The relationship between public health and healthcare has always been essential to the promotion of health. However, this relationship is often simplified into neat dichotomies of individual health versus population health, or treatment versus prevention. In truth, the relationship is far more complex and undefined. The practice of providing direct care mostly remains removed from abstract concepts in public health, such as social determinants of health and health equity. So how do we as public health practitioners bridge the two more effectively? This issue was the crux of my immersion, as I delved into the complex work of addressing racial health disparities in New York City. As an emerging leader at the intersection of public health and emergency preparedness during an historical pandemic, tackling health equity in the United States has seemed to be almost insurmountable. But through my work this summer, I have found promising examples that bridge public health and healthcare, steering a clearer path toward health equity.
This summer, I served as a Doctoral Fellow within the office of the Chief Medical Officer (CMO) of the NYC Department of Health and Mental Hygiene, contributing to the strategic plan: a roadmap that directs how the agency will engage with healthcare systems to eliminate racial health disparities. The CMO’s strategic plan will be central to introducing the Health Department’s goals and priorities, describing activities needed to achieve these goals, and communicating its role in fortifying the public health and healthcare infrastructure. To inform this strategy, we also engaged with CMOs from health systems across the City, preliminary conversations that gave us insight into the relationships between DOHMH and various health systems.
Despite health equity repeatedly being endorsed as central to the mission of public health, health systems are rarely oriented toward achieving this aim. Reducing inequities in health requires dismantling the systems that initiate and sustain racialized inequities in a broad range of societal institutions that are the drivers of such inequities. Through an environmental scan of other jurisdictional efforts to bridge public health and healthcare, I quickly found that while tremendous efforts have been made, American public health institutions have only scratched the surface of bridging these two systems. Ultimately, local public health authorities have seen recent successes in health system collaboration in three main areas: driving coalitions and collaborative groups; maintaining and sharing citywide health data for common health goals; and organizing multiple stakeholders for policy change. For instance, the Los Angeles County Health Action Plan was developed in 2019 to sustain efforts to reduce health inequities through hospitals and managed care organization partnerships and trainings. Harris County, TX, created a State of Healthcare in 2016, documenting the results from several focus groups around the difficulties and opportunities in bridging healthcare and public health. Their Patient Care Intervention Center is a collaborative model that brings together multiple stakeholders to address the health needs of super utilizers in healthcare. Though there are many health collaboratives that exist across the country, few address systemic issues in health equity, and even fewer have tangible and measurable goals.
In the midst of COVID-19, local public health and healthcare systems have been at the forefront of America’s battle. However, equity remains a troubling issue, running deep in the nation’s conscience. So the question remains: how do public health and healthcare institutions align their priorities towards tackling health equity? If we envision public health and healthcare as separate institutions that are accomplishing their respective goals, America’s decentralized healthcare system has a tenuous relationship with public health, despite the capabilities in both institutions. Ultimately, private health systems remain in competition with each other, and are incentivized by payment systems and treatment of disease or conditions. For instance, although 75% of health care dollars in the U.S. is spent on preventable conditions, it is estimated that only 3% of America’s health care expenditure is on prevention.
Rather than approaching public health and healthcare as separate institutions, it may be more conducive to conceptualize public health as the framework in which health systems reside. I believe that it is the responsibility of public health to lead the charge in addressing racial health disparities. Public health authorities are given the scope and capabilities to serve as conveners of health systems because of their broad vision of health that includes social determinants, as well as their ability to maintain and collect data systems that work toward improved health. While developing the CMO’s strategy, I have been holding the complexity and history of this work as I began the process of active listening and relationship-building with multiple stakeholders. I believe that advancing health equity requires a focus on systems change, work that does not exist in a silo but is enmeshed in all facets of public health and healthcare. This unique opportunity has provided me with the space for thoughtful reflection on weaving equity in my work in public health emergencies, and ways in which anti-racism can be better integrated into health system preparedness.
