Rebuilding the Ties of Public Health: A Q&A With Georges C. Benjamin, MD

Am J Manag Care. 2020;26(9):367-368. https://doi.org/10.37765/ajmc.2020.88486

AJMC^®: Your organization publishes the American Journal of Public Health, and your August issue is about public health as a common good. Could you talk about that in the context of what we’ve seen this year?

Georges C. Benjamin: Sure. What we know for sure is that 80% of what makes you healthy occurs outside your doctor’s office and that the social determinants of health—those things in society that can help you more effectively be healthy or can serve as a barrier to you being healthy—are generally societal goods. It’s education, it’s housing, it’s transportation, and certainly it’s access to health care; it’s racism, discrimination, how we treat one another, where we build our communities—all those things make a big difference in whether or not one can be healthy. Recognizing that to be true, and also the fact that we seem to be moving as a society into an “I’ll take care of myself” mode vs an “I’ll take care of us” mode, we’ve been trying to emphasize the fact that we really need to have a new societal compact for health—an agreement that we’re going to all take care of one another.

I think what the COVID-19 [coronavirus disease 2019] pandemic has done is share in the starkest terms how unequal our society is and how disease anywhere impacts everybody, everywhere. [It’s shown] how interconnected we are in the employment area: The fact that some of the people we thought were our most essential workers were the people we ignore and don’t pay attention to every day—the grocery store clerks, the service workers, the people who pick up our trash. That group of people in many ways had an enormous, enormous risk, and disproportionate risk, because some of us may have to telework from home, but they had to go to work. Then, when the economy essentially collapsed because we closed things down, we discovered this group of workers who get up every morning and go to work, but now their jobs are lost. So we went from one of the best job environments to now one of the worst recessions that we’ve had in many years, and we’re pretty much close to [Great] Depression-[era] levels [of unemployment].

I think that in order for us to get out of this, we’re going to have to recognize the societal obligation that we all have for one another to prosper in our society, and that starts now. It starts first by defeating this terribly infectious and destructive disease, [and] it’s going to be about rebuilding our economy, but by the same token, it’s going to be about us building the social supports so that we can all get back on our feet in a reasonable way.

AJMC^®: You mentioned education as a social determinant of health, and this month a lot of districts are going back to school. We also know that a big factor investigators are now discovering in adult health is adverse childhood experiences. What are your concerns, as a public health official, in striking that balance between keeping people healthy but recognizing the need for consistent education and that school might be the only stable place for some kids or where they get their meals?

Benjamin: We’ve always known [about the importance of] school—we haven’t really appreciated it as much as we needed to—but during [children’s] formative years, we’ve known that school and even daycare before that, [as well as] preschool activities, go a long way toward enhancing our children’s social-emotional needs and engaging them in learning how to work and play well with others to improve their socialization skills. Then, of course, it helps them learn reading, writing, and arithmetic, but it’s those other skills that really help them, I think, and society in a bunch of ways that we really don’t think about very much. Their ability to interact with each other, their opportunities for play, and their competitiveness, and their ideas on right and wrong—all those things happen in the schoolyard, in the play yard. Yes, we parents give them some guidance, but it’s the real-world practical experiences that they get that really imprint upon them these important skills.

What’s happened now, of course, is that we have pulled them out of that environment where they would get that, and then we really haven’t replaced it. We haven’t been as innovative as we need to be, because we assume we will stay away for a while, and then we’ll just go back to normal. And now we’re discovering we can’t just go back to normal.

We also always knew that for many children, the place in which they actually got their only real good meal for the day was at school. So food insecurity is growing exponentially—not just [for] these kids, by the way, but for many of their parents, as well, as they lost their jobs. And again, everybody assumed this would be a short-term issue—tragic but short term—and now we’re discovering it’s long term. We really didn’t plan well to go back to school, and so what will happen is lots of false starts and stops as we rethink this.

In many ways, I think people are thinking about this in a 1-dimensional way—you know, how do we make the school safe? But that’s not really the whole picture. The whole picture, in my mind, is how we make sure that children become prosperous and healthy and emotionally well-endowed during these periods, and then build the system around them, whether it’s the educational piece, virtually or in class, or whether it is their engagement with their friends. If play is so important, which I believe it is, and if we’re going to have these kids at home, then we ought to have some virtual playtime. For these kids, many of them were going home anyway and playing on their games. But we’ve got to figure out more structural ways to meet the social-emotional needs of these children. We need to find more effective ways to meet their food security needs and recognize that this is not a short-term event now. We need to reconstruct this thing in a semivirtual [or] hybrid environment for probably the next 6 to 8 months, for sure.

Then we ought to, probably concurrently with this, be figuring out how we can improve the health and well-being of our whole society. You know, how do we how do we get rid of these disparities that we have in education? A lot of kids went home and the kids with means were able to hook up right away—their parents may be able to hire someone to come in and help them with their schooling—but many kids weren’t able to do that. Even if they had access to a computer, they didn’t necessarily have access to Wi-Fi, or if they had access to Wi-Fi, they didn’t have access to a computer, or their parents were home at work and simply just didn’t have the time to spend the quality time that they needed. So they got plunked in front of a computer, and yeah, there was a teacher on the other end, but the education wasn’t as ideal as it needed to be. We’ve got a lot of things we need to do around that.

AJMC^®: I have read some examples of innovative partnerships, primarily in the Northwest, of health systems getting involved with schools and community organizations to make sure kids get what they need. Are you or your organization involved in any of those sorts of discussions? You’ve said that health systems and health care organizations need to start showing up in places where they don’t normally go to bring their voice to the table.

Benjamin: Yeah, we’ve encouraged them to do that, and a couple of systems for sure—for instance, Kaiser Permanente—have been doing that. They’ve reached out, and we’ve worked with Dr Bechara Choucair to look at ways we can put policies in place to encourage health systems and others to do that. We have worked with the Aetna Health Foundation to do a better job of educating the field on both the public health side and the medical care side around opportunities to do that. And I know that my members are in a variety of jobs in which they are trying to bring people closer together to deal with things like food insecurity and housing.

Right now, during the COVID-19 outbreak, we’re in the process of trying to put together a large national coalition to make contact tracing, mask wearing, and physical distancing cool again, recognizing that right now, those are the tools that we have. It’s been so badly politicized that we’re trying to figure out how we can we can make it something that everybody feels there’s a societal need for. As I tell people, the mask protects me from you and you from me. We want contact tracing and testing to be the same thing, in that people see that as a societal good. Then, as part of that, recognizing that if someone has to be isolated in quarantine, the next step is to make sure that they have the capacity to do that. Because far too many people were told, “Yeah, you’ve got COVID-19, go home and quarantine.” But they basically went home and they ended up infecting everybody else at home because they weren’t able to effectively quarantine. Some communities figured out how to use vacant hotel rooms and other places. [We need to] give people a place to go, with appropriate supports, to just stay away for a couple of weeks so they don’t infect anybody else. Then, you know, dealing with things like food insecurity in the family, and once you identify a need, getting social service workers to go into those communities and those homes to try to help them out. I know the health systems are trying to do that.

AJMC®: Also this year, as you know, the Affordable Care Act (ACA) turns 10 years old, but it’s hanging in the balance, at least until after the election. Do you think the ACA or something else is another part of that idea of public health as a common good? And if so, what will it take to overcome the struggles that this country still has with pricing, access, and cost?

Benjamin: Well, I think the debate is over about whether or not everybody should have quality, affordable health care. The debate is still going on as to how best to achieve that. And quite frankly, it will depend on the outcome of this election, whether or not we move forward or whether or not we continue to move backward. We have been moving backward. We’ve not had an organized look at our health system. Right now, it’s been piecemeal and disorganized. And in many ways, you know, some of the things that the current administration has done have been very destructive not only to the health care system [but also] to our health overall—environmental regulations they’ve pulled back on, access to care things that they’ve done. But we’ll see what happens.

The idea is that we need a system with everyone in, and we need to figure out how best to do that in the American way. And we also have to deal with costs and quality and the fragmentation of our system. You know, we still have far too many parts of our system where you can’t move an EKG [electrocardiogram reading] across the street. We’ve got a public health system still sending data in by fax machine. In this age, we ought to be able to move people off of that and into modern-day systems. It’s going to require leadership. It’s going to require a focus on health, and a focus on health and not health care, I think, is the way to think about it. Health care is a part of health.

We’ll need for this to be a kind of a patient-centered system approach to asking ourselves, okay, what are the problems we need to solve and how do we best solve them? Then we align our payment systems and our delivery systems to meet the patient’s needs in a modern era, and not the needs of the guilds. The guilds are just gonna have to get on board with that because, you know, they’re gonna be like dinosaurs. I’m a doc, and I’m a member of a guild—in fact, I’m a member of 2 or 3 of them—but we’re going to find ourselves obsolete and unnecessary unless we begin to rethink our role in this and how we empower patients to do the things that they don’t need us for and empower us to do the things that they really, really need us to do.

AJMC^®: Do you think in value-based care, that can be an incentive, when structured appropriately, to include more of the patient’s empowerment and decision-making into those things you were just talking about?

Benjamin: Yes, I do. I think value-based care is very important. You know, it’s fascinating how quickly a terrible pandemic like this moves us from just putting our foot in the water for telemedicine and telehealth. Now we’re kind of all in, because we had to be all in, and [it] just tells you about the resistance of the health system and the payers to move it in that direction. Quite frankly, I would much rather not have to hop in a car and go to the doctor’s office, only to have them pat me on the back, tell me I’m doing fine, take my vital signs, and refill a prescription. There are so many things that that we can do remotely that they don’t need to see you for. In fact, you don’t need to see the physician; you need to see a physician extender or, in some cases, you just need to have a clerk do it. We’ve built a system that says that we have to take the most highly trained, experienced, credentialed individual and have them do every task in the system, even though we pretend like we don’t—we do. We unempowered patients to really take care of their own health. [There’s] no way for us to fix that now; we just need to build a system around that.

By the way, when we talk about value-based purchasing, value-based health care, we need to really come to some consensus about what that is, because everybody has a different definition. Then we need to align the payment so that it makes sense to do that. That also means that we need to stop shortening the patient care visit; we need to start paying for physicians’ time to talk to patients, examine patients, and not order diagnostic tests. You know, if we start paying more for the intellectual capital that we sent them to school for, and their engagement of the patient, I think at the end of the day we would actually save money, improve health outcomes, and reduce a lot of the medical errors that we have.

AJMC^®: What’s stopping us from doing that now? Do you think it’s the silos, do you think it’s the guilds? Do you think it’s everyone’s invested interests and all of those different areas?

Benjamin: You know, it’s the silos, the guilds, everyone’s invested interests, but it’s also that health care is an entity that continues to do what it does until something better comes along and the status quo becomes unacceptable. And right now, [for] everyone in their own little bubble in many ways, the status quo is acceptable: “I’m getting paid. I’m working hard, but I’m not working too hard. But I’m spending much more time doing paperwork and things that make no sense for us to have to spend time on it.” The health system is just not that positioned to move. When good ideas come along, other industries very rapidly adopt new stuff. We continue to adopt new stuff and hold on to the old stuff. You know, I go back to the original CT scan. The imaging that we are now doing today is just amazing, and yet, we’re still holding on to the old CT scan. That’s just an example. And I’m sure there’s some value for it for somebody, butit just doesn’t make a lot of sense.

AJMC^®: One other discussion that’s been happening since May is about racism as a public health issue. If it is, how do you persuade people to accept that, given some of the divisions?

Benjamin: Well, I think we just have to persevere, [and] I think we have to understand what we’re talking about. The health care community is not going to solve racism on their own, by any means. But we want to play in that area; we want to be participants in the issue around health care. So in that light, the idea of saying racism is a public health problem is to get people to understand that racism hurts people and kills people, and that it’s not just [having] negative feelings about a particular individual or race or gender or whatever. It’s not that—that exists, of course—but it’s also to think about the structural things that our society has put in place that disproportionately advantage others and disproportionately impact and disadvantage other groups, and how, as a whole, all of us suffer from that. [We need] to think about that when we practice medicine every day.

You talked about education earlier. We still have very segregated school systems in many places, and we still have huge differences in the quality of facilities, supplies, resources that go to those schools—[differences] by race. And we still have segregated communities and we’ve designed them to be that way. We seem to like to stay with each other by race, and even when we have integrated communities, we still commonly don’t build those communities up to use their full capacity. So we’ve got a lot of things we have to do some internal thinking about as a society, as a nation, and then we’ve got to really ask ourselves, what are we doing to really improve society as a whole? You know, the racial lens which has been there since the inception of this nation—in fact, before that—is one that we’ve got to finally come to grips with. Because in my mind, from a national perspective, it’s the original sin of our nation, which we have still not come to grips with.

AJMC^®: What do you think public health workers need to hear now? What kind of support do they need, given the stress that they are under?

Benjamin: I think the most important thing for me to tell health workers is that they are not alone, that we got their back. I know that they’re under stress. I know they’re working hard. I know they’re underappreciated. Unfortunately, far too many of their elected political leaders, the folks who were praising them 8 months ago, have now abandoned them and, for a range of political and economic reasons, don’t stand behind them. My message to the political leaders is, if you stood behind your health department the way you stand behind your police department, we’d be a whole lot better off. Because we’ve had far too many health officers who have felt that their bosses did not have their back and have said, “Enough of this. I’m going to go do something else,” or their bosses have pushed them out the door. I think that we need to do some real introspection on that, as a practice, as a health community, and [also] our bosses need to do some thinking about that. Because at the end of the day, those communities that have followed the best health advice and stood behind their health institutions have done fairly well in this outbreak, and those that have not are still struggling.

AJMC^®: Would you like to add anything else to this discussion?

Benjamin: I just think we need to remind ourselves that in 1918-1919, which is the last time we had something really this bad, we got over it. But we got over it with strong national leadership. We got over it by working together. We had antimask societies, we had protests—for other things, not the racial protests—we had tragedies, and people who died. Many of them were very young, by the way. That was a 2-year event, and we’re only about 6 months into this, so we’ve got a ways to go. We have some promising signs [in terms] of therapeutics. We’ve improved and enhanced our ability to care for folks, we’ve gotten really good at taking care of very sick patients with COVID-19, and we may have some additional therapeutics and maybe, if we’re really lucky, a vaccine next year. So help is on the way, but until that time, the prevention message is still wear a mask, wash your hands, keep your distance. And if we do that—do that in a way of solidarity for social solidarity—we’ll get through this.