The St. Louis County Department of Public Health goes by a new name, as of last Friday. According to APHA Health Administration Section member Faisal Khan, MBBS, MPH, the county’s health director, the St. Louis County Council voted in April to add “public” to its title to signify a much-needed change in the way the department conducts business.

Public Health Newswire spoke with Khan about the new era of public health in his department, the unique challenges facing St. Louis and the value that APHA brings to his work — and health departments nationwide. Note: Check out part two of this series, which focuses on the public health department’s response to unrest in Ferguson, Missouri, and its revolutionary approach to addressing the county’s health disparities.

Congratulations on adding the word “public” to your title, a move that APHA strongly supports. What does this mean for the, officially as of today, St. Louis County Department of Public Health?

The magnitude is huge. Although it is a symbolic change, what it does is send a clear, unmistakable signal to all of our partners, the hospital systems, academic institutions, the faith-based organizations that we work with on a daily/weekly basis, to all 600 staff of the health department, and most importantly to the population that we serve, that we, as a department,  are committing ourselves to studying existing and emerging public health issues above and beyond the clinical issues that we have in decades past invested in.

So in that sense it is quite a shift in focus. We believe that taking a holistic, broad-based, multi-sector approach is where the future of public health lies and where the greatest benefit for the people that we serve lies.

Photo by St. Louis County Department of Public Health

With a new name and a new logo, the St. Louis County Department of Public Health will shift toward “emerging public health issues above and beyond the clinical issues,” according to its health director, Faisal Khan. Photo by St. Louis County Department of Public Health

I know the words “health in all policies” might sound a bit clichéd but it represents the very lifeblood of what a public health department ought to be doing. We need to be the catalyst to bring together public works, housing, highways and traffic, parks, hospital systems, universities, community-based organizations and popular opinion leaders to the table. We need to support them with scientific studies and data, and to make decisions based on the best available evidence so we can make a positive impact across the community.

What we are in the process of doing as part of our public health accreditation process is developing a performance management system — and we have metrics identified for all the priorities in our strategic plan, which are STDs, access to care, cardiovascular disease, mental health, substance abuse, asthma, healthy and livable communities and age-friendly communities. We’re in the process of working with IT to turn that into a dashboard that we can report out to the public on so we can educate our partners and the public about progress. That ensures transparency, accountability and ensures that there is longevity in terms of institutional knowledge about how this process began, what we’re doing and how future generations of public health professionals can look back on it and say, “Yes, this had an impact on health outcomes in a positive manner” or, “This spun its wheels.” That’s the ideal model in our minds: something that is measurable, tangible and easily explainable to policymakers, decision-makers, the lay public [and] the media. Everyone.

So that’s where the introduction of the word “public” could not possibly have any more significance.

Faisal Khan, Faisal Khan, MBBS, MPH, is the health director for the St. Louis County Public Health Department. Photo by St. Louis County Public Health Department

Faisal Khan, Faisal Khan, MBBS, MPH, is the health director for the St. Louis County Public Health Department. Photo by St. Louis County Public Health Department

How will your roles and responsibilities change?

I’ll give you some examples. Yes, I think our workload will increase exponentially and it’s a challenge for us to be involved in all of this outside of traditional comfort zones. On the issue of education for example, in areas where you have school systems, where you have neighborhoods existing in poverty, it tells you something when school systems have to have food pantries just so they can feed their students. And in many cases that’s the only food that kids are going to get during the day. So it’s one thing to expect them to be engaged in their academic pursuits. It’s another to then also have to worry about going into neighborhoods where they’re not safe and they’re not having their health care needs met, let alone their nutritional needs.

Our role becomes one of making sure we create the right partnerships to get the private entities. For example: creating community-based organizations with the capacity to provide school-based health clinics. To talk to school systems with our encouragement and involvement to say, “We need to have a school-based health clinic model that addresses a comprehensive set of needs including mental health, substance abuse, primary care and STDs.” That’s something we’re pursuing in the St. Louis region. Obviously different school systems respond differently and some will need further persuasion. Some have been very frank in admitting that they need help and are open to our involvement.

On the housing and transportation side for example: It’s well and good to preach to the public about the necessity for medical checkouts and to take care of yourself and all that — but the lack of transportation is what bothers people the most. They can’t get to the clinic. There’s nobody to tell them how to take care of themselves. And when they do make it to the clinic, they need to take time off from the two jobs that they’re working.

“Prevention isn’t just better than cure, it’s cheaper than cure.” — Faisal Khan

So yes, we work with the transportation department to create, or encourage them to create, new bus routes or shuttle routes from high-intake areas, particularly around senior facilities and nursing homes. That’s where some of the major breakdown occurs. We’ve been working with our parks department to get them to fund and facilitate the creation of recreational facilities which are free of cost for anybody to access, but particularly for youth and young people in relatively underprivileged areas. That’s going to come to fruition in the near future. So kudos to our colleagues in the parks department for listening to us and being willing to work with us.

All of these were policy discussions that we started at the level of, “OK, well how does this concern you guys?” So we said, “This is how it concerns us: Because people end up with all kinds of issues and then they ask us for assistance and we parse them out — and realize they have a transportation issue, they have a funding issue, they can’t pay their utility bills, they’re struggling to make ends meet.” And it becomes a [negative] feedback cycle where poverty leads to unemployment, leads to ill health, leads to disenfranchisement, leads to marginalization.

Then there are the acute situations such as Ferguson or Baltimore. They seem to come to light almost immediately. People need access to crisis intervention services for trauma-informed care. They need to be able to talk to counselors and people in a non-threatening, welcoming setting, which is very often community-based rather than clinic-based. [It’s very important for us] whether we choose to take the route of working with faith-based organizations, or to create a pastoral counseling model that may work, or work with private entities to make sure that services are available.

All of those things require a reorientation of services on our end. It is a gigantic chess board, as you can imagine. The more layers you peel away, the more you realize that really keeping people healthy in their own homes and empowering them to the point where they don’t come into the clinic is the answer. Prevention isn’t just better than cure, it’s cheaper than cure.

What are some of the unique public health challenges facing St. Louis?

This is no secret: The St. Louis region consistently ranks among the top-two in terms of our rates for sexually transmitted diseases. For years, we’ve invested a significant amount of money in operating an STD clinic but we haven’t really invested in prevention. And that, to me, was just inexplicable because we can operate a revolving-door policy where we treat people, they go out the door, there’s nobody to educate them, to train them, to empower them to make good decisions about safe sex.

We’re not going to stop young people, and all people, from having sex. So you have to invest in prevention at some stage to be able to break this cycle. And that’s exactly what we’re looking to do now. Obviously it requires a network of people that we would have to work with, other agencies that do things better than us, and our role is to make sure we coordinate efforts, we gather the data, we support it with surveillance data that we have, we customize our reports to make them actionable and easy to understand for [Congressional Budget Office] colleagues so they can apply for grants, they can act on program plans, they can devise interventions to act on. All of that is ongoing.

Chronic disease is another issue. Cardiovascular disease, obesity, is not something we’ve dealt with effectively in past decades. Missouri is ranked no. 10 in terms of the most obese states in the nation. Close to 35 percent of our population is considered obese or overweight. A lot of that is childhood obesity, which leads to early onset of diabetes in many cases. This sort of “diabesity complex” is starting to make an appearance in clinical literature as well. And that is very alarming.

So working with school systems, community-based organizations and other agencies that have invested in obesity-prevention efforts is something we can do well.

But going back to metrics: Issues of health equity and disparities are a critical component of what we’re focusing on. Some of the data that we have pertaining to different parts of St. Louis are utterly shocking. If you look at a Washington University study called, “For Sake of All.” It was a series of monographs produced by all the agencies that focus on public health in the region. It tells a very shocking story: the link between school dropout rates and health outcomes, for instance. They created a fictitious character named Jasmine: If she were born in North St. Louis, or Chesterfield or Wildwood or relatively affluent West County area, what would the differences in health outcomes be at different stages of life? It is shocking.

There’s a ZIP code not too far where we’re located called Kinloch. It has a population of roughly 500 people and is predominantly African-American. The life expectancy for an adult African-American woman living in Kinloch is 56. The life expectancy for the same person born in Wildwood or Chesterfield is close to 90. Now if that doesn’t prompt you to question what the hell is going on, I don’t know what will.

And these disparities exist for a reason. We haven’t realigned the system when it was needed most and that was 20 years ago.

We are proud to have you as an APHA member. What value does APHA bring to you and your health department? And how do we do more, better, together, to become a healthier nation?

One of the things we look towards APHA for — and this is true for [the National Association of County and City Health Officials] and [the Council of State and Territorial Epidemiologists] and [the Association of State and Territorial Health Officials] as well — but APHA most of all, is successful models of program interventions and policy models that have been tried and tested across the nation. There’s always a need to find the best available evidence on things that we can easily adopt to our situation. That’s something that the APHA has a major role to play in.

And the second thing, APHA’s voice in terms of supporting the work of health departments — federal, state, local — in addressing some major public health issues is of great value. We were pleased as punch to see APHA’s endorsement and congratulatory message on [adding the word public to our name] and we shared that with all the decision makers at the county council level here just to show them, “You guys voted on this. Here’s proof that our peers in the public health world think this is a fantastic step forward.” That’s just one small example.

In terms of learning from our peers: The metro Louisville Health Department in Kentucky is an agency I’ve long admired in terms of almost sea change they’ve brought about in the last 15-odd years, not only because they’ve decided to have a public health focus but that they recognized that they could not possibly keep talking about issues such as healthy nutrition and lifestyles and cardiovascular disease and childhood obesity without actually facilitating changes within the community. It’s all well and good for the health department to preach about these things but when was the last time you saw a Trader Joe’s in a socioeconomically deprived area? Never.

So those chains and organizations need incentives to be able to come in, set up shop and provide their products at a reasonable price so people can afford them. So [former APHA President] Dr. Adewale Troutman, the previous public health director in metro Louisville worked together [with the private sector] and they formed a business health coalition to create this public-private partnership model. I hope to replicate that and that’s on my wish list as well. This actually brought businesses to the area to provide a safe space and an incentive to operate.

And the communities loved it; they responded very well to it. I think the uptake has been great. There will be stuff published about it in the future, I’m sure. But Louisville deserves all the credit they can get and I would love if we could replicate some of that over here.