Contagious Conversations / Episode 12: Public Health's a Team Activity
"APHA is the history of public health in the United States."
As executive director of the American Public Health Association, Dr. Georges Benjamin knows how important it is that everyone can see themselves under the "big tent" of public health. Find out how he and the APHA's diverse membership drive impact by staying focused on three bedrock priorities.
Below: Dr. Georges Benjamin leads discussions at the American Public Health Association's Annual Meeting, one of the largest annual gatherings of public health professionals.
Transcript
Pierce Nelson: Hello, and welcome to Contagious Conversations. I'm your host, Pierce Nelson. Every episode we hear from inspiring leaders and innovators who make the world healthier and safer for all of us. 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. Georges Benjamin, the executive director of the American Public Health Association, the nation's oldest and largest organization of public health professionals.
Dr. Benjamin also previously served as a secretary of the Maryland Department of Health and Mental Hygiene. For the last 20 years, he has been actively practicing public health at the local, state and national level with expertise in the areas of emergency preparedness, administration and infectious diseases. In this episode, Dr. Benjamin discusses our nation's health and how public health has changed over time. He also shares insights on how disparities impact health, how data informs decisions, and how we can bring many diverse views together to tackle the most pressing health challenges of our time. Welcome, Dr. Benjamin.
Dr. Benjamin: Pierce, thank you very much. I'm glad to be here.
Pierce Nelson: Let's get started with maybe a basic question and that is, how did you get your start in public health?
Dr. Benjamin: I always talk about this. I was literally minding my own business. I was chief of community medicine and ambulatory care at the city hospital here in Washington, D.C., and my phone rings and it's the mayor on the other end of the phone saying, "Have I got a job for you. Please come by my house tomorrow so we can talk about it." I knew the city was looking for a new director at the emergency ambulance bureau to be basically deputy fire chief and EMS director and I also knew they were getting ready to look for a new health commissioner. So I wasn't quite sure what job he wanted to interview me for, but certainly I had hope for the health commissioner's job and indeed that was the job that he gave me. If you think about that, that was a career decision either to go further in my career in emergency medicine or to kind of move up the chain to manage what was in effect a major health system for our nation's capital.
Pierce Nelson: That's great. It points out that you never know what life has in store for you and to be open to possibilities.
Dr. Benjamin: That's right. Absolutely.
Pierce Nelson: So the American Public Health Association has been around since 1872 and, by my calculation, that's nearly 150 years. Tell us a little bit about the Association's role in public health and how public health has changed over time.
Dr. Benjamin: You know I tell people that APHA is the history of public health in the United States, and in many ways that's true. We were founded because of concerns about the environmental movement, about the built environment and its impact on health in the early days of our nation, just beginning to think about professionalism of medicine at that time, if health. There was a group of people that got together because they were concerned about that. We've been instrumental in the creation of the Public Health Service, the Department of Health and Human Services, formerly Department of Health Education and Welfare, the CDC, in its creation. We have been involved in the spin off on an enormous number of other organizations, the Global Health Council. We were involved with and supportive of the World Health Organization, in its founding, and of course the Pan American Health Organization.
We were very much involved in the World Federation of Public Health Associations, which is the association of national public health associations like APHA and in fact for over 40 years we were the secretariat for that organization. There was a time when APHA actually accredited the schools, early schools and programs for public health. That was eventually spun out and is now the Council on Education for Public Health, known as CEPH, but we were the original creditors for schools. So we've been involved, we were involved with the Clean Water Act, the Clean Air Act. APHA has certainly been in the centerpiece of public health thought.
We've certainly been involved in range of the infectious disease outbreaks. In fact, I remind people that during the great pandemic, the APHA annual meeting was actually moved because they did not want people to congregate together in large groups. So the meeting, which was earlier in the fall, was moved to closer to December to give people a chance for that epidemic to mature and for people to get a sense of it, and of course this was pre-vaccination era, so it was a lot of thinking about what it actually was.
Also, we were... During Katrina, hurricane Katrina, our annual meeting was supposed to be in New Orleans and because of that terrible tragedy we had to move our meeting. We moved to Philadelphia, and again, later in the year. And there's been time when our meeting did not occur due to one of the World Wars, where APHA did not have an annual meeting because of the war. You know, we've been around for a long time and been involved in lots of parts of the national history as well as the history of public health.
Pierce Nelson: That's great. And I know that APHA has a diverse membership and with that brings many different voices and views. How do you bring all those views together when you advocate for health issues?
Dr. Benjamin: I think we first recognize that all of health is important. So if it hurts people and kills people, it's ours. Then the question is how do you organize that thinking under a few themes so that everyone can see themselves under the big tent? And so we've done that by saying that we have three overarching priorities: access to care, recognizing that care is not just about health insurance but it's also about being able to access whatever services are available; health equity, which we believe is the rock, the basis of everything we do in public health; and then building public health infrastructure as a core value, because if you don't have the resources, people well trained and the political will to actually improve the public health, you're not going to get there. And so those three overarching priorities have remained the bedrock of APHA.
We hope people see whatever they're doing under those three overarching priorities, and then like everybody else, we're juggling in public health. We're trying to deal with the most important issues in a focused way to have the most impact. And that's always a challenge for us because you're always worried about if it hurts people, and there are some early signs of things that are about to happen that you're itching to get involved in it, but resources and timing are everything in trying to improve the health of the public. And so sometimes we have to figure out exactly when to engage in an issue and how to target our resources. Or, by the way, how to leverage what we do with other people for which this may be a higher priority so that we can add value to what they're doing.
Pierce Nelson: That's great. One thing that I've heard you say is that 80 percent of what makes you healthy happens outside the doctor's office. Could you tell us a little bit more about that?
Dr. Benjamin: So I remind people that I'm an ER doc and so it's a very, very painful revelation for me to recognize that I can't fix everybody all the time. But the truth of the matter is that your zip code is more important in many ways than your genetic code. Not that your genetic code isn't important, and not that medicine hasn't done amazing and marvelous things to improve our health and make us healthy. However, having access to affordable and safe food, being in a community that's walkable and bikeable and green, having safe water to drink, safe air to breathe are very important. Being in a nurturing community that is safe is important. The secret to homelessness is a house, and having a home that is safe and healthy is an important issue. Dealing with issues around stigma, racism, discrimination, create enormous stresses on people as well as the inequity of those challenges.
And if we could get all of that right, then we would make my experience as an emergency physician important, but so much less so, because we don't have people going into these systems and spending an enormous amount of dollars and time and heartache trying to fix things that were preventable in the first place. So that 80 percent is very, very important and it includes behavior change as well. I don't want to take away the individual component of that, but we always talk about making the healthy choice the easy choice, that upstream activity that people are experiencing in our daily lives is extraordinarily important.
Pierce Nelson: So you're really talking about the social determinants of health here and I would be interested if you could share an example of how APHA has elevated the importance of the social determinants of health in a way that's impacted communities.
Dr. Benjamin: You know, we've been involved in several efforts around the built environment. For example, transportation and health. We've been part of coalitions that have looked at trying to make sure that people can get transportation so that communities are built to move people and not necessarily just for the convenience of automobiles. We've worked with the Healthy Housing Coalition to try to promote healthy housing. We've done publications around healthy housing as well as advocated for healthy housing over the years. And I think our biggest activity to date has got to be around climate change. And we're working very hard to both on the mitigation side, to get people to reduce their carbon footprints and understand what they can do individually and as organizations, to reduce their carbon footprint. As well as on the adaptation side of the equation, so that people are able to respond in meaningful ways to this terrible tragedy of climate change. It's here, it's impacting our health today and we see that very much as a social determinant.
Pierce Nelson: Another topic that I wanted to discuss is data and why that's so essential and why that's so important. You know, there have been a number of people who've said over the years if you can't measure a problem or an issue, you can't fix it. Can you talk for a moment about how data makes a difference in creating a healthier population, both from a chronic or infectious disease perspective as well as in addressing emerging health threats?
Dr. Benjamin: Yeah. You know, the truth of the matter is if you don't know where you're going, you'll never get there. Or they say, if you don't know where you're going, any path will get you there. The challenge is that public health is very data-driven. That's the good news, is that we try to make scientific decisions based on data, based on the evidence and based on knowledge. Our challenge in public health is the fact, and my good friend Bob Redfield who is the current CDC Director points this out, we're data archeologists, our data is always old. One of the things that we've been trying to push for is to strengthen our data systems and to make them more timely.
When I was the Deputy Health Officer for the state of Maryland, at that time we mandated that every local health department will have a computer. Believe it or not, in Maryland with only 24 local health departments, every health department did not have a functioning computer to do data work on. And in fact, one of the challenges we had was that we still had lots of rotary phones. And so even linking the computers of the day into the telecommunication system was a challenge. So we not only had to get computers, which by the way were fairly expensive in those days, as well as adapting the phone system so that they could use them effectively.
Now that's all changed, Wi-Fi and cloud computing, you know, computing has moved dramatically, but the funding and resources to keep the data-driven systems that we have, have not kept pace by any means. And the interoperability of our data systems remains challenged, so we're still dealing with infant mortality data to try to address the terrible tragedy of infant mortality, sometimes two years in the rear. If you had to manage the stocking of your grocery store two years in the rear, you'd be out of business.
One of the things that APHA is working very hard on, with other organizations I might add, is advocating for more funding for our public health data systems to improve their interoperability, to give them the dollar so that they can stay current, and so that we can make data-driven decisions in a very much timely manner for us to address very, very fast moving threats to disease. Ebola and other infectious diseases don't travel at the speed in which our data systems development have moved, so we need to be able to have real time data that's fast so we can do fast science, fast data collection, fast data analysis in order to be successful as a profession. We need the same tools that businesses like Uber has, or DoorDash has, the ability to share data quickly and efficiently to bring various groups together across disciplines so we can make data-driven decisions beyond the public health community as well.
Pierce Nelson: So what I hear you saying is that really, data is a bedrock component of a strong public health system.
Dr. Benjamin: It's the essence of it.
Pierce Nelson: I want to take a little bit of a turn here and talk more about state and local health departments. And I know that you work closely with CDC as well as the state and local health departments and nonprofits as well as other national partners. What do you think are the greatest needs, or what are the greatest needs that you're hearing about and what's needed to tackle some of our most pressing health challenges?
Dr. Benjamin: Let me start by saying that working in a collaborative way is not easy. Collaborations are difficult because everybody has their focus area in which they want to deal with, and people have different priority needs at a time and they also bring different capacities to the table. So the trick here is to have a coalition which allows people that come in and out bring the capacities that they have to the table when they can best leverage and maximize those capacities and have a working relationship and trust so that you can just pick up the phone and say, "Hey, can you folks be engaged in this process that we want to deal with this advocacy effort or this educational effort?" And then pulling those resources together at really a moment's notice to be able to move an agenda that improves the health of the public.
We have an enormous collaboration that has gone back obviously years with the State Health Officers, the City and County Health Officers, a range of other professional societies and public health organizations that hold us accountable, like the Public Health Accreditation Board, the National Board of Public Health Examiners as well as all of our federal partners. Our efforts are all geared, I think, and driven by the effort to try to be the healthiest nation and if one really looks at how successful we've been as a collective, because public health is a team activity, we've been very successful over the time. Our biggest needs are getting political will and building that political will amongst members of Congress and the Administration, mayors and governors to see that the public's health is broader than healthcare delivery.
I've always thought of healthcare delivery being a part of public health, but that's one of those things I've had to learn to come to that perspective, because public health is much broader than just treatment and curative services or even rehabilitative services. But it does require political will, and our challenge at the end of the day, if I had to pick a single challenge, is getting the political will in place to see the broad public good for what we do.
Pierce Nelson: That's very interesting. You mentioned political will, and recently Congress passed a budget with funding for research on firearms violence by both CDC and the National Institutes of Health. In your view, what's the significance of this funding?
Dr. Benjamin: This is one of the most significant and influential things that has happened. This was an example of what I just talked about, the fact that we have built political will to actually do research on firearms to make firearms safer. You know, this is all about both respecting the Second Amendment and doing a public health approach to firearms, figuring out how to make the tool itself safer, guns as a tool, and then making people safer with their firearms and then making the environment safer with firearms and people in it together. We've known about this for over 20 years. That was the framing that the CDC Injury Center originally had, but for a range of political purposes, they were derailed.
The fact is that they had funding that they cobbled together to do gun research and then that was pulled away. Actually, by the way, got moved to head injury, I'm glad we have a head injury program, but we've had trouble getting that funding and it's taken over 20 years for the public health community broadly, the firearm safety community in partnership with a range of advocacy groups to convince the Congress to finally put those dollars in. Our goal is for those dollars to grow over time, to get good research, recognizing that we may find things that progressives are not excited about because we have views about what we think should happen with firearms, but we'll get the right evidence and as long as we do the good science and then follow the science wherever it leads, again, going back to data, we'll be able to make good, sound, scientific data-driven decisions that I hope will inform the public policy process over time and eventually make our community safer.
This is very, very important. It's a very, very important win for the health and wellbeing of the American people. We're happy that we were a part of it, but the winners here are really the American people that, we hope, with the evidence will be able to make them safer.
Pierce Nelson: We'll be right back with Dr. Benjamin.
Since this is a show about Contagious Conversations, we want to hear from you. Each episode we ask you a question and this episode's question is about the impact of public health and how it affects you in your daily life. What does public health mean to you? We invite you to share your thoughts with us. Just email info@cdcfoundation.org to answer. That's info@cdcfoundation.org, and if you answer the question you'll have the chance to win some CDC Foundation merchandise.
And now, back to our conversation with Dr. Benjamin.
You speak with experts involved in public health at the local, state and national level all the time. From a skills perspective, I'm interested in what you believe are the biggest needs in the public health profession, both from a human capital perspective and then also what are the greatest opportunities for someone wanting to enter the field of public health today?
Dr. Benjamin: There was a time when we wanted everybody in here to have good epidemiology skills and good statistical skills and a good understanding of how the health system worked, learned a little bit about mental health when you got your MPH, but... and you still need those skills, no question about it. But we're now in an environment where what you write and how you write, the ability to address the media in its broadest sense, radio, TV, social media, is becoming a real art form. Building trust to people, with people, with communities, in the old days you’d go face-to-face and meet those communities, I still think that's important, but now we have to figure out how we build trust with communities that are, frankly, in cyberspace. How do you build trust in those communities? How do you make sure that you're dealing with the truth and not misinformation or, tragically now, disinformation? Public health has got to figure out how we engage very effectively in that environment so that we can deal with things very quickly, 24 hours a day, seven days a week in an effective manner.
We've got to deal with risk communication. We, human beings, are not very good at measuring risk and not understanding the relative risk of things. And so we've got to get better at both understanding risk and then communicating that risk in an effective manner to allow people to make their best decisions. We also have to learn new skills around diagnostic testing. As we get new disease processes we have to retool ourselves around what we know and what we thought we knew around things such as the effectiveness of vaccine A versus vaccine B. Vaccines, as you know, are highly effective and safe, but there are many vaccines that we thought you had lifelong immunity with once you got vaccinated, we're now finding that yeah, we got to now be re-vaccinated. As we learn more and more of that science, we do now have to communicate more and more of that to what is, tragically, a growingly step "public" around many of our formal interventions that people took for granted. We have people who, again, who are targeted and committed for this disinformation. And we have to address that as well.
One of the things that's most interesting and exciting for me is that public health has now become a popular topic, even in the undergraduate world. We now have people going to school take a few courses in public health as an undergraduate, but we're also getting people that are deciding very early on they want to get into public health, they get an undergraduate degree in public health. They may or may not go on to graduate school and get a graduate degree in public health, but they may decide, "Yeah, I got an undergraduate degree in public health, but now I want to go into law, I want to go into engineering, I want to go into another health field, I want to go into teaching, I want to be an educator."
And so what we're hoping is those folks that have public health undergraduate training will take that broad knowledge of public health and use that to better understand their role in whatever other job they're doing so that public health becomes a second part of their job. An architect and engineer, when they're building communities, now they're thinking about how can I build that community more healthy? So in many ways our society is moving to kind of a health in all policies, a health in all occupations society which is beginning to think about, and this is what we hope will begin to think about how can we do what we do in a healthy way if we're really trying to advance the public's health.
Pierce Nelson: Thank you for that response. Reflecting back on what you said earlier about your career, how you moved from medicine to public health, and then much of what you've discussed today, including in that last response, really sort of talks about the marriage between health and public health. I wonder if you just could reflect for a moment on what opportunities you see for continuing to bring health and public health together in an effective way to improve health overall.
Dr. Benjamin: Tragically, medicine and public health diverged many, many years ago because, frankly, as we strengthened the practice of medicine, public health got relegated to being "one of the soft sciences" and some people would even say it wasn't really a science. That's not true, of course. But as medicine evolved and wanted really intense evidence about what worked, we kind of did not do the work in many ways to do the science around the broader public health issues to approve that yeah, those societal issues were very important, there is a science and an evidence-base to doing them. We began doing more and more of that now. We're looking at both the health outcomes for doing a range of addressing social determinants, we're looking at the economic benefit of those. We're trying to address what I call the wrong pocket issue there, meaning that if you engage in a health outcome or, let's say, a non-health outcome and you get savings, it may benefit the health system a little bit but it also benefits other systems as well.
So, for example, addressing lead exposure. We know that lead is a terrible, terrible environmental toxin which impacts the brains of developing children and youth, but we know that the savings not only is on the health side if you can address lead exposure, but it also reduces special education costs, it can reduce costs in the juvenile justice system and some costs in the adult justice system. We know that that's absolutely true. We know that if we spend more money on education early on, that we improve the health and wellbeing of children so there is a benefit across society.
As we're evolving more and more in what we're doing in public health, we're finding a lot more about how we can work across medicine and public health in more collaborative ways. And then I need to add to that how we bring in other disciplines, education and rehabilitation services and the criminal justice community in effective ways, bringing the business community so that healthy businesses, both from the occupational health perspective as well as their societal role in trying to improve the community are all very important. Again, at the end of the day it comes back to a health in all policies concept and health in all policy policies, because at the end of the day, if you're not healthy you can't really be prosperous in our society.
Pierce Nelson: So one topic that's been really an underlying feature, I think, in much of what you've discussed with us today is collaboration. Based on your work with APHA, how important would you say collaboration is and how have you seen collaboration make a difference in improving the field of public health and more importantly, improving the health of people overall?
Dr. Benjamin: Collaboration is everything, is very important. We cannot do it by ourselves. We need others to bring a diverse set of skills, life experiences, resources and ideas in terms of priorities to the table for us to really to advance a healthy agenda. I grew up in a middle class family in Chicago and I remember being the Health Officer in Washington, D.C,. and being in a room with a bunch of kids that were going to a trip to England. Those young people were very, very excited, but I did not really understand, from my middle-class perspective, what they were most excited about. They certainly understood they were going to England, but these were inner city kids in Washington, D.C. who were first and most excited about going to National Airport, now known as Reagan National Airport. They lived in Ward 8, which is one of the lower income parts of the city and from their perch in their community, they knew the airplanes kind of came across the water up in the air and over the hill, across their homes, but they've never been there.
Understand that Washington, D.C. is a city of 10 square miles, so if you think about the fact that these kids have not been just outside the city, never been to the airport, didn't know where the planes came from, except they came from over the hill, their knowledge of the world was very limited. Quite frankly, I sat there with my middle-class learning, first understanding the limitations of those young people's world. Now, the good news is they got to the airport, they got to London, they had, I understand, a marvelous time when they got there. And those young people, as they grew up, I'm sure they'll have a great perspective of the world. But if I hadn't been in that room with those kids, I probably would not have learned the lesson of the importance of diversity, diversity of life experiences, because I was charged with trying to expand the view of kids in the community around tobacco, and early sexual engagement, and not using drugs, and the risk of HIV/AIDS.
If I had not understood that these kids had at least some initial barriers to their life experiences, how could I possibly begin to talk to them about all of these other risks to their health? For me it was an eye-opening experience, and I can give you more and more of those kinds of stories where people have brought ideas to me from both progressive and conservative ideas to the table. And if you listen real well―don't talk, but listen―understand where they're coming from first, then you can help navigate that, and that only happens in a group of people with diverse views from diverse life experiences, and bringing diverse resources to the table.
Pierce Nelson: Well, thanks for that response and thanks Dr. Benjamin for joining us today.
Dr. Benjamin: I'm glad I could be here. Thank you very much.
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