WTHC Season 2 Episode 3 Transcript

Public Health, Lost in Translation

Back in January, the Trump administration proposed significant changes to the federal vaccine schedule which have left many parents and providers in a kind of uneasy limbo. For some, those changes have raised practical questions about access and cost. For others, they’ve prompted a deeper sense of uncertainty about who to listen to and who to trust when it comes to information about your health.

Part of the reason there’s so much confusion right now is because our public health system is highly fragmented, spread across several thousand state and local agencies and caught between conflicting guidance and growing political pressure. It’s also because most people don’t understand what public health is or why it matters. And the gap between what public health does and what people think it does is where a lot of today’s challenges begin.

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

University. You’re listening to “Who the Health Cares,” a podcast about the history, politics and substance of our public health system.

On today’s show, I’m sitting down with Chelsea Cipriano, managing director of the Common Health Coalition, a nonprofit coalition of over 350 health care and public health organizations from around the country. The Coalition began in 2023, in the aftermath of the pandemic, when health insurers, physicians, and hospitals recognized the need to sustain the partnerships they established with public health agencies that had become so important when dealing with COVID.

Chelsea started her public health career in the back of an ambulance, as an EMT while in college in Louisiana. She later worked for the CDC and other federal health agencies and then spent years working for various municipal agencies in New York City, including a role as the Executive Director for Government Affairs with the New York City Department of Health during the height of the pandemic.

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Given Chelsea’s work at both the federal and local levels, I was eager to get her thoughts on how state and local public health agencies are faring in the first 15 months of the current Trump Administration. And so that’s where our conversation begins.

Michael: We have, in the United States, an extraordinarily decentralized and fragmented public health system.

Chelsea: Mm-hmm.

Michael: We've got over 3,300, I think, state and local health departments. We have the federal agencies, we've got the Common Health Coalition and all these other players we're talking about. We're now in an era in which federal officials offering public health guidance on vaccines that's at odds with what many if not most state, local leaders, and public health scientists would say is good science.

Chelsea: Mm-hmm.

Michael: In that context, how should state and local leaders respond? How can they respond? What kind of levers do they have? Um, what's going on with that right now?

Chelsea: Yeah, it's a great question. I know it's front of mind for so many leaders and also parents, right, of, there's a lot of confusion out there and they're hearing a lot in the news, and so who to trust, what to listen to and what's gonna be the best course of action to keep their kids safe is what everyone is thinking about.

I do think that first and foremost, as leaders are thinking about this topic, as they're talking about it, really focusing on access. Ensuring that people's access to the vaccines they want remains. I think too, as leaders, whether state and local health leaders or healthcare leaders are thinking about this, taking this frame that we've really been trying to deploy at the coalition of turning confusion into clarity for leaders and providers and turning clarity into confidence for the people they serve.

Two, look to the evidence base. So we have seen from not just the American Academy of Pediatrics, but uh, you know, a whole slew of other provider associations, ACOG, the gynecologists, the family physicians, the infectious disease doctors, the AMA, they have all come out supporting the American Academy of Pediatrics’ recommendations, which were created and are created each year through a robust evidence review about what has changed in the science or hasn't changed. So at this point, look to those evidence-based sources and then think about what providers and patients and families need in order to have that confidence.

And then finally make sure we're working together so that we don't have a patchwork of 50 states, so that the southern states, uh, who maybe haven't been out as publicly about all of this stuff are not getting left behind. So ensuring we're not creating a more patchwork, uh, less equitable, less access issue across the country.

Michael: Yeah. I mean, I think those are all great points. I mean, each of them is complicated. I mean, for example, the access question.

Chelsea: Yeah.

Michael: Number one, you say access to what people want.

Chelsea: Mm-hmm.

Michael: Well, in an era of growing vaccine hesitancy, people may say they don't want access to certain kind of vaccines 'cause they believe what they're hearing, that they're not safe. Access also requires confidence that it's not gonna bankrupt you or cost a lot of money, and I think people are nervous now, am I gonna have to pay for vaccines that they're gonna have to pay for?

Chelsea: I think that that is a very important, important point, Michael. I think that having confidence isn't just about the science or, you know, the fact that so and so is recommending it, it is about making sure that people are not going to have a surprise bill. And we know – the payers, so the, the payer association AHIP, um, did come out in the fall and say, they said that these vaccines would continue to be covered.

That is important not just for the people on the leadership and health side to know, that is providers, family members, we need to be yelling that from the rooftops because, I mean, it was a, it was a point of, of great success in leadership from the payers, but also, it only matters if people know it and if people know that they aren't gonna have a surprise bill because of these vaccines.

Michael: Yeah. And you mentioned the decentralization and, uh, you know, maybe take a state like Florida. Um, we could well have a situation, we probably do have a situation, in which the health department in the state of Florida is saying very different things than the health department in the state of Massachusetts or the health department in the state of New York. And I guess, you know, this gets back to the issue of fragmentation, decentralization and federalism.

Chelsea: Mm-hmm.

Michael: There's pros and cons to having some state and local authority and we're seeing both the pro right now, which is the state and locals do have some ability to, to respond in an era when the feds are going in a different direction, but also the con, they could be going in very different directions.

Chelsea: Yeah, I think that's very true. And there's still wonderful work happening in states, you know, like Florida, like Louisiana, my home, and there are clinicians on the ground who, you know, very importantly, clinicians today can still offer all of these vaccines to their patients. They can still talk to them about the evidence. They can still importantly answer their questions. To your point, people have more questions today.

Michael: Right.

Chelsea: And to dismiss them as anti-vax or against the science is wrong and we shouldn't. And I think that we in public health and those in medicine need to take a hard look at why people are having these questions, where and why trust has been lost and ask ourselves, and what can we do to rebuild it? I think that that needs to start first and foremost with meeting people's needs and making them feel heard and not dismissed if they are asking questions and raising points that need to be listened to.

Michael: You know, we've always had in this country, among much of the population, skepticism about government and, you know, belief in individual rights and individual liberty, et cetera. Um, and the balancing act between protecting the rights of the individual and the needs of the community. At the same time, trust in the public sector and in public health, in a post pandemic world, it seems to have gotten worse, not better.

Chelsea: Mm-hmm.

Michael: Now, we may trust the fire department, um, you know, Americans, but increasingly they don't trust public health. There's no simple answer to this, but why have things gotten worse and what are we gonna do about it?

Chelsea: Man, the million dollar question. Um, I think the loss of trust since the pandemic cannot be overstated and the role of the pandemic in losing that trust cannot be understated. People felt like they were left on their own to figure things out. They felt like government didn't give them the guidance or resources that they need to navigate something really scary. They felt like we were overblowing what was happening.

I mean, I was part of the team planning how to, um, respectfully handle the remains of the New Yorkers who perished in the early days of the pandemic. And that was not the experience for people living in Louisiana. People living in Louisiana were told to stay in their homes. And they didn't know anyone who was dying, or they didn't know anyone who was sick. They are not on top of each other the way that we are here. They were not seeing the body trucks in the streets. It was a real disconnection from what they were hearing on the news to what they were being told to do. And I think that created more distrust because it wasn't matched with the reality.

So I think we can talk all day about the things that went wrong during COVID. A lot of things went really right. A lot of services emerged. We showed that we can have healthcare and public health on every street corner

Michael: The collaborations you talked about before.

Chelsea: Yeah, in the form of testing, in the form of tracing, you know, New York City was offering dog walkers to people who couldn't leave their homes, hotels. I think one of the things that we haven't talked about is we gave people things during the pandemic and then we took them away. So we were showing people data every day here of twice a day of, like, their zip code level data. We showed them that that's possible, that public health can give them that. And then we don't do that anymore.

We don't do that for Legionnaires or, you know, other, other diseases that they're seeing emerge. But we've shown them that we can give them some tools to help navigate something really scary. And so I think there are little things like that every day that could build trust in terms of this service oriented, how are we giving people what they need?

Michael: Oh, that's great. Let, let me sort of build on that a little bit by asking a different kind of question around Bobby Kennedy Jr. and the MAHA movement, Make America Healthy Again. Do you think there's some good that's gonna come out of the MAHA movement and, and how would you sort of see that potentially happening?

Chelsea: Yes. I think unequivocally, the fact that we are now talking about nutrition, um, we are talking about healthy eating, healthy lifestyle, kids getting outside more, these are things that talk to any health department, any public health lifelong career person, they've been trying to scream this from the rooftops for decades, right?

Michael: So is this like Nixon going to China? I'm just gonna be a, you know.

Chelsea: I think, I, it's hard. I mean, it's very hard. I know, I'll speak, I don't wanna speak on behalf of all public health people, but it's definitely hard to hear some of these topics be discussed as if it's the first time that they're being cared about where, you know, we've, we've been working on these, these topics for decades and, um, Michelle Obama and Let's Move, right, made that her priority as, as First Lady.

There have been laws in New York and elsewhere to limit, um, the size, quantity ingredients in foods and, and restaurants for, for many years. Smoking, we've made amazing gains through regulations in public health. But, this is, you know, getting America, industry, and others to the table to talk about–

Michael: Processed foods, for example.

Chelsea: Exactly. Health, like healthy eating as a driver of health. I think it's a good thing. I think there are a number of, um, evidence, questions of course in, in what is being presented, and we should point those out. We should continue to elevate the, the science and the evidence and robust research, but I think that the fact that we're talking about it and the fact that it's on the front page of the news is a win for public health, and we should figure out how to harness it and work with the administration to get those goals across the finish line.

Michael: Yeah, we have to convince people that just 'cause Bobby Kennedy says it doesn't mean it's necessarily bad.

Chelsea: That's right. That's right.

Michael: When you talk, obviously through the coalition, but through your years more generally in the field, you connect all the time with state and local health officials. What do you hear on the ground? I mean, what are you hearing about what sort of impact the new administration a year now in is having? Have things really changed? Are things still kind of chugging along? Is there just a lot of noise? Have there been cutbacks? I mean, obviously there's the vaccine issue. But more generally the work of public health. What do you hear?

Chelsea: I think that we are hearing from leaders across the country concerns about a few things, um, including Medicaid, right, the loss of, of Medicaid coverage.

Michael: Right.

Chelsea: And the impact that will have in the next couple of years.

Michael: Right.

Chelsea: Is massive.

Michael: Massive.

Chelsea: And that is not just about health care, right? That is, Medicaid is one of, uh, is a magical program that is, does do the connection between healthcare and public health behind the scenes. And it is so important for states to be able to drive some of these population health and public health goals.

Michael: Medicaid's 900 billion while CDC is 9 billion. I mean, that's, as they would say, that's where the money is.

Chelsea: That's right. I think–

Michael: Or was.

Chelsea: Right. So that's something to watch. Hasn't happened yet per se, but I think that we are already seeing grave concerns about what it will mean. Two, the cuts that were proposed last year to public health, like the, across the board, all of the sweeping cuts, they have not come to fruition at this time. I don't think that state and locals should, uh, rest on their laurels about not losing that funding. I think they should be working to explain what that loss in funding would have meant, or what it would mean if it comes down later. So one thing in public health that we could do a really, a much better job of doing, and we're working on this at the coalition, is saying, yes, we may be lost $10 million in HIV prevention, but what does that mean for you, healthcare system?

What does it mean for the patient on the ground and their access to prep or services to prevent spread or further disease? What does it mean to the insurance company? And so we've been working to model out some of that, of if there is a cut or a policy change of this amount, what does it mean downstream for the additional and sicker patients that will be showing up in hospitals that they're not prepared to deal with?

Michael: So that, that actually gets to the question, so-called ROI or return on investment question. I mean we, we talk about medical care as though it's obvious to say what the ROI is 'cause we have grateful patients, even though I'm not sure we're getting a real return on investment on $5 trillion that we should in terms of a health system, medical system.

Chelsea: Right.

Michael: But public health has a real challenge, I think, demonstrating its value. I remember talking one time to Dick Gottfried, who was the head of the New York State Health, he was in the legislature and he ran the health committee for years. And he said to me, you know, every day when I go to work, there's some group outside the New York State Assembly that's protesting about something that wants more money for something that's got some interest in something, and I have to walk past them every day. In my 30, 40, 50, whatever it was, years, uh, in New York State government, not once, he said not once have I walked by a group saying more money for public health and here's why. Um–

Chelsea: Yeah.

Michael: Maybe tell me a little about how you think we could do better at demonstrating the return on investment that public health brings.

Chelsea: Yeah, I, I think that you're hitting the nail on the head on a really big problem that we have, and it's solvable, right? Like there's, there are problems that aren't solvable. This one's solvable. I, very quickly, I, I remember this one talk that I went to. It was with Brian Castrucci from the De Beaumont Foundation, and he was in front of an audience of public health people, and he said, if I asked you to draw a hamburger right now, you could draw a hamburger. But in this room of, you know, a hundred public health people, if I asked you to draw public health, I don't think you could. And everyone kind of laughed, but it was a real moment for me of, like, oh no. We are in trouble if, if public health experts themselves can't, succinctly and in one voice, define number one, what public health is, and two, what public health does.

And I think those are two distinct things, but I really believe that we need to get tighter as a field on describing what we are and what we do and not hide behind this narrative of, public health is in the shadows. If it's doing its job, you don't know it's there. We prevent things, we're not meant to be seen. I, in grad school, I was taught, if you know what we're doing, then something has gone wrong. And I think that that has just been a real problem, particularly right now as we're all scrambling for money and resources and trust, um, trying to describe who you are and what you do while also asking to keep your field afloat is not the way we should be going about this.

So, I think that we as public health need to figure out what are our shiny objects and what are our putrid garbages? And I know, Michael, you've heard me talk about this before, but, um, sanitation's a great example. When they talk about their work, when they talk about what they're not getting, what they need in terms of budget or resources, the threat is putrid garbage all over the streets of New York City. We as New Yorkers viscerally know what that would–

Michael: Or snow all over the city.

Chelsea: Snow, sure. But like, we know what it smells like, right? We can, like, envision what that would mean for us and it would be really bad. And so I think we as public health, what's our putrid garbage if we don't have what we need in the public health system, meaning government, meaning academia, meaning CBOs doing on the ground work. What is the putrid garbage for the people that you're serving?

Two, what are our shiny objects? A garbage truck is a beautiful thing. An ambulance, you see it. You hear it. You might grumble at it, but you know it's there. You know that your tax dollars are buying something tangible. So public health often says, you know, we need more money. Or they say, we need a hundred million dollars to do more programming. What we don't always do is say, with $10 million more for this program on HIV, we could be preventing X number of cases more, right? We're, we're often in a defense approach, not an offense approach. But saying we need more isn't the solution. Explaining why we need more and how it's gonna help save costs downstream for others is important.

Two, R-O-I. R-O-I is not a great measure of savings. There are things in public health, like community health workers, like, like vaccines, like, um, other types of prevention programs, overdose prevention programs, where you can show a very clear for every dollar invested, you get $3 back. But we need to better calculate the full financial, economic, social value of programs and investments that do not just rely on ROI.

Michael: So we've talked a lot about how public health could use more money, but there are some tools that public health leaders have been thinking about, uh, you know, that really deserves some additional thought, I think, and some additional investigation as to how public health could be a little more creative in trying to generate some additional funding for itself. Do you have, do you have thoughts or ideas about, you know, some of those avenues?

Chelsea: I do. Yeah, I have a lot of thoughts about that. It's something I spend a lot of time thinking about these days. I think first and foremost, we need to collectively say we cannot philanthropy our way out of this and our ease of just saying, oh, something's hard, we're gonna turn to philanthropy to try to fill this gap, is not possible right now. It's just not. And if we do see some of these bigger, more substantial cuts to the public health infrastructure come to fruition, those gaps are going to be too big for philanthropy to fill alone. Nor should they, nor should they.

So we can't philanthropy our way out of this. What does that mean? Who, who then do we turn to? I think this is where we get to get creative. And that's what really excites me. I think figuring out how to pay for things, being good stewards of the public's tax dollars first and foremost, and bringing non-traditional partners to the table to help fund some of this work when it benefits them downstream, is what we should all be thinking about right now.

So, philanthropy should still have a role. I see a role for philanthropy to act as seed funders, um, in some of these creative models like, uh, public health bonds, for example, where philanthropy may be a seed, a seed, um, funder, and then public health would approach a payer and say, this program to prevent X infections, uh, will benefit you downstream. It would actually save you this amount of money and this amount of suffering for your members. The payer would say, yes, I see that value, and then contribute to this bond that the health department would then spend, be able to actualize and show those savings that could then be reinvested into the program later on.

So, models like that, um, models like in Massachusetts. Healthcare entities who want to do construction, build a new tower or a new building, um, they pay 5% of the construction cost into a fund that the Massachusetts State Health Department then distributes to public health initiatives. So there are models like this all over the country. Uh, we really want to identify them, see what's working, what's not working, where can we get more creative and hit go on experimenting with shared and creative financing. Because the cuts are going to impact all of us and the benefits impact all of us.

Michael: Right. Right. If only we can get, you know, there's all this new casinos going up everywhere now.

Chelsea: Sure.

Michael: You know, it'd be great if we can get a little of that casino money. I mean, it's, you know–

Chelsea: Interesting proposal.

Michael: Not that I'm big, uh, you know, it's just, you know, there are these sources, uh, and figuring out how to make a case for public health to not only get access to some of these funds that are being generated, but to demonstrate that the money is being spent and the impact.

Chelsea: I think that housing is one of those areas where it's both a public health good, right, building more affordable, safe housing. And there are political and societal, you know, physical perception benefits of being able to have people housed. So I do think that the idea of using some money generated in other ways to go towards shared public goods like affordable housing is something we're seeing pick up across the country. I think we could make that same argument for other public health programs that maybe aren't as visible as a building going up.

Michael: Right. And, but we might not wanna say it's for public health 'cause people will say, I don't even know what that is.

Chelsea: I don’t know what that is. Right.

Michael: You know, it has to be something tangible, something exactly concrete that public health is doing that we could say, you might not even call this public health, but call it what you want. This is, you know, this is a–

Chelsea: A grocery store in a food desert.

Michael: That's right. Let me ask, uh, one last question, which is, um, sort of builds off the title of this podcast, Who the Health Cares. How do we make it more likely that Americans across the political divide, across the political divide from your home in Louisiana, to Indiana, to Texas, to here in New York, um, know about and care about the work that public health is doing, know what their local health department is doing and the value it provides and why it, it's providing really the same kind of value as their local fire department, police department. It's, it's providing a, a public good. How do we, how do we start that task? How do we take the next step?

Chelsea: Yeah, I think it's telling the story. It's explaining what we are doing to meet people's needs. I think that we in public health know that we are doing good work for people and that we are making a difference. That's why we went into this field. It definitely wasn't for the money and – or, or the fame.

Michael: Yeah.

Chelsea: Um, we know that what we're doing is making a difference. We need to make sure that others know that we're working for them. And so that's not just telling the success stories, it's talking on a daily basis about food inspections, about water inspections. A lot of our work is more tangible than other pieces. So how do we uplift those examples to make sure that there is a shiny object while the quiet work happens in the background?

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Michael: Thank you so much for being with me this morning, talking about public health and politics and public service. It's, it's been great to have you and, uh, good luck with the real challenges and the opportunities that you have at the Common Health Coalition.

Chelsea: Appreciate it.

That was Chelsea Cipriano, managing director of the Common Health Coalition. What an impressive public health leader! And what a thoughtful and compelling set of reflections on the politics and substance of where things stand in the US public health system.

Let me now offer what I’ll call my five-point recap of the conversation Chelsea and I just had.

Point one, while the CDC has changed its recommendations for child vaccines, eliminating, for

example, the recommended automatic dose of Hepatitis B vaccine for all newborns, parents

can still access the Hep B vaccine and others for their kids. But the situation is still quite

troublesome. Some parents may not know they still have access. Or maybe they think they’ll

have to pay out-of-pocket, even though they won’t. Or maybe they have concerns about the

safety of vaccines, which we should address with respect, rather than disdain.

Point two, the mistrust of public health that increased during the pandemic was unfortunate

but in many cases not irrational. If what you saw on television seemed so distant from the

reality that you were experiencing it’s not surprising that you may have agreed with the folks

who said masking and social distancing policies were an over-reaction.

Point three, the cuts to state and local health agencies so far have been less severe than

expected. To be sure, the CDC itself has been decimated, with hundreds, perhaps thousands, of jobs lost. And the cuts to US global aid have been extraordinarily severe, with devastating consequences that we should discuss in another episode. But so far, Congress and the Courts have limited the potential cuts to CDC funding for state and local agencies. That said, the risk of major cuts is still there and state and local leaders need to be prepared for that possibility. And the looming cuts to the Medicaid program may well have a massive negative impact on the nation’s entire public health system.

Point four, the MAHA movement presents a mixed bag for public health. The misinformation,

especially the idea that vaccines cause autism, is dangerous and needs to be countered. But

the initiatives that focus on healthy eating and the dangers of ultra-processed foods are

longstanding public health talking points, and we ought to take advantage of the opportunity to

make important gains in these areas.

Finally, point five, status quo funding for public health is just not good enough. Public health

remains terribly under-funded, under-resourced, and under-valued. But simply advocating for

more money for public health is not going to change anything. Why? Well, at least in large part

because so few people actually understand what public health is and why it’s so important. Ask a thousand people to define public health and you’ll get a thousand different answers.

As Chelsea noted, we need to change the narrative that most of what public health does is

invisible. We need to make it visible, to tell the stories, and to make the value much clearer. And we need to get creative about developing new financing mechanisms for public health.

Thanks again to Chelsea Cipriano for talking public health with us today, and for what she and colleagues are doing at the Common Health Coalition.

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Join us again in two weeks for a conversation about the role of emergency management in public health. Are we prepared for the next pandemic?

Till then, this is Michael Sparer, signing off from the Center for Public Health Systems, at

Columbia University.

This episode was produced by Grace Rubin.

Our sound engineer is Zoe Denckla.

Alex Weaver is our social producer.

Fact-checking by Monica Stanovic.

Rachel Ferat is the Program Manager for the Center for Public Health Systems.

And Rebecca Sale is the Head of Strategy and Partnerships for the Center for Public Health Systems.

Thanks to all of you!