Working the system
[ Fall 2012 ]
As director of the second-largest health department in Washington State, Anthony Chen, MPH ’06, tackles all the issues—from infections to inequities—that shape people’s health.
The elderly Taiwanese man had been Anthony Chen’s patient for years. When the patient developed liver cancer, Chen worked closely with him, his wife, and his son to address their concerns and calm their fears. Often, he made home visits as the man became sicker. He’d do a physical exam. He’d ask if any help was needed in the household. And he’d talk with the family about how they were coping with a husband and father’s decline.
It was heartbreaking for Chen to watch a longtime patient struggle with his disease. It was even tougher to realize that his death from liver cancer could have been avoided if he’d simply been vaccinated for hepatitis B.
This was one of many frustrations that propelled Chen, MPH ’06—after 16 years in family practice—into the public health profession. Chen, 51, is now Director of Health for Tacoma-Pierce County Health Department, the second-largest health department in the state of Washington, with 270 employees and an annual budget of about $36 million. As director, he works on the full gamut of public health issues: obesity, air and water quality, sexually transmitted diseases, pertussis, flu, oral health—and hepatitis B.
A Preventable Cancer
After working in a number of underserved communities—in Boston, Chicago, and Seattle, as well as in rural North Carolina—Chen came to see that a broad systems approach and population-based public health focus visibly improved the lives of his individual patients. This fact was brought into stark relief through his work since the early 1990s with the Asian American and Pacific Islander (AAPI) community in the Seattle area.
According to recent statistics, AAPIs account for half of the estimated 1.4 million people infected with hepatitis B in the U.S., even though they make up only 5 percent of the population. “When you work with any sizable Asian or Pacific Islander community, you see patients with chronic hepatitis B all the time, because the disease is endemic in their countries of origin and gets passed down from mothers to children,” says Chen. “You look at how much time and energy you’re spending taking care of patients with liver cancer—and it all could have been avoided with a vaccine.”
City Within a City
In 1996, Chen took a job as lead family physician at a medical and dental clinic in Holly Park, a heavily Asian and African American section of Seattle, where roughly 25 percent of residents live below the poverty line. His nine years at the clinic, he says, sometimes felt like toiling in an isolated Third World medical outpost.
“We were only six miles from the nearest hospital, but many people living there were poor or working and didn’t want to travel to the hospital,” Chen recalls. “We gave shots, drew blood, orally rehydrated kids with high fevers in the back room. In Seattle, people don’t think there’s an ‘inner city’—but there is.”
Chen saw how political realities were hurting his patients. After national welfare reform went into effect in 1996, for instance, even legal immigrants face new restrictions on benefits and could not receive public assistance until they’d lived in the U.S. for five years. It was also sobering for him to witness the fallout from Washington State’s failed health reform effort. In 1993, the Democratically controlled state legislature passed a law requiring that all Washingtonians have access to private insurance, regardless of their health status, and mandating that they purchase coverage.
Two years later, Republicans took control of the legislature, repealed most unimplemented provisions of the law—including the individual mandate—but left intact the guaranteed issue provision. The result? Enrollment in health insurance dropped, many bought insurance only when faced with large expenditures, insurers lost money, premiums rose, and a number of insurers left the state.
Medicine and Marketing
Chen headed to HSPH so that he’d have more tools to deal with such challenges. In 2006, he earned a master’s of public health with a concentration in health care management and completed the Commonwealth Fund Harvard University Fellowship in Minority Health Policy. In classes with [[Robert Blendon], senior associate dean for policy translation and leadership development, and Howard Koh, then Harvey V. Fineberg Professor of the Practice of Public Health, Chen learned about the importance of shaping one’s message and providing compelling arguments. “I knew that medicine was important,” he says. “I learned that communication was, too.”
After HSPH, as medical director at several Boston-area health centers, Chen witnessed the launch of health care reform in Massachusetts. “I saw patients come in after not seeing doctors for years,” he says. “Seeing health care reform come to fruition, after seeing it falter in Washington State, was a powerful experience.”
Doing More with Less
In October 2008, as the U.S. economy began to plummet, Chen became Tacoma-Pierce County’s Director of Health. Immediately, he put together a new strategic plan. “Too often, public health is reactive to the economy,” he says. “When I got here, the budget was $40 million with 300 employees. Now it’s $36 million with 270 employees. Instead of just shrinking our programs, we needed objectives and strategies.”
Compared with the state overall, Pierce County residents have worse health, more heart disease, and higher death rates, and breathe more contaminated air. The poorest residents have high rates of obesity and tobacco use. There are disturbing health disparities between African Americans and whites.
Under Chen’s leadership, the Tacoma-Pierce Health Department has tackled these problems head-on, encouraging landlords and property owners to develop smoke-free rental housing, for instance, and working to deliver vaccines to children who need them.
The Big Picture
In public health, says Chen, it’s crucial to look at the big picture. He thinks, for example, about the impact of the recession on children. “People lose their jobs and their kids might not get fed,” he says. “They lose the roof over their heads, and then their kids can’t concentrate at school. They lose their health insurance, and then the kids get sick.” He pauses. “It gets very frustrating when you have to deal with people who don’t see the connection between all of these things.”
In 2011, Chen coauthored a study examining how public health departments in the state of Washington were dealing with budget cuts. The researchers found that there was often no systematic process for prioritizing or cutting programs in response to tight budgets. Because of a state mandate to investigate dog bites and rabies cases, for example, some counties were cutting crucial programs like epidemiology or chronic disease prevention. As Chen sees it, “People end up doing things that may not be evidence-based—instead, it’s just what some lawmaker thinks.”
“Most people don’t understand public health,” he concedes. “They also don’t understand the difference between health care and public health. So funding for public health—which has ‘health’ in its name—may be neglected or may get cut because of political opposition to health care reform.”
“I know public health people are stressed out right now, with their budgets cut down to survival level. They feel they don’t have the bandwidth to think about policy on the national level,” he says. “But we have to get engaged in the debate. We need to be on the phone and travel to our state capitals and DC. We can’t do things the same old way.”
Karen Feldscher is a senior writer at HSPH.