Dr. Howard K. Koh is the Harvey V. Fineberg Professor of the Practice of Public Health Leadership at the Harvard T. H. Chan School of Public Health. From 2009-2014, Dr. Koh was the 14th Assistant Secretary for Health for the U.S. Department of Health and Human Services (HHS), after being nominated by President Barack Obama and being confirmed by the U.S. Senate.
Q: You have spent your life working in many different public health sectors, as a doctor, in government, and now in academia. What led you to public health and how have you seen it evolve over your career?
I can only explain it by saying that public health was, in hindsight, a calling for me. I never planned it that way. I went to medical school and was trained the way all physicians were traditionally trained back then — focus on the individual person, their biology of disease, do your best to care for them and try to cure their illness.
Early on in my training, I noticed that way of looking at health was important but also very narrow – there were many broader ways of contributing to health. During my internship and residency at the old Boston City Hospital, I cared for so many patients affected by social factors like poverty, lack of insurance, and discrimination. Too often, I saw people suffering that could have, and should have, been prevented. That frustrated and even angered me. WHO has this great saying – ‘the highest attainable standard of health is one of the fundamental rights of every human being’. But too many of my patients weren’t living anywhere close to that ideal.
So, I got very drawn to disease prevention and health promotion. It started with cancer prevention and tobacco control, which are still major passions for me. That led to my being appointed Massachusetts Commissioner of Public Health by Governor William Weld. In that role, I ran a department of 3,000 employees, four hospitals, and a $700 million budget while also dealing with the intersection of science and politics through 9/11 and anthrax. I had an incredible life education through it all. I came to Harvard for the first time – the Harvard T.H. Chan School of Public Health – in 2003 and then went on to join the Obama administration in 2009 as Assistant Secretary of Health.
That’s where I met HepVu Co-Chair Dr. Ron Valdiserri and CDC’s Dr. John Ward, who became two very close colleagues and dear friends– two professionals I respect so much. Working with Ron and John and our dear colleague Rosie Henson made it possible to focus on chronic hepatitis as a national priority. All that is something I’m very proud of.
Q: You are a co-author on the 2023 paper, “The Exodus Of State And Local Public Health Employees: Separations Started Before And Continued Throughout COVID-19,” which examined what many are now calling a “public health workforce crisis.” How did you become interested in this topic and what are the main findings of the paper?
Being Massachusetts Commissioner of Public Health gave me a bird’s eye view on state and local officials working in the trenches to protect the public and promote public health day in and day out. In addition, they had to be on the lookout for any and all emergencies that could arise at a moment’s notice. I gained phenomenal respect for governmental employees at the state and local level. They’re the unsung heroes who make a difference in millions of lives, day in and day out.
I also became very familiar with the workforce challenges back then. So, when COVID-19 hit, I was quite dismayed and appalled that state and local officials – who were working 24/7 through several years of the crisis – were often greeted not with appreciation and respect, but rather mistrust and even harassment. That really troubled me. I remain very concerned about the morale of the public health workforce, particularly at the state and local level. We must support people who are courageous enough to choose public health as a profession. As a professor, I always recommend to all my students that they give government public health service a try. Even a summer internship as a student can change your view on the world and teach you about what it takes to really promote public health day in and day out.
When the journal Health Affairs recently asked me to serve as a special advisor and editor on their issue on the future of public health, they also asked if I wanted to contribute an article to the issue. I decided that focusing on the state of the public health workforce would be valuable. I was very fortunate to be introduced to, and work very closely with, a number of colleagues who are all co-authors on the subsequent paper, especially Dr. JP Leider at the University of Minnesota, Brian Castrucci and his colleagues at the de Beaumont Foundation, and Mike Fraser, who was then the CEO of ASTHO.
They all had overseen the Public Health Workforce Interests and Needs (PH WINS) survey for several years. That survey had been fielded in 2014, 2017, and most recently in 2021 in the height of COVID-19. By analyzing those surveys, we were able to document that nearly half of employees in state and local public agencies left between 2017 and 2021; that percentage rose to almost three quarters for those 35 and younger or with shorter tenures.
Of course, we were alarmed by these findings. We viewed the article as a major call for action to rebuild and sustain systems to support state local public health at the ground level. We hope that such rebuilding is ongoing now. We need to do everything we can to grow and support the public health workforce before the next major crisis hits.
Q: In the paper, you and your coauthors assert that increased funding is not enough to either entice individuals to stay in the workforce or attract enough new workers. Why is that the case and what other strategies are important for re-strengthening this workforce?
Funding is necessary, but not sufficient. Funding is always an issue in public health because the needs are always infinite, and the resources are always finite. People who enter governmental public health are in very stressful work environments, putting in long hours for their work which is often not well understood or respected by the public. So, of course, increasing funding is a critical first step in the paper. In addition to salaries, we could pay more attention to extending forgiveness programs for loans and making scholarships more available for people who are willing to enter public health as a field. We must remember that a lot of people who enter public health at the state and local level do so because they feel a powerful sense of mission and calling.
I can’t think of a field that has a greater sense of meaning, purpose, and connection to something bigger than yourself than the field of public health. Those themes, meaning, purpose and connection to something bigger than yourself, underpin the very definition of what spirituality is all about. I now often talk about public health — and public health leadership in particular — in spiritual terms. In teaching leadership at the Harvard T.H. Chan School of Public Health, I often ask students to initially focus on the “why” of leadership — why do they want to go into this field — before they move on to the more traditional dimensions of “what” and the “how”. If we bring those attentions to bear in the state and local health departments, and really touch the heart and the “why” as we try to encourage young public health employees to become supervisors and leaders, we can help them gain new skills and stay abreast of the evolving science, while also being attentive to what’s in their soul.
Being explicit about mentorship has great benefits; we probably don’t do that well enough in any public health setting. Young people are often trying to figure out what this complicated field is all about and are subjected to tremendous pressures. Moreover, public health is, by definition, public, so you’re always on stage, open to criticism and second guessing. Again, young people need support as they gain a foothold and build self-confidence. Then they can hopefully grow, through mentorship, to be leaders that help the next generation.
Q: As a professor, you are uniquely poised to see how schools of public health have evolved before, during, and after the COVID-19 pandemic. Is the workforce crisis a concern at the undergraduate and graduate level as well?
Being a public health professor gives you an opportunity to see so many young people wanting to go into the field. They come from all over the world to study at places like the Harvard T.H. Chan School of Public Health and that is always very inspiring to me. They know the challenges of public health, especially through the COVID era, but they want to make a difference. We need to welcome, support, mentor, and encourage them. A pipeline has been growing for several decades, such that many colleges now have public health as an undergraduate major. We’re seeing a big increase in the number of people who are getting public health degrees. Yet, there are still relatively few of them entering governmental public health jobs, which is what our Health Affairs paper focused on. They’re still hitting obstacles like navigating government bureaucracy, coming up against complex hiring processes, and financial challenges. We need to address those themes as we try to rebuild the workforce going forward.
Q: Under your leadership as Assistant Secretary for Health, the first national Viral Hepatitis Action Plan was developed and released in 2011. How does the current public health workforce crisis impact our efforts to eliminate viral hepatitis in the U.S.?
When I look back and think of the collaboration and partnership that led to the first national Viral Hepatitis Action Plan in 2011, I’m just filled with incredible gratitude. None of this was not on my radar when I started the job in 2009. But through collaboration with my tremendous colleagues like Ron Valdiserri, John Ward, Rosie Henson, and many others, we were able to align the many heroes who had been in the field for a long time but had not been working together under any sort of strategic plan. What appealed to me to even begin was that the need for collaboration was enormous. Also personally, the many hepatitis themes were fascinating. The themes of cancer prevention, in this case liver cancer prevention, started me on my public health journey. The health equity themes were always major for me personally and professionally. As an Asian American, I was really troubled that although the issue of Hepatitis B involved so many people in the AANHPI community, it had really had not been well addressed.
The plan brought all those groups together and that made me so proud. Especially, having Ronald Valdiserri leading efforts on behalf of the Department of Health and Human Services (HHS) for both HIV and chronic Hepatitis was a major step forward. The office he led has kept going through multiple administrations to update the plan which continues to serve as a roadmap and compass for the nation.
In the past 13 years, we’ve seen a lot of progress in terms of advances in testing and treatment, particularly with respect to Hepatitis C. But we still have very complicated challenges, specifically with intersections with the opioid crisis and the lack of enough harm reduction programs like syringe services. Hepatitis C treatment has moved into the area of primary care as well as involving specialists. To do this type of work well, you need to have a big picture view on the social, economic, environmental, and structural barriers that face the nation. We need even more people in the workforce to commit themselves to this issue area, to have that big picture point of view, to be excellent collaborators and excellent leaders, but also be willing to drill down into specific aspects of treatment, surveillance, testing, and ultimately prevention.
There’s a lot of work to do. Hepatitis B and Hepatitis C traditionally disproportionately affect underserved populations: people communities of color and those using injectable drugs, in prisons, and needing substance use treatment. Right now, I’m very involved in health and homelessness as a priority area for my school and university and trying to build national partnerships in that area. The Hepatitis B and C issues overlap with homelessness of course. And the stigma in all these areas can be major: my late mentor Reverend William Sloane Coffin used to say, “we should care most for those society counted least and put last”.
Q: In HepVu’s 2022 Surveillance Status Report, surveyed local health departments reported that they needed at least 3-5 full-time employees to conduct viral hepatitis surveillance but cited a number of challenges in hiring that number even when fully funded, including a lack of qualified candidates. With the imminent introduction of a federal plan to eliminate viral hepatitis, how can we educate policy makers about the absolute importance of adequate viral hepatitis surveillance in order to achieve elimination?
One of the lessons from COVID-19 is that everyone saw the critical importance of surveillance tracking — not only traditional ways of monitoring cases, deaths, and hospitalizations, but also the ability to use new strategies in a timely fashion using cutting-edge tools. All of that applies to Hepatitis B and C as well. I’m hoping that any policymaker who’s thinking about public health today understands that it all starts and ends with the best surveillance possible. When I was at HHS, I had the pleasure of working closely with the Hepatitis Caucus of Congress–this included leaders like Congressman Mike Honda, Congressman Hank Johnson, Congresswoman Judy Chu, and Senator Bill Cassidy. Congresswoman Grace Meng now chairs the Caucus and continues its great work.
I have met so many people affected by the hepatitis epidemic. Many are heroes who have become great advocates and work on behalf of the community, building coalitions and moving forward with efforts to eliminate viral hepatitis in the U.S. I’m hoping that more congressional leaders come to understand that viral hepatitis elimination is possible given all the advances in treatment, vaccines, and testing strategies and that they take steps to end the many health disparities that we see in the U.S because of undiagnosed and untreated viral hepatitis.
