National public health week

By Jay Bhatt, D.O., managing director of the Deloitte Health Equity Institute and the Deloitte Center for Health Solutions, Deloitte Services, LP

COVID-19 was declared a pandemic four years ago.¹ Schools and offices were shuttered, playgrounds were padlocked, and many people were suddenly restricted on where they could gather in public. By April 2020, about half of the world’s population was under some form of a stay-at-home order or movement restriction.² The pandemic called for an extraordinary level of collaboration among all collaborators—from health care systems and health plans to biopharmaceutical companies and medical device manufacturers to the public health sector and community organizations.

“Protecting, connecting, and thriving” is the theme of National Public Health Week, which begins April 5.³ I recently had an opportunity to speak with Dr. Raj Panjabi, M.D. about his experience in helping to lead the COVID-19 response for the White House. I also wanted to get his perspective on how that coordinated response might have created a more resilient public health system. Dr. Panjabi served as the senior director and special assistant to President Biden.⁴ He was the top pandemic and health official at the National Security Council where he played a pivotal role in the largest vaccination campaign in history. He also helped lead responses to other public health crises including Mpox, Influenza, and Ebola (see Public health is becoming a team sport). Dr. Panjabi is currently entrepreneur in residence at Emerson Collective. He also serves on the faculty at Harvard Medical School, and is a strategic advisor to private, public, and social sector organizations. Here is an excerpt from our conversation:

Jay: Public-private partnerships were often effective in responding to the COVID-19 pandemic. What are some lessons from that experience, and what do you see as the next phase of collaborations?

Raj: There were four shifts that the emergency response to COVID-19 drove in our health care system. First, we had to shift how we staff health care. Rather than rely on doctors for the delivery of vaccines and treatments, we relied largely on community nurses, pharmacists, and outreach workers. The second shift had to do with the stuff of health care, like tests and treatments. We didn’t keep tests and treatments walled up in hospitals. Biotech and medical device manufacturers developed portable diagnostic tests and equipment; millions of COVID-19 tests were mailed to Americans at their homes. The third shift was about where care can be delivered. We didn’t deliver vaccines just in clinical spaces. People were able to receive care in pharmacies, community centers, and at home. And the fourth shift had to do with the digital transformation of systems that enable health care. Greater reliance on EHRs [electronic health records], along with the expansion of telemedicine and virtual care, allowed us to go from centralized to decentralized care. These four shifts—in staff, stuff, space, and systems—toward high-tech and high-touch community health care were emerging before the pandemic, but they became more critical during the emergency. This approach to community health care was used by public health departments at the local, state, and federal level, as well as by academic medical centers and suppliers. And it’s the approach that was most effective globally, too. It helped to drive vaccination campaigns from the snowcapped mountains in the Himalayas, to the forests of West Africa. High-tech, high-touch community health care can help ensure no patient is out of reach.

Jay: How can community organizations help expand the reach of health care?

Raj: I worked as a physician at Mass General Brigham and its Chelsea Community Health Center in Massachusetts. At the time, Chelsea was the state’s COVID-19 epicenter with an infection rate six times the state average.⁵ There is a large immigrant population, and some families live in crowded conditions; many of them were essential workers during the pandemic, including those who worked in grocery stores. This allowed infections to spread quickly. I was a part of the vaccination team. We worked with trusted community groups to bring the vaccine to people rather than waiting for them to seek out the vaccine on their own. The community essentially became part of the medical team. Teams of residents/outreach workers knocked on their neighbors’ doors, answered questions, and scheduled appointments. Some people had lost their jobs, and these outreach workers helped people apply for unemployment assistance. Vaccination rates in the Chelsea community, which had started to fall behind the statewide average, caught up with the rest of the state within four weeks. The community went from being a pandemic epicenter to becoming a pandemic exemplar.⁶ Outreach workers, community health workers, nurses, pharmacists generally led the charge in communities around the country.

Jay: Public health and community-based organizations were critical in the response to COVID. How do we scale it? (See The future of public health.)

Raj: The mantra of the vaccination campaign was ‘meet people where they are.’ That should be the mantra for all of health care. The community health care revolution that was accelerated by the pandemic shouldn’t slow down. It could be used for other health challenges such as turning the tide against the opioid epidemic. In many towns and cities, medications for opioid overdose had often been out of reach. State and local leaders have advocated for laws that made life-saving Naloxone available over the counter and made it possible so everyday residents could use the drug to treat overdoses.⁷ Another example is a long-standing program, which is working to reduce preventable maternal deaths by connecting expectant mothers to the care and support they need to have a healthy pregnancy.⁸

Jay: In September 2022, the White House announced $225 million in funds to train more than 13,000 community health workers to expand COVID-19 vaccination efforts.⁹ Some Medicaid programs are now relying more on community health workers. At least 29 states, and Washington, D.C., cover the cost of community health workers. Do you see this additional cost as a challenge? (See 9 questions for the American Public Health Association.)

Raj: We can actually drive down costs when this is done well. Leading organizations are using community health workers and health coaches to educate patients with diabetes and heart disease…at coffee tables in living rooms rather than at exam tables in exam rooms. They are helping prevent costly unnecessary hospitalizations. A 2020 study into a community health worker program returned $2.47 for every $1 invested.¹⁰ Both the private and public sectors have a role to play. Last fall, CMS finalized its Physician Payment Rule, which advances health equity. It permits CMS—for the first time—to reimburse health systems that leverage community health workers and navigators for patients who have cancer and other chronic illnesses.¹¹

Jay: Several years ago, an examination of claims data in one state revealed that a rural county had strikingly high instances of lower-extremity amputations among residents with diabetes. It turned out that this small county had more liquor stores per capita than any county in the state. There were also fewer public outdoor spaces dedicated to physical fitness, and there were fewer primary care providers per capita compared to other counties (see What is ‘techquity’ and why should businesses pay attention?). How can data like this be used for prevention, screening, and for addressing chronic conditions? (See our Health Equity Data and Analytics series.)

Raj: That’s a great example of combining technology and data to get to the root of a health issue. The principles that drive community-based care are relevant when considering data systems. During the pandemic, some communities began testing wastewater to determine virus prevalence. That same wastewater surveillance technology has since been used to detect the presence other viruses. When New York City officials detected the polio virus in 2022, epidemiologists, physicians, and outreach workers educated people in the community about the importance of vaccinations to protect themselves. Last fall, a company worked with the CDC [Centers for Disease Control and Prevention] to scale up genomic surveillance at airports by asking travelers to voluntary provide nasal swab specimens from incoming planes to try and identify any new viruses coming into the U.S., including SARS-CoV-2, RSV and Influenza. That program started with 50 international flights a week, and it was scaled up to 300.¹²

Jay: Health systems, health insurers, biopharma companies, and medical device manufacturers all play a role in improving public health. But they are also employers. What role do they play in improving health among their workers and within the community? (see How employers can spark a movement to help us live longer and healthier lives).

Raj: The pandemic pulled all employers in to the conversation about health equity and keeping workers healthy and productive. The costs of care are increasing, and there is increasing pressure from employees to keep those costs down while improving quality. Some large employers that offer lunch options are including more plant-based options. Some employers have made it easier to access mental health care providers. Tele-mental health can help keep employees healthy and productive, which can indirectly reduce costs for employers. Adapting those models for employee health is part of the future of employee health.

CONCLUSION

Cooperation, transparency, and the early involvement of public health officials and community organizations was invaluable during the pandemic. That experience of working collectively toward a common goal could help ensure that the country, and the world, is prepared to respond to the next public health emergency.

The executive’s participation in this article is solely for educational purposes based on their knowledge of the subject and the views expressed by them are solely their own. This article should not be deemed or construed to be for the purpose of soliciting business for any of the companies mentioned, nor does Deloitte advocate or endorse the services or products provided by these companies.

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Endnotes:

^{1_{COVID-19 Timeline, Centers for Disease Control and Prevention}}

^{2_{Coronavirus: The world in lockdown in maps and charts, BBC}}

^{3_{National Public Health Week, American Public Health Association, April 5-11}}

^{4_{Former head of White House Global Health Security and Biodefense joins bipartisan commission on biodefense, Press release, November 9, 2023; About Raj Panjabi, M.D., MPH}}

^{5_{Researchers aid Chelsea, Epicenter of MA COVID-19 outbreak, Boston University School of Public Health, April 30, 2020}}

^{6_{Local groups in Chelsea team up to launch a hard-earned vaccination site, The Boston Globe, February 3, 2021}}

^{7_{Non-prescription Naloxone frequently asked questions, Substance Abuse and Mental Health Services Administration, April 24, 2023}}

^{8_{Nurse-Family Partnership}}

^{9_{Biden-Harris Administration announces American Rescue Plan’s historic investments in community health workforce, The White House, September 30, 2022}}

^{10_{Evidence-Based Community Health Worker Program addresses unmet social needs, Health Affairs, February 2020}}

^{11_{CMS Finalizes Physician Payment Rule, CMS.gov, November 2, 2023}}

^{12_{CDC expands testing of international air traveler samples to include flu RSV, and other respiratory viruses, CDC Newsroom, November 6, 2023}}

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