番茄社区

Public health has endured a very public critique during the acute crisis of the COVID-19 pandemic and its aftermath.

Now, public health leaders are tasked with the difficult challenge of digesting those lessons and shaping the field into a new and improved version of itself.

Among them is Ashwin Vasan, MD, PhD, Commissioner of the New York City Department of Health and Mental Hygiene (DOHMH), who took the helm almost 18 months ago and has already started making changes at the agency, aimed at setting up the city for future public health success.

"We've always been a city that celebrates and supports public health," Vasan told 番茄社区 in a recent interview. "But the issues are similar [to what's going on across the country]: community engagement and trust building, getting out of the ivory tower ... and into the community."

Vasan discussed those challenges, and his plans for addressing them, in a conversation with 番茄社区 in mid-August. He says he's looking externally at the city's public health needs to inform any internal changes.

"We're trying to bring the external focus and the internal focus into alignment because we know we can't achieve [our external goals] if we don't reform internally," Vasan said.

Modernizing Public Health

During the first year of his tenure, Vasan and his teams identified external public health issues to inform the best internal structure for the agency going forward.

The key statistic that stood out to him was the significant drop in life expectancy in the city.

"We lost nearly 5 years of life expectancy in 2020, and in 2021 we gained about half back, but it's not inevitable that we'll just get back on track and be at our pre-COVID levels," Vasan noted. "We're seeing rates of excess death, premature death, and death in vulnerable populations ... worsen."

He said the key question informing his approach is, "How do we organize our strategy around getting back those life-years and ensuring equity?"

Part of that process is developing a population health agenda for the city that establishes numerical goals for each of the leading causes of death in those three categories, to improve those rates by 2030 and beyond, Vasan said.

Several internal changes are needed to make that happen, he explained, highlighting several key areas. These include investing in a stronger workforce, both for current workers and for recruiting new workers.

Another, he said, is ensuring that equity is baked into the infrastructure, making it a "part of every single program at the agency."

It's also about improving communications and external affairs, he added. "How do we really engage people? How do we build that trust? How do we get out of our offices and into communities to build relationships -- and understand that this simple act can pay off for a long time, especially when you're asking something of communities, like wearing a mask or taking a vaccine? If you've never spent any time with people, it's much harder."

It also requires building data systems that can deliver important information sustainably, Vasan said.

"We did incredible things during COVID around data dashboards, but when you look at the work it took underneath, it's not sustainable," he noted. "It's highly manual and highly circumstantial. And a lot of it was highly funded by emergency federal dollars that are now disappearing."

Perhaps one of the biggest changes Vasan has made is creating a Chief Program Officer position, tasked with unifying the department's many division and subject matter experts.

"Most health departments are organized in a fairly flat way, and we decided we need a unifying body that's thinking interdisciplinarily across subject matter divisions," he said.

The intention is to think of the work as shared services, and it's been called "one DOHMH" to note the need to work as one entity, he continued. He's also created an executive leadership team that focuses more on these big agency questions.

Another key area has been forming a "response readiness" program, which aims to make things run more smoothly in the next crisis. It will focus on mapping out necessary parts of crisis response, including contracting, procurement, supply chain management, and hiring emergency staff -- "all the things that we scrambled to do during COVID that took longer than anyone would have liked," Vasan said -- to be better prepared next time.

Culture Change

Vasan wants to bring more of a crisis-management mindset to the department's daily work structure. When health departments face an emergency, they create an incident command structure "and they pull people from all over the agency into a new command structure to work on the crisis," he explained.

Crisis times also usually mean people are more comfortable working "quickly with imperfect information," he added, and there's less fear of failure.

"How do we start working more like that in non-crisis times?" he asked. "We've shown what we can do when we draw upon the strengths of this whole beautiful agency. Why can't we do that day-to-day?"

"There are sensible things we can do to create new structures which beget smart functions and ways of working that benefit all of us," he pointed out.

Vasan said there's also a scholastic or academic focus on public health, "but we have to remember that we are public servants first."

"The academic-driven culture of public health has to evolve," he said. "That's not to say we stop publishing or doing great research, but we have to put it in the right place. Taxpayers pay us, and we have a responsibility to the public, so we have to think about programs first, results first, and accountability first. With that, you'll have plenty of opportunities to write, be thought leaders, and advance the science."

"Scholasticism is not an end in-and-of-itself, but a byproduct of great work serving people," he added.

It's not necessarily easy to implement such culture change at a large bureaucracy -- the department has 7,500 employees and a $2 billion budget -- but Vasan called it a work in progress.

Part of selling the changes involves "coming up with examples of where better communication, better collaboration, better awareness and visibility can improve the product," he said. A goal is to have employees trust that working differently is "helping us elevate their work in a more strategic way."

City public health employees are "smart enough to know that public health has been under a lot of stress," he noted, "and it's time to pivot, to evolve, to take the next step forward and redefine public health for this new era."

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