“When prevention works, absolutely nothing happens,” says Howard Koh. “And all you have is the miracle of a perfectly healthy, normal day.” One of the nation’s foremost public health advocates, Koh has pursued those everyday miracles for decades. He served as assistant secretary for health in the Obama administration, where he led prevention efforts under the new Affordable Care Act (ACA), helped guide the government’s response to the H1N1 pandemic, and pushed for racial equity. At the Harvard T.H. Chan School of Public Health, Koh is the Harvey V. Fineberg Professor of the Practice of Public Health Leadership and oversees a new effort on health and homelessness. Koh spoke with freelance writer Michael Blanding in November about charting a way forward for public health beyond COVID–19.
Q: How do you view the state of public health right now?
A: We’re sadly seeing the result of a fast infectious-disease pandemic being fueled by a slower, preventable chronic-disease pandemic of, for example, obesity, diabetes, heart disease, and lung disease. Chronic diseases have been allowed to mushroom because we’ve underappreciated and overlooked public health for far too long. Only two to three cents of every health care dollar is spent on disease prevention—and that funding has actually decreased in recent years. As a son of immigrants, I am deeply concerned that COVID-19 has disproportionately impacted communities of color. And as a physician, I have seen that when a loved one dies, that’s a tragedy—but when a loved one dies a preventable death, that tragedy haunts you forever. Sadly, this terrible theme is playing out over and over again nationwide through the calamity of COVID-19.
Q: What did the Trump administration do right in dealing with the pandemic?
A: Operation Warp Speed, for all of its challenges, has generated several excellent vaccine candidates in a very short time frame. We still have far to go in making sure one or more vaccine candidates cross the finish line, is regarded by independent experts as safe and effective, and is authorized or approved by the FDA [U.S. Food and Drug Administration]. After that, we must ensure that supply can meet demand for millions of Americans, not to mention billions more around the world.
Q: How do we ensure that happens?
A: We need to build on ongoing flu vaccination efforts to serve as a successful on-ramp for a future COVID-19 vaccination effort. We also need a more unified national communication campaign for both vaccination efforts, to combat vaccine misinformation on social media, and demonstrate to Americans that our stressed but committed public health system is working 24/7 on their behalf.
Q: What do you see as the Trump administration’s mistakes in managing the pandemic response, and what might the Biden administration do differently?
A: To date, there is no national plan for a unified pandemic response. The Trump administration has not consistently empowered its public health agencies and scientists to speak with one voice. The mixed messages on masks and social distancing have particularly sowed confusion and led to a disjointed response. However, President-elect Biden has announced that his overriding principle will be to empower public health science and public health scientists. Among other things, he has pledged to create a pandemic testing board, fully implement contact tracing, and build a public health job corps. He’s also announced his intention to have the U.S. regain its leadership role with the World Health Organization [WHO]. All these commitments are major steps in the right direction.
Q: How important is the Affordable Care Act in maintaining public health?
A: The possibility of repealing the ACA in the midst of the worst pandemic in a century is just unfathomable. President-elect Biden has expressed support for protecting the ACA and building upon it by lowering Medicare eligibility to age 60 and creating a public option. We will have to see if the White House and Congress can make that happen. Of note, a major, unappreciated part of the ACA is that high-value prevention services must be one of the 10 essential health benefits covered by all private plans. In this way, for example, lifesaving interventions such as colorectal cancer screening can be accessible to all without the need to pay out of pocket. Previously, under the ACA, community transformation grants helped galvanize neighborhoods to address health disparities and advance local health. These have since been eliminated. We need to rebuild prevention and public health from the ground up, especially when health equity is front and center as a national priority.
Q: How can public health advocates best make progress in the coming years?
A: Health starts not just in the doctor’s office but also where people live, labor, learn, play, and pray. Improving public health will require health professionals’ working closely with other sectors of society, including business, education, transportation, housing, and faith-based organizations. Fully reaching a vision of health equity must involve such nontraditional partnerships. I have learned a lot in recent years about working with the private sector as the principal investigator of a grant with the Robert Wood Johnson Foundation bringing the Harvard T.H. Chan School of Public Health and Harvard Business School closer together. We have been exploring how a “culture of health” can serve as a business leadership imperative. These interdisciplinary collaborations represent the future of public health—it will be impossible to reach [U.S. Department of Health and Human Services] Healthy People goals and [United Nations] Sustainable Development Goals without them.
Q: What guides your public health philosophy?
A: I think almost every day about two historic statements from WHO. The first is “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being.” Everyone deserves a chance to reach their full health potential. The other is the WHO definition that “health is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity.” Traditionally, health professionals haven’t spent much time studying absence of disease. So it is exciting to see more recent attention to supporting complete well-being—not just physical but also emotional, mental, social, and spiritual. When a person reaches their “highest attainable standard of health” and enjoys complete well-being, that’s public health success.
