5
Public Health
John Auerbach of Trust for America’s Health introduced the conversation with a question about how public health is navigating this challenging time of both the pandemic and the movement against racial injustice. Key points from the panelists are provided in Box 5-1.
Joneigh Khaldun, chief medical officer of the Michigan Department of Health, said that this is a moment of pride for public health. Her state health department began its planning for COVID-19 in January. Oxiris Barbot, former health commissioner of New York City, said that people need to acknowledge that this is a mixed time for public health in that the disconnect among federal, state, and local response to the pandemic has been a challenge, but it has also been an opportunity because it is kind of a Super Bowl for public health, allowing the field to demonstrate the deep bench that it has. Although it is a difficult time (i.e., protecting the health of the community), it is a good time for the field to distinguish itself from health care (i.e., providing clinical care to individuals). Monica Valdes Lupi, senior program officer at The Kresge Foundation and former Boston public health commissioner, agreed that this is a time of both challenges and opportunity for public health.
José Montero, director of the Center for State, Territorial, Local, and Tribal Support at the Centers for Disease Control and Prevention (CDC), said that one of the challenges in the pandemic response has been the evolving science, but he added that the system’s capacity to respond has been impressive. He noted that the preparations for a pandemic did not just begin with the emergence of COVID-19, but that planning had been taking place for years—he worked on pandemic response planning years ago as a state health official. The pandemic has also highlighted the need for collaboration and integration with health care, and it has also had inequitable effects on the population, with some groups becoming sick and dying at higher rates.
Umair Shah, executive director and local health authority of the Harris County Department of Public Health, agreed with the characterization of the current moment as both a “challenge and opportunity,” but also commented on the often politicized nature of the response to the pandemic. He talked about addressing the invisibility crisis that public health faces using three Vs: raise visibility, which brings value, which in turn brings validation in the form of prohealth policies and/or prohealth resources. Shah said that he just never thought that it would be a fourth V—virus—that would actually raise the profile of public health to the degree that it has during COVID-19.
Auerbach asked the panel about the key lessons from this moment. Barbot commented that risk communication has been critical in responding to the pandemic, and she spoke about how in the response in New York City early, frequent, clear, and consistent communication to residents was critical, as were openness about what was known and areas of unknowns or uncertainty. Having messaging reinforced by leaders in other sectors is similarly important. Barbot expressed concern about how young people considering public health careers regard the targeting and
scapegoating of public health leaders in the pandemic. She said that she would want young people to recognize the value of public service and of bringing science to the everyday lives of Americans. That is a value that must be protected, she added. Khaldun spoke about the importance of equipping public health professionals, epidemiologists, and scientists with the skills to communicate effectively with leaders in other sectors, including political leaders, and with the ability to translate scientific information in a clear and relevant way.
Montero concurred with Khaldun’s comment about communication and added that being able to communicate uncertainty is crucial. Better transmission and translation of data to the public is important, as the public now has more access to certain facts and figures on their phones than ever before. It has been an interesting dichotomy in working with the public that is hungry for information about where people are sick while at the same time “many of them don’t want to tell us when they were sick or who they were with when we are asking them to do contact tracing.”
Valdes Lupi said that community engagement is an important element of the larger communication effort. For example, “we will need to lean on community partners to roll out a vaccination program.” In some jurisdictions, like Boston, there is a high uptake of immunizations, but in some areas, the level of trust is lower and influenza vaccine uptake is low. Communicating complicated issues to the public is a challenge, so working with trusted community partners is crucial. Shah summarized some of the communication skills that public health leaders need but may lack, from risk communications to social media to being able to communicate complex topics clearly and in a reassuring, not scary, manner during times of crisis.
Auerbach added that another important lesson is to respond to the available data about the misery and death in populations of color and to work on issues related to promoting equity. There were two audience questions on that theme, Auerbach noted. How can public health, particularly governmental public health, be influenced to prioritize Black and Latino communities and other populations of color who are disproportionately represented among those who are most affected by COVID-19? Second, how does the field address social factors such as living wages, expanding Medicaid coverage, and ensuring that people have affordable quality housing?
Shah answered first that COVID-19 did not start these inequities, although those preexisting inequities have unfortunately been accentuated and worsened by the pandemic across the nation. Public health has a responsibility, just as it did prior to (and well after) the pandemic, to address the structural and social factors that shape health outcomes. For example, Khaldun said, people need to vote, and greater diversity
is needed both in public health and in different levels of leadership. It is also necessary to be intentional and systematic about addressing equity. Michigan has an equity impact assessment that the state is implementing, assessing the impact of every policy decision on communities of color, and Khaldun emphasized the importance of having data that has been disaggregated by race and ethnicity.
Barbot spoke about how the New York City Health Department has worked to apply a racial equity lens to change the character of its response, and how it has worked to secure better data to inform its work. However, she noted, public health should not allow itself to be imprisoned by imperfect data. Early in the pandemic, when the agency started to see that Black and Brown New Yorkers were dying at twice the rate of White New Yorkers, the health department sounded the alarm even in the context of incomplete data. Public health needs courageous leaders, and being courageous means being able to make hard decisions in light of imperfect data—which is the definition of public health, Barbot said. She added, “To have more courageous leaders in public health, we need a civil society that supports the value of public health.” Public health data should be used, Barbot said, to respond to housing insecurity, food insecurity, and to make it easy for people to follow public health guidance, such as for isolation and quarantine.
Montero spoke about the assets that public health brings to the table in the conversation about the social factors that shape health outcomes. Although public health cannot solve the challenges related to employment, housing, or education, public health has the ability to view health issues and health outcomes in the context of the society and community where life happens. Perhaps public health leaders and workers are not able to change the factors that shape health or the burden of COVID-19, but when public health takes its seat at the tables where those conversations happen, Montero stated, public health has the duty and the ability to raise those issues, and to show how policies in non-health sectors affect health.
Regarding the role of data, Valdes Lupi underscored their importance for policy decisions. Policy and advocacy are highlighting how employment-related issues are contributing to disproportionate COVID-19 burdens in communities of color. Public health leaders understand the value of policies about sick leave benefits, living wages, and stable housing, Valdes Lupi said, and can partner with others to help in addressing these complex issues. An added consideration, noted Valdes Lupi, is the intergenerational effects of these factors on morbidity and trauma for racial and ethnic minority populations. Montero noted that adverse childhood experiences, which affect some populations to a greater degree, are a major issue that public health will need to address through policy and action to
lead to “better conditions for children today” that could yield dramatic results for “prevention down the road.”
Auerbach agreed with key observations made by the panel and shared a few thoughts, including that categorical funding sometimes makes it difficult to work outside of the disease model, and that the issue of racism can be viewed as controversial in some areas and can be challenging for a public health official to speak about. He shared this to set the stage for a scenario that he presented to panelists. Imagine, he said, a state where a new governor was just elected, and the governor comes in and asks for advice. Khaldun started by sharing the actual advice that she provided to her governor about the need to focus on children and maternal health. The state has focused on expanding Medicaid and finding funding for it, and on streamlining cross-enrollment for food stamps and other social services, by integrating information systems.
Barbot said that in order to measure the effect of policies in different sectors on health outcomes, she would focus on premature mortality. “We know,” she said, “that Black, Brown and Indigenous Americans die much earlier than their White counterparts.” Valdes Lupi said that she would, as she did in Boston, implement training on antiracism and work to operationalize an equity ethos through equitable procurement policy, such as contracting with community vendors, to invest in local neighborhoods and minority-owned businesses. Administration and finance may not be glamorous activities, but they are critical in rounding out the work of the public health workforce so that resources are allocated to the breadth of key public health issues.
Montero said that he would propose to his hypothetical new governor a 4- or 8-year plan and would focus on the unique geography and other characteristics of the state. Climate change, urbanicity, and other factors may be issues. A state public health leader needs robust capabilities to rely on from data infrastructure to community support, but such a leader also needs flexibility and political support. Shah added that a governor’s political antecedents are equally important. What did the governor run on and prioritize, especially related to health? The political naïveté of public health leaders will not serve them well in the face of a lack of political will. Barbot said that “we often talk about the art and science of medicine, but we don’t talk about the art and science of public health.” The latter, she said, is the ability to present an investment that has long-term gains in a way that makes the short-term gains more apparent. Public health leaders need to be less naïve and more opportunistic in terms of being clear-eyed advocates for their communities, presenting ideas that have the greatest promise for reducing and eliminating racial inequities.
Auerbach thanked panelists, and began fielding additional questions from the audience.
One was, “How do public health leaders combat misinformation about vaccines and about COVID-19?” Shah said that public health leaders need to be active and engaged on social and other media that communities themselves are involved with, but they also need to recognize the potential shortfalls of different media as they utilize them. Barbot shared her experience responding to the 2019 measles outbreak in New York City. In addition to being in front early with “consistent, concise, approachable, accessible information about what the facts are and addressing misinformation head on,” she said that engaging trusted community members is essential for sharing messages effectively.
Another audience member asked about the steady decrease in public health funding due to, as Auerbach added, the failure to replenish what was lost in the 2008 recession, along with tens of thousands of public health jobs lost.1 The pandemic has further decreased government resources at all levels. Montero spoke about the fact that health departments never recovered at the jurisdictional level from the recession, and the pandemic has had an additional effect. Montero spoke about braiding funding (i.e., using separate funding streams in an integrated way to achieve aims shared by different programs), about leveraging resources, and about partnering with other sectors, especially health care. Public health will also need to integrate some of its silos, and that may help. Ultimately, he stated, “We as a society pick and choose what type of government we set, and what type of programs and actions that program, that government is going to implement. We cannot separate one from the other.”
Public health is a public good, remarked Valdes Lupi, and the field is no longer invisible; there is a need to take advantage of this moment of visibility to advocate for public health as a public good, like schools, law enforcement, and other services. She added that it has been particularly difficult for smaller jurisdictions to obtain adequate personal protective equipment and resources for setting up mobile testing sites.
An audience member asked, “How should public health grapple with political interference?” Public health, Barbot said, is situated at the intersection of science and politics, and at this particular moment, science is “taking it on the chin.” It is important at this time that governmental public health and nongovernmental public health work together,2 and the latter can support government public health officials that are protecting their communities. Montero said that transparency in science, data, and policy making is a key factor on this. Public health is a participatory
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1 See Trust for America’s Health reports on public health funding. See https://www.tfah.org/issue-details/public-health-funding (accessed June 23, 2021).
2 Academia, nonprofit organizations, and public health philanthropy.
decision-making process, and public health needs to recognize that it is not the only messenger and that it needs to work with others to communicate the science. Barbot underscored Montero’s observation about transparency, adding that when politics begin to infringe on decision making, a previously high level of transparency will be affected in an indication of the effect of politicization.
Auerbach asked the panelists to turn their attention to a lightning round. The election is over, he said, and the president has been elected. “You get a call from someone who is working on policy, and they are asking you: what’s the one thing you would recommend that is the key thing that would advance the health of the population?” he asked.
Khaldun would say to build out a national strategy on COVID-19 and to “rebuild trust in public health and the scientific community.” Barbot would call for a “national health equity action plan” that focused on funding public health to target communities that are facing the greatest inequities and that also questions why the United States still has primarily employer-based health insurance in light of the fact that job losses due to COVID-19 have also meant loss of health insurance. Shah would call for ending the devaluation of public health, for supporting and elevating federal agencies like CDC to their previous status, and for ensuring that CDC’s work is well coordinated with state and local public health partners. Valdes Lupi would recommend an infusion of resources into public health infrastructure, such as the $4.5 billion that has been recommended by the recent Trust for America’s Health report (2020), and she would recommend moving away from the categorical funding of the past. Montero would propose a two-pronged approach: first, rebuild and improve public health infrastructure; second, address core capabilities and functions as part of a national strategy that aims to tackle health issues through addressing the social determinants of health.
Shah said that he would raise the position of governmental public health so that it is no longer subsumed under another agency, but is placed at the highest levels of government, for example, at the federal level as a cabinet-level position or at the state level as a secretary-level position. Khaldun said that she would draw attention to the nation’s mental health needs, given the collective trauma that the nation is currently experiencing, its effects on children, and its consequences for generations to come. Also, she added, public health needs strategic partnerships with business, education, health care, and others so that when the next pandemic hits, the sector is ready. Valdes Lupi built on Khaldun’s comment by underscoring the importance of building on the strengths and assets of communities and their resilience during this time. Also, the work of public health needs to be trauma informed in order to respond to the trauma and health inequities that communities of color have been experiencing for generations.
Montero concluded by stating that society is experiencing a kind of posttraumatic stress disorder, and that an integrated response will be needed. Moreover, the opioid epidemic is continuing, and the pandemic is uncovering and intensifying other health issues. All of these issues, along with ending the pandemic, are all on the public health sector’s long to-do list.
