26 high-burden TB countries, additional TB cases between 2025 and 2030 are estimated to range between 1.66 million in moderate impact to 10.67 million in worst-case scenarios. Corresponding TB deaths were estimated to increase by a range of 268,600 to 2,243,700, respectively, for moderate impact and worst-case scenarios. The authors conclude that the “loss of U.S. funding endangers global TB control efforts, jeopardizing progress toward End TB and Sustainable Development Goal targets, and potentially puts millions of lives at risk.”
In contrast, in March 2024 the World Health Organization presented modelling data on the costs and benefits of TB screening coupled with TB preventive treatment in Brazil, Georgia, Kenya, and South Africa. This showed significant health and economic benefits in all four countries and an approximate return of $39 in U.S. dollars for each dollar invested. This report has been touted as the “investment case.”
Also in March 2025, author John Green released his book Everything is Tuberculosis, based on his personal experience with Henry Reider, a young person afflicted with MDR TB, and whom he met at the Lakka TB clinic in Sierra Leone. Green was compulsively driven to conduct his own research about TB, its history, and its impact on humanity. He exposed that many people in high-income countries with relatively low TB incidence consider this a disease of the past, yet globally it continues to account for more than 1 million deaths annually—making it the leading infectious killer of young adults.
Based on past experiences and future projections, it is perfectly reasonable to anticipate the looming resurgence of domestic and global TB as our next predictable surprise. In fact, between October 2024 and July 2025, news media has reported the occurrence of TB in Immigrations and Customs Enforcement detention centers in at least four states. This places inmates, detainees, and guards at risk of TB. Having recognized this imminent threat, we must now implement the advice provided by Bazerman and Watkins and respond to the clarion call for immediate action. We should rapidly prioritize the mobilization of key stakeholders to minimize preventable illness and deaths.
Domestically, the National TB Coalition of America and Stop TB USA are crucial partners, able to schedule congressional briefings with elected officials in local, state, and national settings to raise awareness and articulate and justify the need for continued investments in research and services for people with TB infection or disease. Other key stakeholders include affected communities, such as TB Survivors–We Are TB to continue to provide much-needed support and advocacy.
Professional organizations—such as the National Association of County and City Health Officials, the Council of State and Territorial Epidemiologists, the American Thoracic Society, Infectious Diseases Society of America, American Academy of Pediatrics, American Public Health Association, American Medical Association, and others—should intensify collaborations with the Centers for Disease Control and Prevention’s (CDC) Division of Tuberculosis Elimination and Division of Global Migration and Health, and CDC-funded TB Centers of Excellence and TB Trials Consortium for heightened surveillance, prompt detection of outbreaks, and rapid and proper responses.
Other key partners include the National Institutes of Health, National Institute of Allergy and Infectious Diseases-supported TB research in academic institutions, such as the Tuberculosis Research Units and TB Research Advancement Centers (TRAC). We should soon schedule brainstorming sessions with other NIH-sponsored TRACs, Centers for AIDS Research, and CDC-sponsored TBTC and city/state-based TB programs to identify implementation science research coupled with preparedness and response capabilities to help address urgent threats and realities and inform timely updates of evidence-based guidelines.
Continued U.S. involvement in global TB efforts must now rely on the reconfigured functions housed in the Department of State, Global Health Security and Diplomacy, more specifically its President’s Emergency Plan for AIDS Relief, Office of Regional and Multilateral Diplomacy, and CDC’s Global Health Center and its country offices. Other opportunities for collaborative work in global settings include strategic partnerships with the Global Fund to Fight AIDS, Malaria, and Tuberculosis; the Stop TB Partnership; and WHO.
On January 20, 2025, an executive order announced the withdrawal of the U.S. from WHO. This will no doubt present challenges to U.S. government entities. This should not, however, prevent those in academia or professional organizations from continuing to provide expert consultation in support of WHO’s normative functions for global health evidence-based policy derivation. I and other U.S.-based professionals have continued to serve as subject matter expert peer-reviewers to WHO and their regional offices.
USAID previously funded TB research and coordinated the U.S. TB Working Group to align and facilitate global TB initiatives. In its void, TB will continue to cause havoc, and we must now explore how to leverage various existing international collaborations with U.S.-based academic institutions, such as the Emory TB Center, NIH Fogerty International Center-supported Emory-Georgia TB Research Training Program, Ethiopia-Emory Research Training Program, and TB research by University of Georgia-Makerere University College of Health Sciences.
Clearly, this is no time for complacency. This is a time for urgent and concerted action. I echo Green’s closing admonition: “…we must work together to end tuberculosis and all other diseases of injustice.” It is up to us to rise to the challenge!
The Cost of Failing to Sustain NIH Investments in Health Research
Everyone will need health care services during their lives. We just don’t know today what specific medications, surgeries, or preventive therapies we might need in the future. For decades, National Institutes of Health (NIH) research has represented an investment in the health of people in our nation and in our families, so they (we) have access to the best-possible care when the time inevitably comes.
Since the beginning of the current administration, support for the NIH and the extramural research it supports have been under attack. But in the context of the U.S. budget, the NIH budget is modest for all the good it does. Support for the NIH was less than 1% of the federal budget in 2024, and 83% of that money went directly to U.S. researchers, institutions, and our communities. By making modest federal investments today, we can all have confidence that the right medications, procedures, and knowledge will be there when we need them for ourselves, our families, and our communities.
Americans invest tax dollars in NIH research. NIH scientists do the work of understanding the most common diseases that Americans will encounter and developing a rigorous program of research from the basic science bench to the patient’s bedside. They do this so that when we or our loved ones get sick, there is knowledge and medications to prevent what is preventable, to cure what is curable, and to relieve suffering and prolong life when cures are not yet available. NIH also supports the career training of researchers, serving as a critical resource to assure an ongoing pipeline of scientists to address the health challenges of the American people.
Even if your priorities are economic, there are important reasons to support a comprehensive program of health research in the United States. The commercial development of medications that grow from NIH funding also benefit other U.S. industries. In 2023, the U.S. exported over $100 billion in biopharmaceutical goods outside of the country, and the value of medical tourism to the United States was nearly $8 billion in 2023. Those medical tourism dollars also benefit other U.S. businesses, including travel and hospitality business. For every $100 million in NIH funding, researchers generate 76 patents, which in turn spur another $598 million in further research and development.
NIH scientists do the work of understanding the most common diseases that Americans will encounter...so that when we or our loved ones get sick, there is knowledge and medications to prevent what is preventable, to cure what is curable, and to relieve suffering and prolong life when cures are not yet available.
If you’re unclear as to whether the research that NIH supports is relevant to you and your family, try this exercise. Think about the health concerns that you have and that the people in your life have: your parent with Alzheimer’s, your spouse with high cholesterol, your child with a developmental concern, or your neighbor with debilitating arthritis. You can go to reporter.nih.gov, enter the health condition you are concerned about, and see a list of the investments that have been made in health research to prevent these diseases, to preserve quality of life for those who have them, and improve outcomes for those who experience them. Treatments are available for many of the health conditions—anticipated or not—that we and our families will develop. The development of those treatments was done in advance, decades before we needed them, through NIH planning and funding.
I have multiple perspectives on the issue of NIH funding. I am a health researcher. My research focuses on infectious diseases and is mostly funded by federal grants. I am also a cancer survivor. I was diagnosed with cancer in my early 40s, with a family that included two young children. I received surgery to remove my cancer followed by chemotherapy treatment. My surgery and chemotherapy treatments were successful, and today I am free from cancer.
I am alive today, as a parent, a husband, and a health researcher, because the scientific knowledge needed to cure me was there when I needed it. Decades before I needed cancer treatment, some of my tax dollars—and some of yours— went to supporting a carefully thought-out program of health research that anticipated the need for chemotherapies and treatment protocols for the cancer I would be diagnosed with. Similar investments were made toward research on dozens of other cancers that researchers knew would impact the health of other Americans in the future.
This advance preparation is what NIH research oversight and funding processes accomplish. Using guidance and consensus from experts inside and outside of government, NIH scientists develop, debate, finalize, and fund investments in the diagnosis, prevention, treatment, and care for the health conditions that we and our families are most likely to encounter.
At every step, government scientists consult with—and ultimately seek approval from— experts outside of government for the broad contours of planned investments. Non-government experts, free from conflicts of interest, objectively evaluate new proposals and evaluate their merits. A second group of objective experts approves recommended grants to be awarded. Scientists receive money and are required to provide regular updates on scientific progress and to share findings in ways that are transparent and accessible to the public. There is objectivity, accountability, and transparency at every step of the process.
As all aspects of federal spending are under scrutiny, it is critical to take stock of the value of federal investments in health research and to speak up for investments in science. Decisions made by Congress threaten to reduce future NIH funding opportunities. The value of investments in science can be evaluated in different ways. We can quantify economic returns on investments in research, but for many of us— as researchers and parents, as scientists and patients— there is even greater value in knowing that we will have access to rigorously proven, effective therapies when we or our loved ones need them.
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Rollins Magazine is published twice a year by the Rollins School of Public Health, a component of the Woodruff Health Sciences Center of Emory University, for alumni and friends of the school.