A Strong Public Health System Depends on Making the Invisible Visible

SHANOOR SEERVAI: The global pandemic may be entering a less acute phase, but it has already taken a huge toll on the nation’s public health system. The profession itself is more visible and more divisive than ever before.

I’m Shanoor Seervai, and today on The Dose we’re going to talk about the future of public health here in the U.S. with Dr. Dave Chokshi, who led New York’s pandemic response as the city’s commissioner of health. We’ll discuss how this extraordinary experience, including the urgency to vaccinate over 6 million people, has informed his ideas about the future of public health. Dr. Chokshi is a primary care doctor, public health expert, and a professor of medicine at New York University.

Thank you for being with me today.

DAVE CHOKSHI: Thank you so much for having me, Shanoor.

SHANOOR SEERVAI: So we know that the public health system in this country was not in great shape before, but COVID exposed just how fragmented that infrastructure is. What are your thoughts about how we might pick up the pieces of the broken systems across local, state, and federal levels, or must we reimagine the public health landscape entirely?

DAVE CHOKSHI: I think both are actually true, but it is important to root this conversation in the fact that we have had a weakened and disinvested public health infrastructure spanning decades. We only have to look at the resources that are dedicated to public health in comparison, to, for example, total health expenditures. Public health gets less than 3 percent of the nearly $4 trillion that are our national health expenditures. And in some ways you get what you pay for. That proportion has actually declined over the last several years, and that meant that we didn’t have laboratory capacity, we didn’t have sufficient epidemiologists. Certainly when it came to contact tracing and community health workers, we didn’t have the human and physical resources that we needed just to get the job done even when we’re not in a pandemic.

So that’s a big piece of it. But the second part is also what you mentioned, which is that this pandemic has exposed the ways in which it’s not solely about resources. It’s also about organization — across different levels of government, across sectors within a particular place, and ultimately what we believe the accountability in public health is about. So we’re going to have to try to take on both because we’re still in a pandemic and the next public health crisis is likely sooner rather than later.

SHANOOR SEERVAI: And most of our listeners understand this, but why is there this organizational separation between the health system and public health?

DAVE CHOKSHI: Well, there shouldn’t be. I think about this from the perspective of the patients that I take care of. The everyday person could care less about our various boundaries. People want to be healthy, and they want to know that there’s care available when they need it. The fact that we do have this silo has to be rectified, but there are ways to do this, and New York City in particular because we have a relatively robust public health care system, as well as a very strong public health department, is a potential exemplar, particularly in the ways in which those two organizations work together over the course of the pandemic. But at the scale of the United States, that’s a rarity. And we have to think about how to forge those connections more deeply.

SHANOOR SEERVAI: So money of course could solve some of these problems, but public health has also seen these cycles of boom and bust before. The funds flow in to address an emergency, and then some positives are achieved, but then the money dries up and the foundation isn’t really fixed. So what’s the ideal path forward from this moment that we’re at?

DAVE CHOKSHI: Well, when we talk about boom-and-bust cycles, we have to acknowledge that it’s even worse than that in many cases. You look at the last 20 years, anytime there’s a recession, public health is actually raided for funding for other parts of the government or the economy. The same thing happened with the public health and prevention fund that was enshrined in the Affordable Care Act. At every turn, the money that was supposed to be dedicated to public health and prevention was actually redirected to other things. So for us to get out of those vicious cycles is going to require a real step change in our thinking. And as we hopefully continue to emerge from the pandemic, this is the right time to be thinking about it.

But let me not mince words, it will take massive investment in public health. We’re talking about an order-of-magnitude increase in funding. And that’s a hard thing to fathom with respect to where we are right now when, frankly, we can’t even get additional COVID funding while we are still in a pandemic.

So I think it requires reckoning with some deeper forces, and I’ll just lay out two or three briefly. The first is it requires us to reckon with the psychology of prevention and public health. It’s always easier to round up funding for cancer treatment than it is to prevent cancer in the first place. And that’s because success is often invisible when it comes to public health and prevention. There are some ways that I think we can change that, but it requires us to grapple with that in the first place.

The second thing that I’ll mention is that public health bears some responsibility for this as well. We have moved away from being service-oriented and action-oriented, and we saw some of the ways that really left communities in the lurch during the pandemic, whether it was COVID testing or having trusted people who come from neighborhoods to try to combat misinformation. Public health also has to turn the spotlight inward in the wake of COVID-19 to understand what we need to do differently and better.

SHANOOR SEERVAI: And both of these things point me to this question of how to measure the return on investment and make that visible. So how are leaders thinking and talking not only about what to invest in, but then how to measure it and make sure that that seeps into the psychology of how people think about prevention and public health?

DAVE CHOKSHI: That’s exactly right. It’s about making the invisible visible. Making sure that people understand the successes that are attributable to public health. Let’s just take the vaccination campaign as an example. We vaccinated over 6 million New Yorkers. It was estimated that that resulted in about 50,000 lives saved and hundreds of thousands of hospitalizations averted. That’s because of vaccination, that is because of public health that our schools were able to be reopened when they were, and that our economy was able to be reopened as well. We have to do that at every turn when it comes to public health interventions. When you look at tobacco, the media that the New York City Health Department puts out to try to get people to quit smoking not only has saved lives, but for every $1 invested, $32 is saved.

So this all needs to be shouted from the rooftop for people to understand what the economic return is. There’s one last thing that I’ll mention about this, which is that we have to challenge the false dichotomy that doing things for public health means that it comes at an economic cost. This is simply false. Investing in public health is good for the economy as well. COVID-19 showed that so vividly, and we have to make sure that people don’t forget that.

SHANOOR SEERVAI: And since we’ve been talking about communication, I don’t know, I don’t imagine that this was a part of your training in medical school, but your work as a commissioner required hundreds of media appearances during a pandemic, which was and continues to be highly politicized. So did you come away with any insights about how to manage the misinformation ecosystem?

DAVE CHOKSHI: Well, misinformation is something that we have to contend with because it’s costing people their lives and their health. Again, we saw this during COVID-19, particularly misinformation around vaccination. It’s part of the reason that, at the health department, we set up a misinformation unit — the first time that we had done that at the New York City health department, and I think the first of its type in a municipal health department in the United States. But our conviction was that if we’re concerned about health and prevention, then we have to understand misinformation and fight that as well. There are a few things that we learned when we were doing that. One is that we best fight misinformation by taking a public health approach, by preventing it in the first place. But it requires some of the same tools of public health and epidemiology. For example, we built a surveillance apparatus to understand what was it that was actually being spread on WhatsApp or social media, so that we could very rapidly respond to that in a proactive way.

We often didn’t contradict directly whatever the message was, but it was very important to inform what I would say in my PSAs, what we would emphasize in our media appearances. So having that loop of understanding what was actually being spread and using that to be more proactive about our information was crucially important. The other thing that we have to acknowledge when we talk about misinformation is the role of technology and social media. When I served as commissioner, we sent a letter to some of the big tech companies exhorting them to understand what their responsibilities were, not just as a matter of speech, but as a matter of health, as a matter of saving lives. And this is something that’s going to require us to, I think, become even more aggressive in saying that it’s not just about the purveyors of misinformation and disinformation, but also the amplifiers of it.

SHANOOR SEERVAI: When we talk about the response to the pandemic in New York City, what worked that could be replicated in other parts of the country, and what could have gone better if only you had more resources, staff, or money?

DAVE CHOKSHI: Well, one that I’m very proud of is the New York City Public Health Corps. Fundamentally the Public Health Corps is the workforce that we should have had before COVID-19. It is comprised of people who come from the neighborhoods that they’re serving. It’s people who have lived experience, who know exactly where to go to gather community intelligence and map that onto what we’re seeing for the city as a whole. It’s people who have the ability to work with neighborhood members who may have limited health literacy to improve that, and to make sure that our messages are landing as trusted messengers in those communities that they’re from.

SHANOOR SEERVAI: And just for our listeners who are not in New York City, I imagine you’re talking about communities that are extremely diverse in Queens and Brooklyn and The Bronx. So paint a little bit of that picture for me, and then how the Public Health Corps operated.

DAVE CHOKSHI: That’s exactly right. Each New York City neighborhood is very different with respect to cultural and ethnic diversity, languages spoken. And there are ways to scale this. It’s bespoke at the level of a community, but it’s scaled at the level of New York City. We invested $235 million to start this as a collaboration between the health department and the public health care system. But it required a great deal of humility from all of those parts of city government, because most of that funding is actually being channeled to 100 community-based organizations, because those are the organizations that have already earned the trust in the communities that they’re serving. So the Public Health Corps is very important, not just in times of crisis like a pandemic — although they will now provide that ready workforce for whatever the next disaster is — but also for what I think of as all of the slower-moving disasters in between emergencies. The opioid crisis, chronic diseases from diabetes to hypertension to heart disease.

SHANOOR SEERVAI: And do you think this model could be replicated in other parts of the country during times when there isn’t an emergency like the one we’ve been in for the last two years?

DAVE CHOKSHI: Yes, that’s exactly right. And let me clarify to start. This is a model that has really taken from other parts of the world. Community health workers have a long and impactful lineage in many places from Costa Rica to India to South Africa to Mexico. And the evidence base for them is irrefutable when it comes to health outcomes and growingly return on investment as well. So New York City certainly derived inspiration from global community health worker programs, but it is different to bring them about in the United States health environment because of what we were talking about with respect to how much of the dollar flows through health care in the United States. So that’s why it was very purposeful that this is a collaboration across public health and health care to try to set the example for other places across the country.

SHANOOR SEERVAI: If we talk a little bit now about the people who are working in public health, what do you see as the future of the profession?

DAVE CHOKSHI: Well, we are at a precipice. We are at a truly critical juncture when it comes to the public health workforce. Public health officials have been harassed and threatened. I know that from direct experience. But staff at all levels in public health are exhausted and burned out and traumatized. That’s very real. It has to be contended with. A lot of the solution is structural. What we’ve been talking about with respect to investment, but also making sure that there are career ladders and opportunities for people who enter into public health professions.

There are some things that give me hope. More so than at any point in my career, the number of young people who are inspired to pursue a career in public health, that’s at an all-time high. And I do think of course it’s related to what we’ve seen with respect to pandemic response. It’s up to us as a country and as a field in public health to channel that interest and to make sure that that translates into the best and the brightest and, most importantly, the people who come from communities that are in the most dire need of health improvement actually do pursue careers in public health and do it in a way that is actually leading the transformation that’s called for.

SHANOOR SEERVAI: And you mentioned career ladders, but what are the other incentives that young people have to be in this space, especially when they’ve just seen people, as you say, be harassed and really have a tough time?

DAVE CHOKSHI: So we do have to make sure that the idealism that can drive someone to the field in the first place is paired with everything that’s required to retain someone, which has to do with financial means, as well as making sure that the work environments are safe and welcoming for people to stay in for the long haul.

SHANOOR SEERVAI: And before you were New York City’s health commissioner, you were chief population health officer at Health + Hospitals, the largest safety-net system in the U.S. Could you talk a little bit about how your work as a physician and then attending to the health of some of the most vulnerable populations in the city is shaping your thinking about the future of public health?

DAVE CHOKSHI: Each of my patients has a story, and this is why I love practicing medicine, because you have the enormous privilege of being able to bear witness to the struggles, the traumas, all of the disadvantages that have compounded and often result in a health catastrophe. It has certainly deepened my understanding of what it takes to generate health. Understanding that so much of it has to do with all of the forces beyond the walls of my clinic — education and housing and transportation and food. And that’s what was always animating for me, to be able to take the extraordinarily moving experiences that I had trying to take good care of my patients and bring them into other realms, whether it was a board room or into policy discussions in City Hall.

And we need more of that. We need more people who are able to bear witness. The interesting thing about this is that across the political spectrum, when you ask people, “How should we be investing our money to produce health?” Two-thirds to three-quarters of them will say what we know: the social determinants of health. Food and housing and education are where we should channel those investments. So it’s our job, those of us who are in health care and health policy, to be able to change the funding flows in accord with what we know.

SHANOOR SEERVAI: If you look back at your time as health commissioner in New York, I mean, in many ways, the city is a microcosm of some of the inequities we see across the United States, and it was very, very stark how different communities were impacted differently. Can you talk a little bit about what it was like to witness that and what you could do about it in your role?

DAVE CHOKSHI: Yes, this has to be one of the stories that we hold on to as we remember the devastation of the pandemic. And that’s the story of how it was not borne equally. How there was this, what I think of as catastrophic combustibility of historical patterns of injustice intersecting with disease. And we saw this across the country, including in New York City. One memory that I have for a patient of mine, who I’d been taken care of for several years, he had kidney disease and diabetes, and I was particularly worried about him with respect to his risk from COVID-19, but he was also a restaurant worker.

So I saw him in May of 2020, he had survived that devastating first wave, and the city was just starting to come back economically. And he came to see me and he said, “Doctor, they’re offering me my old job back in the restaurant, but I’m a little worried. What do you think I should do? Should I go back even though COVID is still here?” And remember, this was before vaccination, of course. And I thought about how it was such an impossible choice for him, because on the one hand he needed to work for his livelihood, to be able to feed his family and make rent. And on the other hand, he was at significantly higher risk from a severe outcome.

SHANOOR SEERVAI: So what can we do to make it so that in the next pandemic, which is going to happen, this restaurant worker, or perhaps another one, wouldn’t have to make the same choice?

DAVE CHOKSHI: Well, I look back to history for some guidance with respect to how we should navigate this at a societal level. You think about what happened in the 19th century. There were successive cholera and yellow fever epidemics, including here in New York City. And after enough of those, the people of New York City said enough is enough, and that’s actually where my health department, the New York City Department of Health, was born from. The impetus to say that investing in sanitation systems and other ways to bring public health to the fore was warranting.

So I see us here in the 21st century, and we have a fork in the road. We have to decide in the same way that our forebears did: Are we going to go the way of the pioneers and the 19th century and say, “We need to invest in public health and think about it as infrastructure in the same way that we think about roads and bridges,” or are we going to let this opportunity pass us by? And if we take the opportunity to build that community-based public health infrastructure, to embrace a mission of health equity as fundamental to health, then that’s what will help to protect the patient that I described and so many others.

SHANOOR SEERVAI: It’s probably fair to say that you had a very stressful job. Are you taking some time to catch a breath, or what’s next for you?

DAVE CHOKSHI: As I’ve been reflecting on the past two years, I have to say sometimes I feel like I’m someone who survived an earthquake and the many aftershocks that are happening in the wake of that initial devastating wave in New York City in March and April of 2020. And, you know, what I appreciated over the past two years is that forgetting is all too easy. So it’s up to us who experienced the pandemic in a different way to share our stories and to make sure that this translates into durable change over a longer term. We have to build better systems, more robust and protective structures. And then to connect it to the earlier part of our conversation, which is making the case for massive investment in public health, particularly the public health workforce that we need for the future, and to do it in a way that makes it very clear that this is better for all of us, not just for the most marginalized among us, but for our community as a whole, for our economy. So those are some of the things that I hope to share.

SHANOOR SEERVAI: Dr. Chokshi, thank you so much for joining me today.

DAVE CHOKSHI: Thank you, Shanoor, for having me.

SHANOOR SEERVAI: Listeners, before I let you go, I want to tell you about a new public health initiative from the Commonwealth Fund. We recently launched a Commission on a National Public Health System to articulate a vision for how the U.S. could create a national public health infrastructure that improves health and equity every day and enhances the nation’s preparedness for future crises. You can find more information on our website, commonwealthfund.org.

This episode of The Dose was produced by Jody Becker, Mickey Capper, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. I’m Shanoor Seervai. Thank you for listening.