Transcript: WTHC Podcast Season 3 Episode 1

MUSIC

 

Hi, I’m Michael Sparer, the Director of the Center for Public Health Implementation at Columbia University.

 

Welcome to season three of “Who the Health Cares,” a podcast about the US public health system: what it is, who does what, and why all of us should care about it.

 

Last season, we explored a wide array of topics, including public health and emergency preparedness, the role community health workers play in rebuilding trust in public health, and the need for new collaborations between the public and private sectors.

 

This season, with midterm elections on the horizon, we’re focusing on the politics of public health. Can or should public health leaders simply “follow the science,” or is public health inescapably political?  And if it is inescapably political, what does that mean for how public health leaders should approach their jobs?

 

We’ll also examine how the Trump Administration has approached public health policy, and we’ll ask whether and how the mid-term elections might change that political calculus.   

 

We’ve got a terrific array of guests lined up for this season, including current and former leaders of state and federal agencies, a couple of important voices from the non-profit Foundation world, and one of America’s leading analysts of the politics of public Health. I can’t wait to get started.

On today’s episode, we’re looking at where public health fits into our larger health system—and how better coordination between public health, healthcare and social services could help all three work more effectively.

My guest today, Dr. Mandy Cohen, has spent much of her career thinking about these questions from nearly every level of our health system. Dr. Cohen is a physician and public health leader who served as Director of the CDC from 2023 to 2025. Before that, she led North Carolina’s Department of Health and Human Services, overseeing the state’s public health, Medicaid, social services and mental health programs. Today, Mandy is a National Advisor for Mannatt Health, advising public and private sector agencies and organizations on how best to navigate the complicated and transformative health system.

Mandy and I talked about what she learned from working across those different parts of the health system—and why she thinks we need to build better bridges between them. We discussed challenges facing the current CDC leadership, the success of North Carolina’s effort to use Medicaid dollars to address food insecurity; and the complicated relationship between science, policymaking, and politics.

Here’s my conversation with Dr. Mandy Cohen.

Mandy Cohen:So I'm a physician by training, but always was thinking about the larger system that we were practicing medicine in. And while I love the interaction with one patient by one patient, um, and I certainly like the intellectual pursuit of the, the science, I was always thinking about the system, and it would come back to me for when I'd have real experiences where the system let me down as a provider, and then certainly let my patients down.

And, like, I saw that firsthand even before I went to med school. My mom was a nurse practitioner in an emergency room. And where all the broken parts of our system often show up, right? The emergency room. It's where poverty shows up. It's where addiction shows up. It's where lack of services and access to primary care shows up.

So I always had that in the back of my mind. So for me, I was interested in, I was like, "Well, where is the system defined?" And that was government. Um, and so I had this opportunity to go to government after I trained, um, at Mass General. And, you know, I was actually at the VA first and before I went to CMS, and I went to CMS after the Affordable Care Act was passed because I, you know, it was this generational new opportunity, and I said I wanted to be part of that.

I went to the innovation center first, thinking again about what do we pay for, and how does that shape the future? Um, but it was really when CMS was in a crisis that I got my first step forward in leadership opportunities. Um, and it's when healthcare.gov

Michael Sparer:It didn't work so well at first.

Mandy:It didn't work, exactly. October 1st changed my career. But it was when I realized that I really loved operations, right, and solving problems. I got to learn about leading through a crisis up close. And I was put in charge of things that normally a doctor who is policy-oriented isn't put in charge of. But it made me realize, oh, I'm an operator, and I became chief operating officer and chief of staff at CMS. And I think it allowed me to take on these other leadership opportunities in North Carolina.

And thus, when crisis hit during COVID, I'd seen crisis before. And I think one of the reasons why I think we were successful in North Carolina comparatively to, to others is because I, I brought the operator lens, right? It was a lot of communication, yes, and that was very important, and there were a lot of lessons learned there.

But I also think there was a lot of operational lessons learned of how do you deliver results, how do you, how do you organize this massive effort across government but also across private sector? I think that's ultimately what led me back to, uh, CDC to help CDC recover, uh, post-pandemic.

Michael:Yeah. And you had, you had gotten yourself an MPH along the way as well, so I think you had sort of both the medical care and the public health perspective. Uh, and I think you're probably one of the first, if not the first, uh, CDC directors who's both led sort of a health and human services agency at a, at a state level, which really has Medicaid as, as sort of, uh, the big fiscal piece of it, but also led a, a public health agency like the CDC. So bridging those two worlds has been a lot of what you've done

Mandy:Yeah, and I love playing those roles of being that bridge. And a lot of how I see the world is our lack of bridges has really put us, uh, in a not great place for the people that we serve.

And I, I think we saw that in COVID. Like, the silos in our system between public health and health delivery I think made us slower and less good at responding. Uh, and we've learned a lot of lessons. But I think it's beyond that. It's even how we deliver health for individuals. We thought very differently about that in, in North Carolina when I became secretary.

And, you know, we had some pretty exciting innovations and r- and results there that I know we're gonna get into. But I think it's, again, how do you bridge worlds is really important here to, in service of communities.

Michael:Yeah. Well, it's certainly the case that we have a, uh, fragmented and decentralized healthcare system, a fragmented and decentralized public health system. And so the whole question of, of who does what in that system becomes really critical and important.

So I wanna sort of segue a little to think about this question of, of who does what around the topic of what we would call the social determinants of health, you know, your income, your education, where you live, uh, and sort of what we would call, to use all the acronyms in there, health-related social needs.

I mean, do you have the, the transportation that you need to get to the doctor's office? Do you speak the language, et cetera? There has been, um, an increased recognition, uh, in the last decade, 15 years, of the importance of these, I guess, what we call non-medical determinants of health.

And I know in North Carolina, in your role as the head of the agency there, you really made a significant effort and put together the Healthy Opportunities Program, you know, to try to have the Medicaid program begin to address, uh, at least some of the social determinants that were limiting the ability of low-income populations to get the healthcare that they needed. Maybe tell us a little bit about that story.

Mandy:Yeah. Well, I mean, it starts with a clinical experience of mine, right? And it starts, as often these things do, with a patient where I was seeing a young woman, 24, who came to see me because of hair loss. And the long story short is I ordered a lot of tests. I ended up sending her for CT scans.

Um, I was thinking about what specialist to send her to when my medical assistant, who checked in the patient now for her second visit after all of those things came back normal, said, "Do you think your patient has enough to eat?" I had not asked my patient anything about what was going on in her, in her life outside of this very narrow medical issue that I was looking at for her.

She did not link those together, but she clearly had started to signal something to someone she trusted more than me, which was my medical assistant, about what was going on in her life. But I think the, one of the big learnings for me from that was how easy it was for me to order tests and CT scans.

Click, click, click. Very easy, right? That's a system. Like, a system has created this opportunity for me as a doctor to order lab tests and order CT scans, order medicines electronically, fast But when I actually did talk to my patient, who I then found out had left an abusive relationship, was living out of her car, was eating intermittently, obvious- like hair, you would imagine, is the last thing on her mind, but she had an insurance card 'cause she was a full-time grad student.

But she didn't have money to pay for the food and the housing. And I will tell you, it took us weeks, maybe months, to line up the resources to help her. Minutes to spend thousands of dollars on healthcare, weeks to get her stable, to, to a stable place, both from a, you know, housing and- and, and look, I'm, I'm not saying that healthcare needs to solve all the problems with everyone walking in the door. That is not true. But that ratio is off.

Michael:And so then you become secretary, and then you have an opportunity to sort of take that learning that you had and put it into that program. Yeah.

Mandy:Exactly. And right, and so that has to start with paying for things differently, right? You get what you pay for. And we in Medicaid had not paid for those other components, and so they were not operating as part of the system. So in North Carolina, we went about doing a couple of things. One, you needed to pay differently, so we had to put a waiver in place to say, "We wanna use our money to pay for food, and housing stability, and for transportation, and, and to intervene for, for interpersonal violence."

And then you have to create the infrastructure to do it, so you can't just change the money. And I think sometimes people forget this. It, it's both incentives and infrastructure. Then we had to have a data system that linked everyone so that if you walked in the door of your doctor's office, we had to make it just as easy for you to navigate to those services as it was to order the lab test.

So between that as well as the, the organizational architecture, we had these hubs that, um, were, were intermediaries to make sure that we could pay for things like housing remediation. So example, for a kid with, with asthma, you know, the most expensive way we can treat asthma is in the emergency room.

But if we actually go to that asthmatic kid's house and we do housing remediation, meaning like get rid of mold or cockroaches, or rip up the carpet, that is something that Medicaid had never paid for, but the opportunity to pay for it here gives you the opportunity to keep people out of high-cost settings like emergency rooms.

And that was the whole premise. Took a lot of work to get there from an implementation perspective, um, because we were the first, and it's always hard to be the first. But we saw, and now have had an independent evaluation to show that we can save money, net of all the costs that I just mentioned. So whether it's paying for the h- home remediation or paying for the, the navigation service to enroll someone in SNAP, once you account for all those costs, we still save money in North Carolina.

And in a day when everyone is trying to really be conscious about state budgets and affordability, every state should be running to look at what we did in North Carolina and improve upon it and do it better than we did. But start from where we, where we were. Know that you have to get the incentives right and you have to get the infrastructure right, but there's a playbook there for states to replicate.

Michael:So it, it really is a remarkable story. Uh, and just to bring politics into it for a moment, um, do you worry – first, I gather there was a period where the state, a year or so ago, said, "We're not gonna continue to contribute funds to this program," and, and so there was concern and had to be suspended for a little while, and then there's always concern, I would imagine, in the current administration and depending on what happens with the timing of the waiver.

I mean, in order to put that program into place, since it's not, as you said, the normal course of activity for a Medicaid program to do that, you've gotta get these special waivers from the federal government. You've gotta get the state to put up some money, you know, to support it. How do you think about the politics of that?

And, and as you look at Medicaid going forward right now, and you look at cuts in state budgets and you look at, you know, potential cuts in waivers, are you optimistic or pessimistic that other states are gonna be able to follow what you've done and, and that even North Carolina is gonna be able to continue, uh, into the future?

Mandy:Yeah. Look, I understand how it can feel counterintuitive to folks to be like, "Wait, I need to invest and give people more, and actually I'm gonna save money?" Like, it, it doesn't compute right away. So I understand the need to walk people through the data, to walk people through the interventions and why they work.

And, and look, this isn't about doing everything for everyone. You have to be focused and disciplined and rigorous to the evidence on what we do. So there are particular groups of folks that I think lend itself better to intervention that can actually save money. So for example, high-risk pregnant moms is a, is a great example, right?

Because we're- who shoulders most of the NICU costs for the state? It's Medicaid. And there's a time boundness to those interventions, 'cause Mom's only pregnant for a little bit of time, turns out.So there are, there are ways to be rigorous, and I think as people get getting more comfortable with seeing this data play out at large scale in multiple places that are not just North Carolina, I think that you're, you- you'll see more of that.

But I think the, you know, the politics are, are real here, and we're having a debate in our country about where do we wanna put our resources, and who deserves that help? Right? So, like, that's a conversation. In North Carolina, look, we're a purple state. I think we are very much a microcosm of what the country is.

We have some very challenging state budget constraints. And so yeah, there needs to be that constant dialogue, but what I think you're seeing in North Carolina is, one, we got that waiver from the first Trump administration. So that's notable. Second, that when there, there was a lapse of, of funding, and then you saw the Republican legislature put it back, right?

And so there is support for it. So clearly doing something right there in terms of… you know, like, look, North Carolina's a special place. Sometimes we have to stub our toe before we, before we run ahead, but this isn't about everyone getting everything all the time. You know, there has to be rigor and, and process and infrastructure to make sure that this works, and works well.

Michael:I wanna ask you on this whole question of who does what, I wanna, you know, give you an example of another state, uh, and something happening here in New York State right now, and ask your opinion about it.

In New York State, uh, the health department here, um, has put together what they call the Prevention Agenda And the prevention agenda, among other things, basically requires every one of the 57 or 58 local health departments here in New York State to do a community health assessment, which they've had to do for years, but then to come up with what's called a community health improvement plan.

But the assessment and the improvement plan are required by the state these days to have as their focus the non-medical determinants of health, the social determinants of health. So each local health department is required to come up with a plan as to what are the key social determinants in their particular community.

Is it obesity? Is it opioids? Is it gun violence? Is it unemployment? You know, what- whatever it happens to be, and then come up with a plan to address them. And it, it raises a question, I think, that I've been sort of thinking about, especially with three thousand local health departments, there could be three thousand answers to this question, but thinking about what's the role, say, of the local health department.

And here in New York State, the local health department, among other things, is being asked to take on the role of explicitly addressing social determinants of health, and I'm curious as to your thoughts on, on that.

Mandy:So I probably have a different take maybe on how I, I would approach it, and how public health, social services, and I'd say the health delivery, and then Medicaid, which is like the payer of all of it, how does that all fit together? And I think in the best circumstances, everyone is playing to their strengths.

Michael:Mm-hmm.

Mandy:Um, meaning that there are ways in which the health delivery system can be great at identifying people at risk, right? Like my patient coming to me for hair loss. They, they walk through my door, but yet the, the delivery of service doesn't need to happen in the health delivery system, right?

Frankly, you want it to happen from folks who are, know how to deliver that kind of service, but also have the trust of the communities. Now, public health, I actually think, can be a good glue between the social services and the health delivery if, if we're all talking the same language, we're all having shared accountability, and we're all understanding what levers we have to pull.

But then when you come to the action, I think we need to be clear on roles and responsibilities, and you need someone ultimately accountable, right? And I will say going in, I had a, I had a bias to say, "I don't want the health delivery to be part of this." And that was my bias going in. This was eight plus years ago when we were designing it.

Coming out the other end, I'm not so sure, and here's what I mean by that. The health delivery system is quite good at scaling, and we needed their backbone for scaling to get some of the interventions that we wanted done. Things l- like, you know, that we could get standardization and scaling, whether it was from contracting to pay or the, the data infrastructure.

Michael:Mm-hmm.

Mandy:So there are times where you wanna utilize the strengths maybe of the delivery system, even if they're not gonna deliver, right? But maybe they're great at having a data backbone that you can build upon, right? Because they have their EHRs and what have you. And I think being humble enough across all of those entities to say like, "Okay, that might not be my best role, but we do need one data system. We can't have five." So someone has to be in charge to say, "We're gonna call the play," and then hold people accountable for that.

Michael:You know, I think public health, particularly at the local level, often becomes, uh, by virtue of necessity, the gap filler. I mean, for example, in Mississippi, the local health departments, which are really part of the state system 'cause they have a centralized system, but they generate over 50% of their revenue providing clinical care services, most of them.

Now, ideally, you'd say if there was a, you know, a high-quality community health center in the community that was actually seeing people, maybe things would be different. But public health often does end up, you know, sort of trying to balance these roles of the sort of the classic foundational tasks they have. I mean, they've gotta do the inspections of the restaurants and the septic systems.

They've gotta, you know, do the death certificates and the birth certificates. They've gotta do the infectious disease, and then there's the social determinants. So the- all these buckets become very hard. If, if you're a local health de- department official, you're, you're balancing a lot these days.

Mandy:Yeah, and I, I just don't think that you can be good at all of those things. And I think if all of them are priorities, you're not going to be good at the things that, that no one else can do.

Michael:Right.

Mandy:I would prefer that everyone works in their, to their highest, best use, but that means we have to, at the state level or a regional level, be making sure that we're funding the appropriate things.

To your point, it's nice for me to sit here and say that, but then we're sitting in Mississippi and they're not getting what they need, and they're just putting out fires. And I, and I respect what they're, they're trying to do, but if we policy makers, we leaders, are doing our job, then we're trying to avoid that, them having to make that hard, hard decision.

But at the same time, that means we do need them to take on particular roles with competencies around data and data expertise and metrics and accountability if they wanna step into that role. Um, so it's, you know, it's gonna be a learning, uh, process here, but I still feel like those clinical jobs should be left to our clinical partners. There are some times where, where those lines blur, but, like, let's make that the exception than the rule, and all play to our strengths.

Michael:And if we could figure out, you know, I'm a political scientist, but I certainly couldn't answer the question of how public health could and should do a much better job of making a political case for itself. I mean, I think you tried in North Carolina, in effect, to make the political case for addressing the social determinants.

Um, you know, we have a $6 trillion healthcare system. I mean, the CDC gives out, what, 9, 10 billion a year? I mean, put aside when there's a, a major crisis. Just generally. You know, so you've got Medicaid, which is, I don't know, a trillion dollar program these days, and, and the CDC giving out $10 billion or whatever it is, and how do we get more funding for public health?

Mandy:Yeah. Well, right. My dad joked when I went from my role in North Carolina Health and Human Services, and I took the CDC role, there was a line in, like, my intro about the budget of CDC, and my dad goes, "I think you got demoted." Meaning that my budget in North Carolina, 'cause it had Medicaid, it had the social services, it had mental health dollars, right? Was, was very large, was probably three times the size of the entire CDC budget.

And the CDC budget, 80% of that goes out the door to state and locals. Now, this is where, uh, I think it's very necessary to make others your champion, and I think we did that well in North Carolina. It wasn't about public health leading, it was about solving problems, right? So for me, I never called this a public health intervention in, in North Carolina. That wasn't the right packaging. This was about health for communities, right? That's why we call it Healthy Opportunities.

It wasn't owned by any one place. It wasn't just a Medicaid thing. It wasn't just a... Right? And so my advice to those who are thinking about this, and maybe even the folks in New York who are putting together these, these action plan, think about the problem you're solving and use that as the way to advocate for the resources.

And once you do, then they're like, "Oh, I see you solved the problem related to substance abuse here. We worked really well. Let's invest in the next thing and the next thing." And then all of a sudden... Don't, don't create a point solution. Create something that you can build a platform to, and then you're really, uh, have some opportunity to make progress.

Michael:So it sounds like one of the real skills a, a public health director, a local health director, or a state health commissioner needs is, in a certain sense, coalition-building.

Mandy:Absolutely. The best health directors I've seen, and there are many in North Carolina that are wonderful, are incredible collaborators. They know their hospital CEOs. They know their DSS directors. They know their community, uh, faith partners. And they manage those relationships and leverage those relationships 'cause when you're resource-poor, you need to leverage every relationship that you possibly can. So I think that is a huge skill.

I think the other, though, is around, you know, data and accountability. We don't wanna get away from our core of what public health is. We are, we are nothing if we don't have great data. And, uh, continuing to, to invest and train to make sure we're taking in the best of what new AI tools, et cetera, have to offer for public health, I think, is gonna be incredibly critical.

And then it's training on those core things that no one else can do, right? The, the epidemiologic work, as you were mentioning about restaurants and making sure the food is, is safe, right? No one else is gonna come and do that job. We gotta ace the, the things that our, our only public health can do, and then partner, leverage, work together for all the gaps that we know exist.

Michael:Two questions sort of, uh, following up on that. One, just a, a quick one on the business community, uh, and whether public health should be doing a better job of bringing the business community into those conversations. And then the second question's on data, but talk to me about the business community first.

Mandy:Yeah. Yeah. I remember early on in my tenure as CDC director having an introductory conversation with one of very, very, very large re- retailers, and I thought our conversation was gonna be about one thing, and actually his interest was in RSV vaccination, um, because he- they could see a dip in their workforce every winter, not that their employees had RSV, but it was their kids.

And then moms and dads were out of work because the kids were sick. Um, and they would, they would see a dip in productivity and just a, a lot of call-outs and just a lot of challenges for their workforce. And he was like, "How can I help you get the message out about this new RSV immunization for babies?"

And I was like, "This is amazing." And it's just a matter of, again, if you're local, make sure you're getting in touch with your local chamber. Who are your largest employers? You know, again, knowing what their biggest challenges are. A lot of them are having affordability challenges, and so what are the ways in which public health can bring some health to the- that workforce that can maybe offload some costs from that business?

And then the next thing you ask them for, they're gonna be like, "Oh, remember how amazing public health was in this thing that solved my problem?" When you come to them and for an ask, maybe it's to fund something, a table or whatever, uh, then, then they're gonna be a lot more receptive.

So I think there's both, uh, how do you solve problems for employers and work together, 'cause they want their employees and their communities to be healthy, and then how do you involve them from a funding perspective as well? Because we've had, um, our, our employers end up being some of the greatest philanthropists for some of our work as well.

Michael:That's great. Well, speaking for a moment about the CDC and the work that continues at the CDC, obviously the CDC today is a much different place than it was when you left, if for no other reason than the workforce is, is significantly smaller.

And thinking about the, for example, the confirmation hearings that Dr. Schwartz had some time ago, you know, she sort of said kind of several times, sort of over and over again, sort of her, her line was, "Confirm me, and I'm just gonna follow the science," you know, "I'm gonna go where the science takes me." And I don't think anyone would say the science is unimportant.

Obviously, the science is critically important. But it seems to me, anyway, uh, as an outsider, that there's, uh, a lot more to the job than following the science, particularly because the science doesn't tell you the policies to actually put in place. But tell me a little bit about sort of the role of the CDC director as you see it. Is “follow the science” sort of the right mantra, or, or is that sending you down the wrong path? Tell me a little about that whole issue.

Mandy:Yeah, Michael, what a great question. I think this is really misunderstood, um, in terms of the role of CDC director. And I, I wrote a bit about this when Erica was going through or was just confirmed as, as CDC director to explain that, yes, science has to be v- one very important input into a policy-making process, but it is not the only input.

And as a CDC director, your job is to make sure you're putting data and evidence in front of policy makers early so that they can understand, like, "Hey, we, I don't know what this is yet, but it's a signal and we might be something. I just wanna put it on your radar. I might be back," right? If there's, like, a new emerging threat.

Or it's, "Hey, we've gotten this new data. We're gonna have to make a hard decision about X, Y, or Z. Let's walk through the pros and cons of what this is." And we have to understand that you can make a range of policy decisions based on some piece of evidence. Think about how we do speed limits on our highways.

Public health would tell you if we lowered our speed limits, we would have less deaths from car accidents. And in fact, we did that in the '70s. We did it, and there was such uproar about it that the policymakers are like, "Nope, we cannot sustain that." And now look, do I think they are anti-science when they – no, they understand there's data, and they're making a different risk calculation and a different policy decision.

So I, I think we have to understand that policymaking is messy, that there are a lot of inputs, economic inputs, you know, stakeholder inputs. Politics does come into play with it, and that is the reality and has always been. That is not new. Now, there are some times though, particularly recently, we are seeing such a discrepancy between where the evidence is and where the policy is that you're seeing that good leaders are like, "Look, I can't be in this role anymore." So there are, there are bright lines, but I, I think there is a lot more nuance and a lot more challenges in a policy-making process, and I think that's hard for people who only spend their time with evidence.

I get that. But I think we all have to remember science evolves, too. We learn as we go and we, we, we do our best. So, you know, I think CDC director has  probably never been more challenged than in this moment because she has both the normal challenges of the messy policy process, and there are places where we are seeing such a divergence of policy from the evidence that it's a really, really tough moment for the agency and for her.

Michael:Are there, when you think about sort of the champions for public health in Congress or state legislatures, et cetera, you know, it's hard to be a champion for prevention in a sense. It's much easier, you know, if people are going without needed surgeries and dying because they don't have insurance.

From Ted Kennedy on, we can have people saying, you know, we should not have people dying in the street because they're uninsured. But it, it's a much tougher case, I think politically, to make a case for, for prevention and for public health. Um, what do you think it takes to be a, a sort of a politician who's also a public health champion?

Mandy:Yeah. Well, first I, I break it down. Like, prevention seems so massive and far away. But people really do want to be healthy. They do want their families to be safe and protected. And so I always start with values, and then I move to solving problems, right? Because to your point, we don't wanna see a problem of people dying in the street for X.

I think you can map those same sort of values into the work that we do, um, and say, "Okay, how can we bring those values into this problem-solving?" A lot of times I can get agreement no matter what side of the aisle on some values as well as identifying problems. Where we differ is the solutioning.

Michael:Right.

Mandy:But what I've come to, to see is that if you can build trust with those other decision-makers, that you're like, "We're agreeing on values. We're agreeing on identifying a problem. You're mapping this solution. I'm mapping that solution.

Could you give me a little bit of time to try my solution to the problem that you're identifying? And, like, if it's not working, I'm gonna come back to you, and maybe we'll, we'll try your solution, but how about you try, you know, my recommendation here? And here's the evidence I'm looking at. Here's why I'm thinking that this is the right solution."

And again, having that dialogue, it takes time, right? It takes that relationship building, and then you gotta deliver, right? And so I, I wanna reiterate that for public health, being focused, being prioritized, and then delivering is ultimately, I think, gonna get us further faster because folks will be like, "Oh, public health really, you know, was a real value add here."

For us in North Carolina, that was the opioid crisis. Like, that is what Healthy Opportunities stands on, is because we were able to do work in the opioid crisis. It was more focused, but it built rapport, and it built this, um, feeling that we could solve hard problems together. And it allowed Healthy Opportunities to come in next and build upon the goodwill, if you will, that we got by solving some of the work in the opioid space.

So I'd really encourage folks in, in public health to think about, you know, those solving problems and, and not be a champion for public health, big P, big H public health, but be a champion for solving problems for health in your community, and then how do you use that as the way to, to move forward, particularly in this moment of time when there's so much challenge and, and divisiveness in some of these issues. Find the place where you can get some alignment, deliver those results, and then step forward from there.

Michael:And there are some natural areas, whether it's opioids, whether it's infant mortality rates, you know, where I think the public health system and the healthcare system and the social services system. They all need to work together to create a, a real population health system.

And I think about education. Um, there've been major cuts in the US Department of Education, and sort of cuts in the ability to monitor what's going on in the schools. And, and a lot, as a result, is now being shifted down to the state and local level at a time when state and local governments themselves are under budget constraints. I mean, when you think about some of the cuts both at the CDC and Department of Education, how much trouble are we in?

Mandy:Yeah. I mean, look, it's challenging times, and any time you have less resources and less talent, you're gonna have to prioritize even more, which, what I've been trying to give advice to folks is not to degrade everything 20%, 25%, because then it just is going to seem to the individual you're serving that you're more complex, slower, clunky, right?

It- it's not gonna feel good to the human you're serving. What I'd rather see is, as a state or a locality, shrink what it could offer, but do the things that they offer, do it really well. Going back to the deliver part. Um, and I know that's gonna be really hard. It means stopping doing things that feel super important, back to that Mississippi example, where there's, they're solving real problems and filling real gaps.

With less funding, less resources on the education side and on the CDC side, you're not gonna be able to do all things. You need to prioritize. Okay, are we gonna look at our new kindergartners, and is that the data we're really gonna prioritize right now? And maybe the data on our high schoolers, we're not gonna be able to invest in right now, but we're really gonna focus on that transition from pre-K to, to kindergarten, and that's it. Right? So I think you gotta get smarter about where are the opportunities to bring in more funding and, and collaborate together.

Michael:Yeah. I mean, if you're a doctor, if you're a surgeon, you could show that you delivered. You send the patient home, they're cured. If you continue to make sure that, generally speaking, the food is safe to eat and the water's safe to drink and there's no infectious disease outbreak, it's invisible, you know? And so, you know, you're delivering, but people don't realize you're delivering.

Mandy:Yeah. And this is why public health has to define its own success and tell its own story.

Michael:Yeah.

Mandy:So let's go back to opioids, for example, right? So that could also get super diffuse. Well, one, like, let's track overdoses, let's track overdose deaths, right? So that's a very hard metric, if you will. But then there are other process metrics, to your point, of, like, what are the things that are invisible, and, and how do you make them more visible?

One, you have to tell the story when nothing happened. And I talk about story when, uh, probably my third week as CDC director, we had our first cases of malaria, domestic malaria. I don't know if you remember, Michael, this is summer of 2023. Domestic malaria for the first time in 25 years. I was like, "Oh, great."

Um, but we did a great job. It was in Florida. The local folks did a great job, lot of collaboration I won't get into, but I tell that story often because we didn't close Disney World. And that's how I start the, the story. I was like, "You remember that time that we didn't close Disney World?" And everyone was like, "What? What story are you talking about?"

Michael:Wow. Right.

Mandy: We have to tell the story and go back and say, "It was great work, and your kids went to Disney World the summer of 2023 because of public health." And you gotta take the victory lap, and often we kind of move on to the next thing. So you gotta hold yourself accountable for that, and then you gotta tell the story.

Michael:Last question, and then I, I should let you go. Um, as you think about sort of the, the next generation of public health workers, staffers, leaders, you know, people entering the field now, what sort of message do you think they should hear that maybe they're not hearing as much right now? That from a former CDC director, um, and leader in the field such as yourself, it would really, you know, be important for them to hear.

Mandy:Well, one, first, this is a great field, and as much as there is some, you know, turmoil right now, trust me, I, I have been to so many communities. They want to be protected. They want to be healthy. There is more alignment than meets the eye, I think, in some of the headlines in the moment. So one, you are in the right place. So number one.

But second is that, look, we have to also make sure that we are changing with the times. So that means the way we communicate has to be completely different. Communication has to look a lot more like entertainment, attention-grabby things. And again, that's not really our style. To your point, we like to be invisible. Well, eh, that's not a thing right in this moment. So, like, we gotta get good at the storytelling and all that. It's not that every person in public health needs to be a jack of all trades and be great at it, but as a leader, you have to respect.

As much as you respect the rigor in the science in, you know, as, as a laboratorian, I need you to respect the communications work that you need. So that's that. And then lastly is on relationships. I do think that, um, there's too much of us talking to ourselves, and your question about employers was a great one. It's like, look beyond the usual suspects of our partners here because, like I said, I do think there's universal values around protection of health, on keeping communities healthy if we can connect at the right moments on the right problems.

So manage those relationships. Get good at starting relationships, about maintaining relationships in peacetime so that when crisis comes, those relationships are already there to build upon.

Michael:That's amazing advice. Uh, thank you so much for joining me today. This has just been terrific.

Mandy:My pleasure. Thanks for having me.

MUSIC

 

That was Mandy Cohen, former CDC Director, former North Carolina Health and Social Services Commissioner, and currently a National Advisor to Manatt Health.

 

Couple of thoughts before I close out today’s episode.

 

First point, as Mandy noted, PH is inescapably political, and in this context, the role of CDC director is to put data and evidence in front of policymakers and let them decide.  Almost always there are a range of plausible options, and political, cultural, and economic considerations matter.  That said, there are times when the gap between the evidence and the proposed policies is so wide that public health officials need to push back and refuse to implement a proposed policy, even if it costs them their job.

 

Point two, Mandy pointed to her experience in North Carolina to demonstrate that state Medicaid programs can effectively address social determinants such as housing instability and inadequate food options, by screening beneficiaries to understand their needs and then paying for the needed services.  The North Carolina Health Opportunities Program has led to better outcomes at lower cost.

 

Third point, there is an ongoing debate over the extent that local public health agencies should engage in direct clinical care activities, or in addressing the social needs of their community members.  Mandy acknowledged that sometimes PH agencies take on such roles because there is no one else doing it.  But she suggests that in an ideal context, medical care organizations should provide medical care, social services agencies should provide social services, and public health agencies should provide public health services.

 

Fourth and final point, Mandy emphasized that the public health community needs to do a better job of telling its story, making visible the often invisible work of the public health worker.  She gave a wonderful example of the work Florida officials did to keep Disneyworld open and safe in 2023, at a moment when the state had its first cases of malaria in 25 years.  Parents should have heard that they could take their kids to Disneyworld only because public health did its job.  But most parents probably had very little idea about that public health success.  We need to become better communicators going forward.

 

And with that good advice, we come to the end of this episode of Who the Health Cares, a podcast that is doing its best to get the word out about what public health does and why it’s so important.

 

Join me again in two weeks when I talk with my longtime friend and colleague Larry Brown, one of the nation’s leading analysts of the politics of public health.

 

Till then, this is Michael Sparer, signing off from the Center for Public Health Implementation, at Columbia University.

 

The “Who the Health Cares” production team includes: Zoe Denckla, Rachel Ferat, Grace Rubin, Rebecca Sale, and Alex Weaver.

 

Thanks to all of you!