Contagious Conversations / Episode 24: The Modernization of the Public Health System
Transcript
Claire Stinson: Hello, and welcome to Contagious Conversations. I'm your host, Claire Stinson. Every episode we'll hear from inspiring leaders and innovators who make the world healthier and safer for us all. Contagious Conversations is brought to you by the CDC Foundation, an independent nonprofit that builds partnerships to help the Centers for Disease Control and Prevention save and improve more lives.
Joining me today is Dr. Anand Parekh, chief medical advisor for the Bipartisan Policy Center. Prior to joining the Bipartisan Policy Center, Dr. Parekh completed a decade of service at the U.S. Department of Health and Human Services, including a role as HHS Deputy Assistant Secretary of Health, playing instrumental roles in the implementation of the Recovery Act’s Prevention and Wellness Fund, the Affordable Care Act’s prevention initiatives, and HHS’ Multiple Chronic Conditions Initiative. Dr. Parekh is a board-certified internal medicine physician, a fellow of the American College of Physicians, and an adjunct assistant professor of medicine at Johns Hopkins University. In this episode, we discuss the importance of prevention in America's public health strategy. Dr. Parekh discusses the CDC Foundation Lights, Camera, Action National Summit Series that will advance recommendations from multiple partners for a modernized U.S. public health system. Welcome Dr. Parekh.
Dr. Anand Parekh: Thank you, Claire. Great to be on the podcast with you.
Claire Stinson: We're so happy to have you today. So, to get started, Dr. Parekh, you joined the Bipartisan Policy Center in 2015, and since then you have led several efforts tackling key policy issues ranging from the opioid crisis to the obesity epidemic and nutrition, to health and housing, to emergency preparedness, among others. Talk to us about this work.
Dr. Anand Parekh: That's right. The Bipartisan Policy Center is a nonprofit organization in Washington, D.C., founded by four former Senate majority leaders 14 years ago, to try to take the best ideas from all sides to promote health, security and opportunity. Now, bipartisanship, I think to some, may be an archaic concept. And I will admit that, at times, it is a bit lonely waving the bipartisan flag, but that is really the mission, to unify the country and take the best ideas from all sides. And we do that in a number of areas. Health is one of our biggest programs. We cover a range of issues as you mentioned, from the healthcare side to the public health side. On the public health side, we cover topics including the future of public health, the COVID-19 pandemic, the opioid crisis, the obesity epidemic. So, there are a number of issues that we concentrate on, and I provide the clinical as well as the public health expertise for the organization.
Our main audience is Congress, as well as the Executive Branch. To that end, our work informs at the federal level. We at the Bipartisan Policy Center have been helpful over the last many years on a range of issues and laws that ultimately have been passed, including MACRA, which focused on physician payment, 21st Century Cures which focused on biomedical innovation, and more recently on the reauthorization of PCORI, which is the Patient-Centered Outcomes Research Institute. So, we cover quite a bit of ground and try to touch on a number of issues which require bringing all sides together.
Claire Stinson: It sounds like you guys really do run the full range of issues. What is your focus area in health?
Dr. Anand Parekh: I have really gravitated towards what we call population health and the four Ps that try to maximize the health of the nation. We need to concentrate on public health, prevention and primary care. So, to maximize population health, primary care, public health and prevention are absolutely critical, taking into account the broader social determinants of health, as well as the need to advance health equity, the idea that all Americans deserve the opportunity to attain the highest level of health. My focus has really been on those most important public health issues facing the nation, obesity and nutrition, the opioid epidemic, COVID-19, those population health issues that are leading to preventable, really morbidity and mortality, in how to tackle those critical issues.
Claire Stinson: Thank you for sharing that. And the Bipartisan Policy Center, with partners, recently developed the Public Health Forward framework to create a 21st century public health system. Why is that framework needed?
Dr. Anand Parekh: COVID-19 has been a once-in-a-generational event, once-in-a-century event for public health. Previously the Bipartisan Policy Center had released a set of recommendations in terms of how the federal government could take a better leadership role given what has happened with COVID-19, and the Bipartisan Policy Center focused on issues such as improved intergovernmental coordination, improved public health data infrastructures, as well as improved public health financing at the federal level. But we also realized that it would be important to put forward a framework for state and local officials, both state and local elected officials, as well as public health officials. That's why we, as well as a number of partners, collaborated on developing a five-year vision for governmental public health in the United States, as well as an actionable framework for these state officials. I think the impetus for this really was two-fold.
The first is that through the COVID-19 relief packages and the American rescue plan, there has been a significant infusion of funding to state and local public health. It's not the long-term sustainable investments in public health that we know we need, but it is significant short-term funding. And it's important that those funds are spent wisely. We also saw during COVID-19 the politicization, unfortunately, of public health. At the end of the day, we feel strongly that public health can't be a blue issue or a red issue or a Democratic issue or a Republican issue. It needs to be embraced by both sides of the aisle. So, in many ways, this was also an effort to take back public health. Take back public health, so we can explain the important role of public health, both to policy makers, as well as the public.
Claire Stinson: This framework sounds really important. And in other podcast interviews, I know we've talked about COVID-19 serving as a catalyst for so many issues. Would you agree with that characterization?
Dr. Anand Parekh: Absolutely. There are so many facets of the COVID-19 pandemic where we see the need for improvement, whether it's how we collect public health data and report and share that data―so, the public health data infrastructure―as well as the lack of data on race, ethnicity and other demographic variables that are so critical to address health disparities as well as health inequities. We see that with the workforce that is working so hard during COVID-19, yet we know that there's a deficiency in terms of the public health workforce. We also need to ensure that the skillset of public health officials are meeting what is required in terms of future challenges. We're seeing the importance again of public health financing, the importance of fostering partnerships, engaging communities. All of these issues are really important, and they have come at the forefront, really, because of COVID-19.
Claire Stinson: Really important to remember right now. Dr. Parekh, the CDC Foundation is convening a national series on the future of public health in collaboration with several public health partners to advance recommendations for a modernized U.S. public health system. The Lights, Camera, Action name for the summit series is purposeful in conveying the public health landscape at this time. And an action-oriented approach is needed to really move the field forward. You recently participated in the first summit in December about achieving a diverse and effective public health workforce. And in your comments, you said that if public health doesn't do its work, we all suffer. Tell us what you mean by that.
Dr. Anand Parekh: One of the things that we're learning during the COVID-19 pandemic is how we speak about public health. When we released Public Health Forward a few weeks ago, Governor John Kasich, former governor, said this quite well, that oftentimes I myself do this. I start to talk about public health in the context of public health areas and capacities and foundational capabilities, but the general public doesn't really understand what that means. I think when we talk about public health, we need to talk about it in a way that people and relate to. What public health does is influence whether we have clean water and clean air. And public health has a role in controlling infectious diseases. And public health has a critical role in preventing motor vehicle accidents and preventing injuries like falls, a critical role in reducing obesity and tobacco use, improving maternal and child health.
And so when we speak about public health in this way, I think we make public health more relatable to the public, which otherwise takes many of these things for granted. So when I said, "If public health doesn't do its work, we all suffer." Whether the public realizes or not, every day public health is working for the public and saving lives. So, I think it's just really critical to remember that if we don't support public health and the public health workforce, then all of our health will suffer. The community's health will suffer. The population's health will suffer.
Claire Stinson: Really important points. And this first summit focused on the public health workforce. But Dr. Parekh, we have a public health workforce in place. So, what's needed in that workforce that we don't have today?
Dr. Anand Parekh: There are a number of things. The first is the quantity of the workforce. We've seen over the last decade, even prior to COVID-19, tens of thousands of state and local public health officials and workers who have left the field. A recent study showed that we need at least 80,000 additional public health staff at the state and local level. So the quantity of public health staff and officials, I think, is one area where we need to focus on. The second is the composition of the public health workforce. We need everyone from nurses and clinicians and epidemiologists and statisticians, to community health workers and many, many other peer counselors and peer support counselors. And so we need many different professionals working within public health and understanding who we need as well as the overall professionalization of the field as well…who needs to be certified or licensed? How do we bring in community health workers? There is some work to be done with respect to the composition of the workforce.
The third is geography and the distribution of that workforce. In some areas, we have more capacity versus others. You think about rural America, and there are many areas within rural America where we don't have enough of a public health workforce. And then of course from a health equity perspective, the diversity of the public health workforce is absolutely critical to build trust with communities, individuals who know their communities, and that can help to reduce inequities and disparities. So, what's needed in the workforce that we don't have today is a sufficient quality, the right composition, the geographic distribution and optimal diversity really to move public health forward.
Claire Stinson: That's interesting. It sounds like we have quite a lot of work to do in that area.
Dr. Anand Parekh: That's correct. I think we've made strides, and I think there's a lot of attention here. I salute the CDC Foundation for focusing it's first summit on the public health workforce. Our Public Health Forward report also listed a number of recommendations for state and local elected officials, as well as public health officials. We need to focus on recruitment and retention of public health officials. Each jurisdiction needs to do assessments of who currently comprises the public health workforce. Where are the gaps? How do you build pipelines to meet those gaps? So, these are very important steps that are needed across the country to support our public health workforce that is currently working so hard.
Claire Stinson: Absolutely. And it sounds like these are really important goals. Was there anything that you heard during the summit that surprised you?
Dr. Anand Parekh: I think there's a general appreciation of the state of the public health workforce. There's also a sense that not only do we need to focus on the recruitment and retention of public health workers, we need to improve hiring and promotion policies, ensuring that there's competitive pay, there's merit pay. We need to build a learning environment. So, in terms of career development and career advancement, public health professionals feel supported and they see public health as a long-term career as well.
Claire Stinson: Right, and the public health workforce is arguably more important now than ever before. So thank you for sharing that. Dr. Parekh, you wrote a book titled Prevention First: Policymaking for a Healthier America. And in the book, you argue that disease prevention must be our nation's top health policy priority. You also make the case that building a personal culture of prevention is not enough, and elected officials and policymakers must play a greater role in reducing preventable deaths. Talk to us more about this.
Dr. Anand Parekh: What we see in the United States, and if you look at the leading causes of death, it's really preventable chronic diseases. What we have built in this country, our $4 trillion healthcare system is really a system that focuses on rescue medicine. So, it's responding to the complications of preventable conditions. What we need to do is work more upstream to reduce those risk factors: driving chronic conditions and preventable conditions like obesity, like tobacco use, like substance abuse, like vaccine preventable illnesses. And we need better support systems also, such as housing, such as nutrition to support individuals. Now individuals have an important role when it comes to prevention and their health, but broader policy systems and environmental changes are absolutely necessary to support individuals in making that healthy choice the easy choice. And I think that's why it's important that when we talk about prevention, individual and personal responsibility is not enough.
We need the policy systems and environmental changes to support those important choices and behaviors that individuals make. You only really have to look back to COVID, and during the pandemic here where we've tried to mitigate the social and economic consequences of the pandemic. But early on, for example, during the acute phases of COVID, when we recommended stay-home advisories, or we asked individuals, "If you're sick, please don't go to work." Without having paid leave and paid sick leave and these types of policies, it's very difficult for Americans to make the healthy choice in an easy way. So, I think that's where we really need to focus on these important policies, systems and environmental changes to support individuals. The question is why hasn't that yet occurred? Why hasn't prevention been prioritized? And Claire, it's been my experience, particularly over the last 15 years here in Washington, D.C., that D.C. is a pretty reactive place and for public health and prevention to be elevated, you really need to be proactive about that.
You also have to be patient because when we talk about prevention, you don't always get quick wins, but here in Washington, D.C., sort of quick wins is what people are looking for. Then when you have the wins, those wins may be invisible because when prevention and public health are working, you're many times averting bad things from happening. So those wins are invisible. Policy makers continually, also I think, need education about the evidence-base behind prevention and public health. Otherwise, stereotypes or misconceptions can form, nanny state arguments can become the argument of the day. We also, from a finance perspective, haven't focused on issues such as prevention and public health. Again, we spend $4 trillion on health in the United States and only less than 3 percent of that goes to public health. Only 5 percent of that goes to prevention. And only 6 to 7 percent of that goes to primary care, which is half of our pure countries. And those three groups are not mutually exclusive either. So ultimately, I think the question for all of us is "How healthy of a nation do we want to be?" And where we put our resources really define our priorities, and our priorities define our values. So, to really make prevention our nation's top health policy priority, there are a number of things that we need to do. And that includes ensuring that policymakers know the important role that they have.
Claire Stinson: It really does sound like the book focuses on policy making for a healthier America. And it goes back to what you said earlier that if public health doesn't do its work, we really do all suffer.
Dr. Anand Parekh: That's absolutely correct.
Claire Stinson: We'll be right back with Dr. Anand Parekh.
The CDC Foundation is convening a national summit series on the future of public health in collaboration with the Association of State and Territorial Health Officials, the National Association of County and City Health Officials, Big Cities Health Coalition and other public health partners to advance recommendation for a modernized U.S. public health system. The Lights Camera Action Summit Series will include four virtual convenings, leveraging recommendations across a variety of research, including the Bipartisan Policy Center's Public Health Forward. Learn more and register at futureofpublichealth.org. And now, back to our conversation with Dr. Anand Parekh.
So, Dr. Parekh, you have said that our country doesn't invest enough in public health. How can our country better invest?
Dr. Anand Parekh: The best research studies suggest that we have about a $34 per capita gap in assuring the conditions that populations can be healthy. So we ought to be spending at least $10 billion annually on public health, more than what we are currently doing. And about half of that ought to be going to the foundational public health areas. So these are the things like communicable disease control and chronic disease prevention and maternal and child health and injury prevention and environmental health. A lot of the topics that we talk about in public health.
But the other half really need to go to support what are called foundational capabilities, those things that are absolutely required irrespective of the threat that we're facing, whether it's COVID-19, whether it's the opioid crisis, whether it's the obesity epidemic. So for example, surveillance, laboratory capacity, data and information technology, policy communications, partnership development, all of those capabilities are critical, irrespective of the threats. And when we talk about the public health and infrastructure, that's what we don't have at a baseline across the country. And that's really where some of the critical investments need to be made, long term sustainable investments to support the public health infrastructure.
Claire Stinson: Important points. Do you think that COVID-19 has put a spotlight on the need for these investments?
Dr. Anand Parekh: COVID-19 is certainly a crisis. I think it's also an opportunity for policy makers in the public to finally realize the importance of public health, to ensure that we don't take public health for granted. Over the last six months in Washington, D.C., the buzzword has been infrastructure. And you hear about roads and tunnels and bridges and the power of grid and energy. You know, I've been waiting to hear about public health because public health is really part of our nation's infrastructure. It's working for us every single day. I think we have heard and seen some conversations about the importance of ensuring that public health is considered as part of infrastructure packages. Currently, one of the pieces of legislation being debated in Congress with Build Back Better legislation is in fact, a down payment to support the nation's public health infrastructure in some of these foundational capabilities.
And so I'm hope that there is a better understanding, on both sides of the aisle, about the important investments at the federal level. And then again, as I said, with respect to public health forward, in the interim, there are things that state and local elected officials and public health officials can do. Those are articulated in Public Health Forward, in the report recently released, but states and localities right now can be, for example, blending and braiding funding, resource sharing between departments, ensuring there's flexible and not just categorical funding, doing assessments to see what the gaps are in how much they're spending on public health versus how much they need to be spending. And then not only implementing public health programs, but communicating to the public and policymakers when there's a social and economic impact of these programs. So again, we need work at all levels, federal, state and local on the governmental side. And certainly the private sector has a critical role as well, in terms of advancing public health forward.
Claire Stinson: Thank you for explaining the importance of the need for these investments in our country. So, how can we do better to reduce preventable deaths in this country?
Dr. Anand Parekh: Reducing preventable deaths is already the number one priority of our public health system. We need to make it the number one priority of our healthcare system as well. In my book, Prevention First, I talk about a number of different strategies related to both value-based healthcare transformation and how we pay healthcare professionals, as well as the need to pay for, not just clinical services, but community prevention services as two opportunities to reduce preventable deaths. But ultimately, I think we need to engage policymakers on, again, both sides of the aisle, in all of the core issues that we've been talking about today from vaccine preventable illness, like COVID-19, to substance abuse to obesity and tobacco use. So there is low-hanging fruit in all of these areas, but they require the leadership of policymakers on both sides to enact those policy systems and environmental changes that can support individuals in making healthy decisions.
Claire Stinson: Thank you for sharing that. So, Dr. Parekh, here we are closing out year two of the COVID-19 pandemic. What do you see as our nation's biggest challenges ahead with the pandemic?
Dr. Anand Parekh: Claire, I'm concerned about complacency. It can't be acceptable that every day have over a thousand deaths due to COVID-19 and over a hundred thousand cases of COVID-19. This is now a vaccine preventable illness. I'm worried that a good portion of America thinks that we're done with COVID-19. Yet we know that COVID-19 is not done with us. And so I think we need to continue to focus on winning the hearts and minds of the American public, particularly those who are unvaccinated, because we know that vaccinations and boosters are really our way out of this pandemic, while assuring that our global response is as robust as our domestic response because global health is U.S. health. We have absolutely seen that with respect to COVID-19.
With that being said, I think we also have to realize that while we tackle the COVID-19 pandemic, we can't take our eye off the ball of all of our other health challenges. Many of which that I've talked about today, that have been exacerbated because of the COVID-19 pandemic. Whether it's the opioid crisis, whether it's the crisis of youth mental health, whether it's the obesity epidemic, whether it's diabetes, many of these important issues, tobacco use, we've seen tobacco use go up during the pandemic. Many of these issues have been further exacerbated by COVID-19. Now we weren't doing very well before COVID-19. Life expectancy in the United States had been stagnant for a decade prior to COVID-19 because of many of these issues, and then COVID-19 occurred. So, I think it's going to be important on both fronts, the COVID-19 front, as well as tackling these other health challenges. We're going to have to do really both.
Claire Stinson: Important points. Thank you for sharing that. And we can't lose sight of all of these other health challenges aside from COVID-19. What do you see as the biggest challenges ahead with all of these other health challenges?
Dr. Anand Parekh: I think the biggest challenge is being able to address all of these issues simultaneously. We can't just say, "All right, right now, we're just going to focus on one issue, and then we'll get to those other issues." All of these issues, I think, demand our attention. We've seen, for example, with respect to substance abuse in the opioid epidemic, we just recently crossed a hundred thousand lives lost in the last 12 month threshold. We never had been at that point. And so it begs the question, particularly at the federal level, we've been spending billions and billions of dollars trying to tackle the opioid crisis for the last few years. And yet, the numbers continue to get worse, and we need to recommit to prevention, to treatment, to recovery. We need to make sure the federal government is a partner to states and localities, and we're trying to save lives. So, that's sort of one example.
I think we've also seen declines, for example, in many of the areas that we were making progress in such as mortality from cardiovascular disease. In fact, a recent study in the journal Circulation showed that two thirds of COVID-19 hospitalizations could have been prevented if it weren't for one of four conditions: obesity, high blood pressure, diabetes or heart failure. So, what it speaks to is a lot of these preventable chronic conditions, not only do we need to prevent them during usual times, but they're also critical to ensure that we're resilient for public health emergencies, like COVID-19. The underlying health status of the American public, which has not been optimal, which has been further exacerbated by COVID-19, that's where we need to focus. The healthier we are as a nation, during non-crisis times the better, but during crisis times, that'll just make us more resilient so we're able to withstand public health emergencies like COVID.
Claire Stinson: It sounds like we have quite a task ahead of us. Are you hopeful that we can tackle these other health challenges as a country?
Dr. Anand Parekh: I'm hopeful. I think we all have to be hopeful in the field that we work in, of public health. And I think while we focus on the science and the evidence, we ultimately have to be hopeful by reminding ourselves that we need to partner with the public. And we need to build trust because just having the science and the evidence and policies are not enough. Ultimately, working with the public, realizing who we serve, meeting them where they are, understanding their aspirations, perceptions will help us go a long way in helping us address these challenges.
Claire Stinson: So true. And we've focused on that time and time again in this podcast, that trust is key in all of this, with public health. So, really important points there. Dr. Parekh, we have a lot of students that listen to this podcast. For my last question, to build a more robust public health infrastructure and workforce, like we've been talking about, what is your advice for those listening to this podcast right now who want to pursue a career in public health, or maybe expand their work in the field?
Dr. Anand Parekh: My advice, Claire, is that there's no better field than the field of public health. You have an opportunity to help people, not just one at a time, but help improve the health of populations. Public health is all about science. It's about service. It's about building relationships as well as trust. And I think I'll end by saying something that my first boss in government, first Assistant Secretary of Health who I worked for, reminded me about 15 years ago, which I thought was quite elementary. That public health is made up of two words, and we spend a lot of time on that second word of health, trying to understand the science and the evidence, and what works and how to implement programs as well as services. But we often don't spend as much time on that first word of public. And why that's important is ultimately if we don't understand where the public is, if we're not able to meet them where they are, if we don't understand their aspirations, their perceptions, then we're not going to be able to partner with them in a way to optimize health in this country.
And so, just remembering the people who we're trying to serve, who we're trying to help will be absolutely critical for public health in the future. And really everyone in public health and who aspires to go in public health needs to remember that, that it's really both the health piece as well as the public piece that will help move public health forward for the nation.
Claire Stinson: Well, I love that we're ending on that note. We need to focus on the public in public health. Thank you so much for sharing your perspective today, Dr. Parekh. We appreciate you being a part of Contagious Conversations.
Dr. Anand Parekh: Thanks for having me.
Claire Stinson: Thanks for listening to Contagious Conversations produced by the CDC Foundation, and available wherever you get your podcasts. Be sure to visit cdcfoundation.org/conversations for show notes. And if you like what you just heard, please pass it along to your colleagues and friends, rate the show, leave a review and tell others. It helps us get the word out. Thanks again for tuning in, and join us next time for another episode of Contagious Conversations.