Regaining Trust in Our Public Health System

(upbeat music) - Hi, this is Jim Nickman. - And this is Brian Elbowl, and you're listening to Conversations about Healthcare Delivery in the United States. A podcast series featuring our conversations with prominent experts, innovators, and leaders in the health sector. - Dr. Aksira Sparbo is president and CEO of the United Hospital Fund, an independent nonprofit dedicated to building an effective and equitable healthcare system for every New Yorker. She's a nationally recognized physician, public health practitioner, and innovative leader at the intersection of public health, social justice, and healthcare delivery. She previously served as commissioner for health of New York City and Baltimore City, and was a primary care pediatrician in Washington, DC. Thank you so much for joining us. - Thank you for having me, Brian. It's great to be with you. - Wonderful. So I was hoping we could start big picture. Could you tell us a little bit about your view of the role of the public health system in society, right? How has this changed over time, and how do you see it really evolving, or how should it evolve moving forward? - Yeah, you know, I've been thinking a lot about this, and first and foremost, right, the foundation is that the role of public health is to protect and promote the health of individuals and communities, and that the way that public health is sort of evolved, and will continue to evolve, needs to be responsive to that core sort of mandate. And so if we think about the way in which public health has evolved, right, it grew out of a need to protect individuals and communities from industrialization. And then it matured into protecting individuals against communicable diseases, in addition to industrialization, right, you know, polio, TB, et cetera, of which continue. And then most recently, looking at protecting individuals from non-communicable diseases, such as obesity, diabetes, et cetera. And so, you know, as I think about how public health needs to evolve, I think that those categories are still relevant, but what goes into the categories is different. And so for example, I think that with the rise of income inequality and the degree to which that has impacted the health outcomes of communities differently based on the resources that are allocated to individuals and communities, I think that public health has a role to play in protecting communities and individuals from the ever sort of increasing impact of income inequality in this country. And so, you know, that's why it's so important for us to be talking about health equity and all the public health we work in, all the public health work that we do because, you know, unless we shine a light on those issues, we're never gonna get to a place where every person in this country has the greatest opportunity to fulfill their full health potential. - Yeah, and do you see that shift or that kind of slight change in focus to more equity in incoming inequality as a big fundamental one or as kind of a natural evolution than something that public health has always been doing and paying attention to? How do you think about that shift? - I think it's probably more of a, an incremental shift that is now accelerating given what was uncovered by COVID and the racial reckoning, you know, spurred by George Floyd's murder. So I think that, yes, public health has been working in this area for decades. Primarily through the lens of disparities, but when we talk about now moving into addressing inequities, for me, that has an underlying red of a power imbalance that unless we talk about it explicitly, doesn't get incorporated into potential descriptions of what the issues are as well as what the potential interventions might be. - Mm-hmm, mm-hmm. Yep, so let's keep that equity, slash disparities, lens in mind as we kind of shift to talk a little bit more about COVID directly, right? So you're leading the arguably the most important health department in the country at a time where New York City was the epicenter of the pandemic. And I'm wondering if you could just tell us a little bit about that, right? What was your, what was that early period of the pandemic light? How did things have to change? You know, what were your immediate reactions and how did that shift over time? And what surprised you a little bit about that time in your reaction? - Yeah, you know, I would have to say that, first and foremost, it was surreal because on an almost hourly basis, what we were planning had to be adjusted based on new information that we gathered, and that new information, you know, oftentimes was scientific information about what we were learning with regards to transmission and the way in which the virus affected the human body, but also, you know, we had to deal with ever-changing data coming in about sort of the politics of this response and how we were then going to have to adjust our public messaging so that, you know, the public wouldn't get with lash trying to decide, you know, what guidance they should be following. So centrally, you know, my job was to take in this information and set the plan for response and keep my team focused on the central mission, which was to protect and promote the health of New Yorkers and to do it in a way that was as a way as protected from politics as possible, right? Because one of the things about public health is, for me, it's defined by the intersection of science and politics and we dealt with that for generations, but COVID, you know, took that to another level. And so my job was to have the team focus on the science of the response and as much as possible be protected from the non-science of the politics. And you know, one of the surprising things was the degree to which there was a mismatch between what localities such as us and other big cities and other places that had COVID early on thought the response should be as compared to what the response ended up being at the federal level. And that was, you know, surprising and not surprising in a good way, you know, was very disappointing that we couldn't get to a point of greater harmony faster because the country needed it. - Yeah, I think that kind of, the politics component and how that translated into some of your messaging and trust in the public health system, I think is an interesting kind of story we should maybe play out a little bit. I'm wondering if you could talk about that. So even if you insulated your team from some of the politics and tried to get them to focus on the science, you had to focus on some of the politics there, right? And understanding how to translate that. How did you do that, right? And how did you kind of think about that taking the political data almost as you described it into account when you're thinking about a messaging that's gonna really translate in that and that individuals can trust. - Yeah, you know, I think there are a number of different areas. One was on the most basic level internally, we were talking about the need to recommend masking and taking into account the fact that there would be push back from a certain number of people on the infringement, quote unquote, the infringement on rights of asking people to mask. And we made a decision, at least in New York City to initially not call it masking, but call it facial cover, right? Because we thought that that would be less threatening to folks. And like, you know, I don't know if that made a difference ultimately, but it certainly got New Yorkers to adopt the use of face coverings and ultimately masking, I think to a much greater degree than other places in the country who were similarly affected ultimately as we were. And so, you know, I had many colleagues who visited the city during early middle late part of COVID to say, "You know where else in the country are people masking to the degree that New Yorkers are?" Especially in the beginning. And so I think my hope is that, you know, us taking into consideration the politics around that and politics small P, let's say initially and then politics big P, ultimately, made a difference for us. The other thing that, you know, I had to contend with was certainly the politics big P, and being mindful of my responses to certain questions on press conferences, not being overly politicized or distracting. So to give you a specific example, I will never forget that I was on a press conference virtually where I was asked to respond directly about whether or not people should consider injecting bleach as a treatment for COVID. And, you know, never in my wildest dreams would I ever consider having to answer that kind of question. And I had to do it in a way that was straight-faced, right? Because like, I seeming even remotely to somehow criticize, you know, the executive at the national level would have been, I think, pretty bad for the city and for me personally, because it was so clear, even in that early period how viscerally people were reacting to the recommendations that we were making. And so, you know, the fine line that public health officials have to walk to not offend or isolate themselves from, you know, who they're trying to protect. And that was something that was, you know, challenging. Yeah. And then how important is, I mean, so really what you're describing is, you know, you need to have a basic level of trust that the public has in you as a messenger or in this system overall. How important is that to kind of motivate the type of behaviors or changes that are important from a public health system? Like, what's the role of trust there? And how did that, how did that kind of shift over time during the pandemic? Trust is central to everything and especially in a pandemic, it's critical. And so, when we were adjusting our messaging to the public, every time we got a new piece of data, we had to take it into consideration with that arc of a narrative that we were trying to build so that even if we were getting conflicting data, the messaging that we were giving the public was consistent. So, for example, everything that I would say, I would press us by saying, this is what we know right now with regards to the science and it may change. As it changes, we will be updating this guidance and saying that over and over again, gave us, I think, a certain amount of latitude to incorporate changing and conflicting data as it came in without necessarily losing, you know, the public's trust completely early, too early on in the process. I think, you know, so I think where then that trust began eroding was when we, one of the things I've said in other places is, you know, when we didn't have the tools that we needed to go into battle and to have a plan that we could execute as we had traditionally done. That's what got us into trouble. So, specifically, when we were unable to do more widespread testing early on because of the snafu is at the CDC, that was a huge hit to trust because that then opened up for what I call armchair epidemiologist to then, you know, capitalize on the uncertainty. Because of the lack of testing that kind of, you know, took things off the track that we would have wanted and that we should have had from the beginning. Yeah, yeah. So, I also want to think about trust from an equity lands, right? And so, how do you think about that meeting? How do you think about how various messages or approaches are going to resonate with you talked about income inequality, you know, different groups, different racial ethic groups, different minoritized groups. How do you think about how some of the trust in messaging resonates differently there and what that means for equity? So, in terms of messaging, there is the message and then there is the messenger. And one of the things that we did early on and it was an outgrowth of the equity equity work we had done at the health department for a number of years before COVID hit. And it was, you know, engaging trusted messengers to convey the information that needed to be shared in order to help communities, whether this, this pandemic. And so, for us, that meant not only translating messages into, you know, whatever the 14 official languages are that New York translates stuff into, but then also engaging faith-based messengers, labor messengers, and so forth. So, that by saturating all of the ways in which we convey messages, whether it be social media, traditional media, radio, or face-to-face messages, we were able to have that same message conveyed by different people. And, you know, that worked for us. And I think that it worked for many people across the country. The other thing is obviously in conveying messages, we need to acknowledge historical arms that have been done. And reasons why people may not be open to hearing particular messengers or messages. And so, you know, I think the, the amount of attention that was given to the ways in which people of color have been hurt by the healthcare delivery system. I think it was important for us to acknowledge that and be able to move past that. Yeah. Yeah. So, I want to talk a little bit about the healthcare delivery system, right? Because obviously one of the, you know, quirks or benefits of public and challenges of public health is that you're not a system that doesn't have itself. You interact with lots of other systems, right? Including the healthcare system. And I'm wondering if you could talk a little bit about that relationship, right? How do you see that? What does that look like? Out of these groups interact together or not to kind of improve the health overall of individual or societies? Yeah. You know, and for this, Brian, I'll go back to my, my earlier response about the evolution of public health, right? So, when public health first came to be as a field, we were very aligned with the healthcare delivery system as it was back, you know, in the, that turn of the century in the 1900s. And there was, I think, more integration of public health and healthcare delivery at that time. And over the course of the subsequent decades, there has been sort of this distance between public health and healthcare delivery so much so that, you know, the vast majority of dollars that are spent on creating and promoting health, go to health, healthcare delivery systems and not to public health. And so COVID, I think, was an opportunity for us to bring those two systems back together. But one of the things I don't think we talk enough about was that the lack of investment in the public health system was born by the healthcare delivery system. Right. So, if we say that differently, if all of the interventions and all of the things that public health needed to have a successful response were in place, I definitely don't think we would have seen the degree of a call or honestly devastation in our hospital systems. If we had had a stronger public health coordinated system, we would not have seen that in healthcare delivery. And so my hope is that as we emerge from this pandemic and there's lots of conversations going on about the need for public health investments that we think about investing in public health systems. the same way that we think about investing that investing in healthcare delivery systems and that we don't continue to shortchange public health because in the end we just end up paying for it just in the lives of Americans. What do you think those investments need to consist of? What are the most important investments we need to assure that that doesn't happen the next pandemic or just in all the other issues you mentioned, chronic diseases and otherwise, right? What does the public health system need? So a number of different categories. One, and this has been talked about a lot, and I think it's important to emphasize is public health infrastructure, which means a technology infrastructure that is 21st century technology, not 20th century technology. One that is able to communicate with the healthcare delivery system and with the social services delivery system, right? Because that intersection is where the power of public health lies and we need to have those three systems be able to talk to one another. The second one is people as infrastructure and developing our public health workforce to value the skills and have proficiency in the skills of community engagement in operationalizing an equity approach to situations to the same degree that they're able to run whatever the fast code is that they need to run. So those two things need to be equally value. And then the third thing that I would say is that we need to invest in reminding the public of the value of public health in their lives. We don't often talk about public health as being about the business of everyday life. The fact that public health touches every person in this country from the moment they're born to the moment they die and the degree to which we can help individuals and communities do that within a place of equity and dignity, then having public messaging that reminds them of the role that public health plays in that space I think is important. So I think those are the big buckets that I would highlight and certainly there are lots of others but I think those three good ones to get us on the road to a more cohesive public health system. Three good ones and three big ones and three hard to get ones and any sense of how shift things in that direction a little bit, how do we get there? That's a good question. I think one is subsidizing public health education the way that we subsidize medical education. Another one is when we think about providing reimbursement or money at the federal level for the healthcare delivery system remembering that these healthcare delivery systems can't function at their best without a strong public health system in their communities. So thinking about if I as the federal government I'm going to give X state dollars for their healthcare delivery there needs to be Y dollars to accompany that to help support the public health system that's going to make that healthcare delivery system work at its maximum best. And then I think lastly thinking about public health campaigns or and communication campaigns to remind people of how public health shows up in their lives on an everyday basis and have it be something that targets young people, right? We reinterpret the message for young people, we reinterpret the message for different racial and ethnic communities but at the end everybody gets the same message that we can't as a country reach our full health potential without a strong public health system and that without it we also can't reach our economic full potential because you can't do that if you don't have a healthy population. So that speaks to the fact that people approach public health from lots of different perspectives, right? You can think about this from a policy, management perspective, nursing, other components of clinical medicine, data, right? What are the sort of like treat your skills or disciplines that that can go into influencing or working in public health, right? Well, what are the various components there and how do those act are interact? Yeah, that's a great question and I think it's a central question because oftentimes historically we've talked about in public health the importance of interventions focused on individuals and communities and that's important but if we don't accompany those interventions with structural interventions then we never get to saturation and sustainability and by structural interventions I mean ones that are focused on policy whether it be big big-peat policy or little-peat policy as well as interventions that infuse themselves into other disciplines, right? So in public health we talk about the intersection of health and housing, transportation and housing and so I think to the extent that we have a public health workforce that can think more holistically about the levers that are in play when influencing the health of communities is important but you know really thinking about when we think about the educational trajectory of educators, of planners, etc. incorporating public health into their curriculums, right? It's not just about us you know having a course on law to graduate and get an MPH but thinking about you know what should an electrical engineer know about public health? I think there's a lot there you know and and so the point being that the science of public health certainly is a discipline that we need more people in but we also need to export that science and incorporated into other disciplines from the perspective like early on as they're starting their degrees so that when they get into positions where they are then influencing the ecosystem, the health ecosystem of communities, they're doing it from a perspective that's been informed by public health values. Yeah I think it really speaks to the interconnected nature of public health, right? You know you can't just have public health people paying it into the housing, you have housing people understanding public health and that's I think definitely where the action is going to be at and I think it's definitely our thing to do, right? And it's going to take some work for us to get there probably. Yeah and you know oftentimes people are concerned about public health becoming too diluted if it looks to influence so many other disciplines and I think just the opposite we need to think of ways in which we reinforce public health's importance in those disciplines and if we can start that early on and continue it through the development of you know different careers, I think that just benefits us because we can only be in so many places at once. Yeah yeah and is this something you think that that that governments or health systems need to do or or you know or is this something that we have to figure out a way to invite into all these other systems housing and otherwise they're doing it like whose responsibility is it here to make it happen? I think government certainly lays a major role a through the way in which they support graduate education, b through the grant making that they do and incorporating you know a health and all policies approach to the programming that's done not only through you know programs that are explicitly public health but again through you know transportation development programs through housing development programs they need to be or they should have I think the public health lens for greater impact on the health of communities. So I wonder if we could sum up with some forward looking components here, right? So maybe as you look forward, what do you think the public health system or public health is poised to do well? And what do you think the challenges are in a looking forward way? Whether that be in response to the next pandemic, in response to the chronic disease challenges we know are there or all of the above? Yeah, I think what public health is good at is also the thing that is most challenging, right? So for me, I think re-engaging the public and gaining the public's trust is critical and doing that so that we can get back to a place where people accept the values of vaccinations so that we can get back to a place where people accept the value of or understand the balance between individual rights and community obligations, civic obligations. I think public health is very well poised to play a central role in re-engaging community in those conversations and I think it's also one of the most challenging because public health needs more voices, conveying our message and getting alignment of those voices is very challenging in an environment where we have social media making it so easy for false information to be conveyed and so weren't not for social media, I think public health would have a very well-worn playbook for re-engaging communities and getting the message out, right? But the curve balls of social media make it hard and the reality is when I was at the New York City Health Department, we had a whole department of staff who their only job was to do social media and to do public outward facing communication and the reality is that most health departments in this country don't have the level of resources that they need to mount that same response, right? It's both a proactive and reactive need that's needed to address social media challenges and so I think when we think about investing in the infrastructure for public health departments, we also need to consider the modern-day realities that were not so when public health you know started growing up and started you know moving into adolescent to an early adulthood, we need to think about public health today, every health department, whether they be local or regional, needs to be able to address the social media falsehoods that affect the everyday lives of the people that you know they're they're entrusted to protect. So you started with the evolution of public health as it relates to industrialization and working conditions and things like that, I'm wondering if we could end it with how does public health engage in that debate, right? How does public health engage in social media and a greater degree? How does public health engage with a skeptical public or business community? What are the kind of keys to making that happen? It starts with attracting as diverse a workforce as possible, creating the conditions where that diversity which is which is reflective of the communities they come from having a voice through the messages that are conveyed because that's how public health remains not only responsive to communities but relevant to communities, right? We need messaging that will not just be one-sided meaning, you know, communities please love us again, but communities, this is how we can be helpful, this is how we can be authentic partners, this is how we can help navigate systems to help ensure that the health of communities is at the center of everything that we do, because I do think that in many communities we no longer have that and that goes back to our roots, and I'm so glad that you took us back there because yes, it was about public health, bringing light to those issues, but it was also about communities asking for public health's support and help in addressing those and going up against forces that they may not have had the full sort of complement of skills to fully address. Yeah, I appreciate you ending it with the community and focusing on what they need there. So thank you so much for joining, it's been a wonderful conversation. Yeah, thank you Brian, it was really fun, thank you. Great. Now a message from Spring Republishing. Variety, flexibility, accessibility, and the freedom to choose what works for your busy life. That's the Spring Republishing way. Visit springrepub.com/publichealth for content and tools to move forward in your career. Use code podcast for 25% off your next purchase. So that was a fantastic conversation with Dr. Oksideris Barbo. I really like how she started with the roots of public health and how it was really in industrialization and really focusing on workers and how we need to to some extent come back to that and keep it moving forward in the public health system is going to be about investment and infrastructure. This is investment in the workforce and education and pure dollars in the system. It has to come from the public health arena, but also from healthcare and the social service sector. And we have to really think about how public health needs to be a key part of each of those other policies. Public health policy has to be housing policy, how should be transportation policy, how should be food policy, etc. And I also appreciated our discussion about trust and how a key component is building trust in the public health system using that trust to improve the public health and making sure that the public feels it and believes it. And that's something that you know might have got lost to some extent during the pandemic. It's something we really do need to come back to and make central of a focus to everything we do, particularly for marginalized communities. That's a really key component here, individuals who we need to listen to and make sure we are speaking to the needs of as we're coming up with these messages and these approaches. So all in all, I thought a great conversation. This concludes another great episode of Conversations about healthcare delivery in the United States. 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