News and Commentary Bridging Public Health and Health Care to Accelerate Change: An Interview with Dr. Michelle Morse on Advancing Racial Equity

Our recognition of Black History Month and its theme of Black Health and Wellness continues this month with an interview with Michelle Morse, MD, MPH, the New York City Department of Health and Mental Hygiene’s inaugural Chief Medical Officer. During our recent interview, I had the opportunity to talk with Dr. Morse about her office’s strategic plan for the coming year, which envisions a city where all New Yorkers can “realize their full health potential, regardless of who they are, where they are from, or where they live.” While her work focuses on the health and wellbeing of New Yorkers, Dr. Morse’s ideas for tackling inequity and promoting wellness—in many ways—apply to myriad people, places, and communities. We also discussed the ways in which health professions educators can work to promote health equity and touched upon Dr. Morse’s piece entitled “An Antiracist Agenda for Medicine,” which demonstrates how educators can ask critical questions aimed at advancing anti-racist practices. Dr. Morse’s research in racial disparities has been subject to ongoing attacks by neo-Nazi and other White supremacist groups. A recent NEJM Perspective piece discusses the divisive and misleading backlash to her work and the continued need to work in solidarity toward ending structural racism in the health professions. We at the Macy Foundation stand with Dr. Morse and all those participating in anti-racism work, and we continue to reaffirm our commitment to advancing equity for all.

The following represents an excerpt of our conversation.

Holly J. Humphrey (HJH): Michelle, it is wonderful to connect with you again! How did you make the decision to leave the academic world and take on the challenges and opportunities inherent in your new position with the New York City Health Department?

Michelle Morse (MM): In many ways, the transition feels like a natural progression. I spent 15 years doing a lot of frontline health systems strengthening and public health work in the Global South—in Haiti, Rwanda, and places around the world—when I was in my role as Deputy Chief Medical Officer for Partners In Health in Boston. That helped me to see the power of public health and of building systems that protect communities and do the important work of prevention.

In the United States, some of the institutions that really do that prevention work the best are public health departments. Part of the transition for me was not about leaving academia; in fact, I still have my academic appointment at Harvard Medical School. But rather, it was about this progression towards policy change, social change, and systems change. You can do that work from the perch of a public health department or a local public health department in ways that you can’t in many other spaces.

I also had the opportunity to work on the Ways and Means Committee on Capitol Hill through my Robert Wood Johnson Foundation Health Policy Fellowship in 2019–2020. I wanted to understand what our democracy looked like at its breaking point, towards the end of the prior administration. To me, it was important that I be part of the solution to some of the fragmentation we were seeing across this country. On the Hill, I got to see how much progress needs to be made when it comes to public policy and health equity. During my time on the Committee, it became clear to me that there is a tremendous amount of work to do to embed health equity in our legislation, in the policies we have on the books, and in our payment policy for Medicare and Medicaid, amongst many other things.

HJH: Would you share your goals for the new Chief Medical Officer (CMO) role and give readers an overview of the strategic priority areas laid out in the CMO Strategic Plan for 2022–23?

MM: It is a profound honor to serve as the first-ever Chief Medical Officer for the New York City Health Department. Often, it is times of crisis where this kind of institutional infrastructure gets built or gets expanded. I think that that’s a huge part of the reason why this role was created by Commissioner Chokshi.

In addition to being Chief Medical Officer, I am also the deputy commissioner for the Center for Health Equity and Community Wellness (CHECW). It’s a 500-person division in the health department that is focused on everything from community engagement to Medicaid policy to strengthening networks of Federally Qualified Health Centers and independent practices across the city and everything in between, including food justice and food policy.

CHEC Well has been running action centers in high-priority neighborhoods for 100 years. The model of the action centers is to bring together health department staff who are focused on community engagement—nonprofit and other social service and health staff from community-based organizations—and building relationships with the priority communities to offer a “one-stop shop” model for care. By priority communities, I mean the communities that have experienced disinvestment, often have the worst health outcomes in the city, and often have the fewest resources.

The reason why the 100-year anniversary of that model is important is because the action center model was also created at a time of crisis in 1921, just after World War I. During an unprecedented moment of crisis, whether it be World War I or a global pandemic, sectors that are in fact interdependent but don’t always work closely together came together to combine efforts. The best evidence of that combined-effort success is that New York City just hit 95% of adult New Yorkers who have now received one dose of the COVID vaccine. That never could have happened without public health and all of the different health care delivery and social service organizations coming together.

I think it is important to acknowledge the history that public health and health care delivery have not always worked well together, and that the incentives and priorities are not often aligned. Bridging public health and health care is the goal of this Chief Medical Officer role in so many ways.

With regards to the strategic plan, the three pillars of my strategic plan are:

·       Bridging public health and health care

·       Anti-racism in public health practice

·       Institutional accountability

I see this role as serving as a convener and an accelerator of those areas of priority. There are programs within each one that I think are great examples of how we can do that work. The one I want to mention is the Coalition to End Racism in Clinical Algorithms, which is, to me, one of the strongest examples of bridging public health and health care. Our goal within the coalition is to get all the biggest systems across New York City to say, “We are no longer going to do this practice of race adjustment that we know is harmful for the care of communities of color.” We are going to end this practice as a city, and we also are going to evaluate the impact of ending that practice on racial health inequities, as well as develop a patient engagement plan to engage patients whose care may have been delayed by this practice to make sure they get the care they deserve.

It is a citywide effort to bridge public health and health care and accelerate changes in health care delivery that are going to advance racial equity for the whole city. I think that’s probably the most tangible example of what we mean when we say bridging public health and health care.

HJH: The strategic plan opens by citing the way in which COVID-19 has disproportionately affected Black New Yorkers in comparison to the city’s White residents. The plan also envisions a city where all New Yorkers can “realize their full health potential, regardless of who they are, where they are from, or where they live.” What does this vision mean to you, personally, in the context of Black History Month and its 2022 theme of Black Health and Wellness?

MM: We often forget how profound the economic impact of racism is and how much poverty plays into health outcomes. I think that’s the best way to encapsulate what this phrase and vision mean for me, especially in the midst of Black History Month. A study that I had the honor of being a part of looked at what would have happened to COVID transmission if the racial wealth gap had been eliminated prior to the COVID pandemic happening. What we found was that if, in Louisiana, reparations for descendants of enslaved people had been paid prior to the pandemic happening and the wealth gap had been eliminated prior to the COVID pandemic, COVID transmission would have been 30 to 68% lower for the whole community, not just Black people. These paid reparations would have had profound impact on things like who was an essential worker or a frontline worker and who wasn’t; who had access to buy masks and hand sanitizer; and who lives in crowded housing or multi-generational households. These are all things that are profoundly impacted by wealth.

This study offers the perfect example of what Black health and Black wellness should be about because it gets at the injustice of the racial wealth gap, which is rooted in the history of slavery in this country. It also gets at the fact that eliminating or reducing poverty for Black communities, specifically, helps everybody. It has a positive health effect for the whole community, not just Black people.

HJH: The CMO Strategic Plan places a strong emphasis on the partnership between the NYC Health Department and health care delivery partners such as nonprofit hospitals, safety-net facilities, and community health centers. How can educators and learners in the health professions contribute to your goal of advancing health equity and/or help to enhance these partnerships?

MM: Oh, I am so glad that you asked me this question! The Coalition to End Racism in Clinical Algorithms (CERCA) is a great example. The idea behind CERCA is very tangible. The use of race-based clinical algorithms is one of these practices we as physicians do every day and never critique, never question, never wonder, “Where did that come from? Why did we start correcting kidney function for Black race and only Black race?” I never asked that question in residency. And so there is such a powerful opportunity to ask harder, more critical questions. CERCA is wonderful because it forces faculty members and students alike to be critical, and to develop their critical thinking skills or what I would call critical consciousness. It is also very much aligned with critical race theory.

The other thing I would encourage them to do is to take a look at the institutional inequities at their own institutions. When I was at Brigham and Women’s Hospital, Dr. Bram Wispelwey and I published a framework in Boston Review that highlighted that Black and Latinx patients were significantly less likely to be admitted and hospitalized on the cardiology service as compared to White patients when they came into the emergency room with heart failure. That is institutional racism by definition because it is inequitable access to a resource—cardiology specialty care—by race. Think about what examples of racism are operating in your clinic, in your hospital, within your walls, and study it. And then find a way to address it. It sounds simple, but it really does require people to take some initiative.

In our framework, we are actively working on the closure piece right now. We have a council of community members—the Wisdom Council—who themselves or their family have been impacted by racial inequities in cardiovascular care. They are helping us to understand what it would look like to achieve closure. How can we come to an agreement that Brigham has done what it needs to do to fix this inequity? They are the people who help us to figure that out. We do not get to say we fixed it. The people who have been directly impacted are the ones who get to say how and when we have fixed it.

HJH: What have I not asked you about that you would really like us to highlight or feature?

MM: I would like to mention the resolution declaring racism a public health crisis that I was heavily involved in drafting, which was passed by the NYC Board of Health in October. It is a very powerful, very concrete roadmap for holding health departments accountable for anti-racism work. It is a helpful framework for other institutions that are not health departments. It can be useful for health care delivery institutions as well.

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