Acting Assistant Secretary for Health Karen DeSalvo, MD, MPH, MSc, knows all about “Health in All Policies.” The longtime APHA member brought numerous sectors together as New Orleans health commissioner shortly after Hurricane Katrina, creating an award-winning health care network and, according to APHA Executive Director Georges Benjamin, MD, writing “the blueprint on how to make a large health system more efficient and resourceful even during fiscally challenging times.”

DeSalvo, who also leads the Office of National Coordinator for Health Information Technology, will join health commissioners from Baltimore, St. Louis and Chicago to discuss “building healthy and just communities” at the Closing General Session of APHA’s Annual Meeting in Chicago on Nov. 4. In a conversation with Public Health Newswire DeSalvo discussed why Health in All Policies, the theme of this year’s meeting, works — and how health is not merely the goal, but an “enabler” of nationwide quality-of-life improvements.

Karen DeSalvo visits with school children

Acting Assistant Secretary for Health Karen DeSalvo visits with school children during a recent trip to eastern Tennessee. Photo courtesy HHS

Q: A recent Commonwealth Fund report showed us again that when it comes to improving health, the U.S. is not as competitive as it could be. What needs to change for the U.S. to join the healthiest nations?

A: We’ve made tremendous progress in advancing life expectancy and quality of life for most people in this country.

Yet we still lag behind many other industrialized nations. And in some parts of this country we lag behind developing countries, particularly when you start looking at some of our most vulnerable communities like those that are low-income and some communities of color. So in spite of the great progress, it is true we have a lot of work left to do and in some cases we are losing some gains.

The general sense in today’s world is that we’ve made a lot of great strides in health care. And health care is transforming to see if it can meet new challenges and take a more holistic approach to health, of thinking about outcomes and working with populations. This is really going to take more of an all-hands-on-deck approach and for us to get back to this basic definition of what public health is, which is “the collective action of society to assure that everyone can be healthy.”

That requires not just a really strong health care system, where we’ve had much our attention focused for the last few decades—but we’re going to have to increasingly shore up and have public health heed the call to action. (Public health) must see that it’s ready to be not only at the table, but lead in communities and help address these non-medical determinants of health that are causing premature morbidity, and premature mortality, for people all across the country.

Q: How can HHS partner with the private sector, APHA and the broader health community to help us reach that goal?

A: First, we have a major responsibility in health care. We are a major payer, purchaser and in some cases provider of care. And so we recognize that and we had to lead in seeing that everyone had a means to pay for their care. That coverage expansion was a success story, and we don’t want to end there.

We’ve been aggressively working, particularly for the last year and a half, on creating a better care system so that when you have access to care it is really great care, person-centered, team-based and able to support coordination. That really has been our work around delivery-system reforms: to see that we pay for care differently to move from fee-for-service to fee for value. Again, (we can) wrap that system around a person so that there’s integrated mental health and, in many cases, social services and other kinds of supports for patients and communities. So we have a responsibility to push the health care system to a place where it is thinking not just about those medical determinants and getting to a place that delivers the highest quality of value as possible for the consumer, but also causing the health care system to look outside its walls and look into the community to find the natural partners that are able to help people not only regain health but to stay healthy in the first place.

These are the kinds of models, whether they are accountable care organizations or patient-centered medical homes, we’re going to continue to push. We know our work and we can’t end there. That is a huge stream of work that the private sector with private payers, with private providers and organizations are doing really well on the ground. And that in and of itself is really important and gives us a chance to save money and reinvest in other determinants of health.

At the same time we have a responsibility around leading by example and working to change how public health is supported and can operate on the ground. Particularly thinking through how we support public health in this new era. That’s a concept that I’m going to be talking about in my remarks at the APHA Annual Meeting. This modern public health world that we are quickly moving into, one in which public health as the local governmental institution has a responsibility and an opportunity to lead our collective impact around improving the public’s health. This is a multi-sectoral approach that takes the opportunity to address environmental systems and policy-level change.

I think for us at the HHS level, we need to be clear in talking about the importance of achieving health through levers beyond health care, that great health care is necessary but not sufficient to reach the kind of health outcomes that we want for our nation. And that public health is the natural partner to health care and to the other sectors as we advance this. It’s going to require us to really think hard about how we are funding, what our expectations are, how we are setting priorities through our metric systems and how we are supporting the development of leadership and the work force on the ground to make certain that public health is continuing to be ready. There are great examples of this happening, and I think that we have been trying to support those in some ways in partnership with foundations and with governmental entities, but we have a lot of work to do.

I think public health is undergoing its own transformation or revolution. And I want to help facilitate that. Having been at the local level, I know that it’s hard work, but it’s rewarding work. When you achieve that kind of a flexible, nimble structure that can not only take care of the everyday business, but be able to surge when there are new health challenges and work with new sorts of partners out in the field. I want to make sure that public health is ready to do that on behalf of people in this country.

Karen DeSalvo, MD, MPH, MSc, acting assistant secretary for health and national coordinator for health information technology at the U.S. Department of Health and Human Services. Photo by HHS.

Q: What is your vision of a healthy America?

My vision is actually sort of an anti-vision. When we have health in this country it’s going to be more of an afterthought. Health is sort of an intermediary to having a great quality of life, to having economic opportunity and emotional and intellectual fulfillment. And if you’re a kid and you’re not impaired by a health challenge, like asthma, and you can go to school tomorrow and play sports and be with your family and friends, that kind of quality of life is the place I want you to get.

I want health to be an enabler of that. So I always look at economic opportunity and educational attainment and overall quality of life as where success resides, and health is an intermediary of that. So I want to get to a place where (health) is not a struggle or a concern for people, whether that’s from acute or chronic disease.

Q: You’ll be the closing keynote speaker at our upcoming Annual Meeting in Chicago that has a theme of “Health in All Policies.” Why is this approach so important to improving the health of Americans?

Health in all policies is a part of the culture change that’s going to have to happen at the federal, state and local level to make this healthy America a reality. I believe it’s the only way that we’ll be able to sustain any gains we make because when you have a health in all policies approach — I’m going to use a Southern expression — everybody’s got a “dog in the hunt.” That means your public works leadership and your public safety leadership and the business community — everybody’s thinking about how what they’re doing impacts the health of their neighbors. It doesn’t just fall upon the shoulders of public health, which we all know is under-resourced, underfunded and struggling to keep up with the challenging demands of health in this country.

On the other hand public health can lead, convene and be the intellectual driver to create the environmental changes that help make the healthy choice the easy choice. I was just in Johnson City, Tennessee, on Monday. The tri-city area in eastern Tennessee is doing exciting work. Johnson City has a “Healthy Johnson City” initiative, which is terrific. I had a chance to visit a school and talk with the principal and the city commissioner in Johnson City. They were talking about how they focused their shift on health to encourage nutritional and physical fitness in their community. And as part of the story the commissioner told me a story about how the public works department came to the city commission meeting and said, “We’re going to replace this sewer line so we figured when we cover it back up, we’re going to create a fitness trail. Because we know we want everybody to be more active.” It wasn’t like there was a checklist or a special project in health in all policies; it’s just the way the city government is thinking about the health of their community.

I just think that’s the most beautiful, perfect example of where we would like folks to go — where it comes from the heart, it comes from the work of all the agencies and where they need support, and local public health is there to do that and lift up the story. It’s a concrete example and it’s the way I would like to see every community in this country start to move forward. Nobody should expect to carry the full weight of the health of the community. It has to be everybody carrying a part of it.

Q: You experienced many successes as a local health officer in New Orleans, despite facing challenges. Your Annual Meeting remarks will be followed by a discussion among local health officers from Chicago, Baltimore and St. Louis County, communities also dealing with many challenges. What role does achieving health equity play in building healthy communities?

When you dig into the data, things like life expectancy, you see things like men and women in low-income strata are actually losing years of life. Overall our life expectancy numbers look like they’re creeping up but really when you dig into it, they’re inequities. And they happen along lines of race, ethnicity and income, but also geography. People know that your ZIP code is probably the strongest determinant of your life expectancy.

And it just shouldn’t be so in a country like ours. We ought to be able to create a healthy enough environment in a country this wealthy, with this many resources and these kind of strong communities where we’re looking out for everybody in our neighborhood. Equity is a part of that. It’s really about knowing the data that says the more inequity that there is in a community, the worse it is for everybody, even if you have higher income.

So it’s incumbent upon all of us to help all of our communities and neighbors because at the end of the day (equity) helps everybody, even ourselves. So I think equity has got to be central to the way we’re looking at the efforts that we undertake. I think public safety is one of these areas where it’s an important social determinant, and if you think about nutritional and physical fitness — you want to think about the leading causes of death — nutritional and physical fitness, tobacco use and exposure. So often what a local health commissioner is going to hear when doing a community health assessment and improvement plan is that those neighborhoods want to use their parks and playgrounds. They want to walk and be active. They’re quite knowledgeable that there are barriers to them in their built environment and that’s why very often public safety is something that gets in the way.

In New Orleans it was such a recurring theme for us and I think it was one of the ways we helped people understand that public safety wasn’t about policing and tactical. It was really about the community’s health and how we all needed to make an investment and seeing that kids had safe places to grow up in, which included their neighborhoods, parks and playgrounds.

If we really want to have healthy communities we have to be able to give everybody safe, clean, quality places where they can learn, live and play that we would want for our own communities.