In this week’s installment of the AMA’s Prioritizing Equity YouTube series, explore how public health officials from New York City have worked to center equity during the COVID-19 response. Join us as the New York City Department of Health team shares how partnerships and community collaboration has been key in bringing the city to a suppression phase during the pandemic.
- Torian Easterling, MD, MPH—Deputy commissioner for health equity and community wellness at NYC Department of Health and Mental Hygiene
- Demetre Daskalakis, MD, MPH—Deputy commissioner, disease control at NYC Department of Health and Mental Hygiene
- Neil M. Vora, MD—Director of tracing at NYC Health Department/Health + Hospital Corporation
- Aletha Maybank, MD, MPH—Chief health equity officer, group vice president, Center for Health Equity, American Medical Association
Sept. 3, 2020
Dr. Maybank: Good afternoon everyone. Welcome to the next edition, or this edition, of Prioritizing Equity Series. My name is Dr. Aletha Maybank, and I'm chief health equity officer at the American Medical Association, overseeing the Center for Health Equity. Our role at the center is to help facilitate a process to embed equity across the entire enterprise of the American Medical Association.
I'm really excited about today's session for many reasons that I'll explain in one second, but I just want to remind people of the resource that we have, the Health Equity Resource Center for COVID-19, which is on our AMA website. I highly encourage folks to check it out. You will find this series and all of the other episodes that we've had. Also, I encourage to see the one that we had last week on the political determinants of health. Then we have another exciting one on voting and health coming up after this week.
So one of the opportunities that has really happened for me in this role, and I come from, many of you know, a public health space. Been in governmental public health most of my career, and now in this AMA space, and more so in health care. What's been really valuable in being at AMA is their mission is to promote the art and science and medicine, but then the betterment of public health. So I'm able to marry these worlds together that I have been a part of and now newly a part of. I've had this opportunity to be part of a task force to reimagine and reinvision the essential public health services, which most of us who have public health backgrounds of any sort, whether our formal degrees or have been in public health departments know that this is really the bread and butter of what we do in public health, how we organize in public health.
They were started back in the nineties, during reform during Clinton-time health care reform to really formalize and structure public health. Now this year is its 25th anniversary. So there are many folks across the country that have been asked to come together for the revisiting, revisioning of it. So there's going to be a launch this coming week, September 9, it's going to be joining the de Beaumont Foundation, The Public Health National Center for Innovation, The Public Health Accreditation Board and other leaders in public health across the country.
I think it's very relevant. We'll make sure we put the link in so folks can register. We'll put the link into the chat box. But I think is very relevant for this conversation today because what has really been elevated and exposed during this time is really a lack of understanding of the public health infrastructure really and the importance of it and the system of it. Also elevated the tremendous underfunding of the public health system as well. Oftentimes I feel that's really due to the narrative that we have around health in this country. Oftentimes it is all about health care and health services, which we know are very important, but not this broader context of health and really what creates health fully.
Today I have with me, the New York City Department of Health team. Of course, I'm extremely biased. I value these folks. I've worked with these folks. I admire their leadership and their commitment to public health and especially to equity as well. We all were kind of in a time at the health department in which we were figuring out how do you center equity in all of this work that we're doing? For the team, beginning in March 2020, it really confirmed, it was the first confirmed case, and you all can correct me on that if that's not right, in New York City for COVID-19. 8.5 million people live in New York City and health leaders really had little time to waste to figure out what to do to manage and control the spread of COVID. Figuring out testing, figuring out tracing that, all these things at a really rapid pace.
We have today with us, Dr. Torian Easterling, who is deputy commissioner for health equity and community wellness at the New York City Health Department, who filled my shoes, which I'm very proud of. We have Dr. Demetre Daskalakis, who's deputy commissioner at disease control, New York City Department of Health. One of the most dynamic leaders that I know, and just very clear leaders, I think in this space of public health in general, but especially around the work that he leads, and Dr. Neil Vora, that I had the opportunity to work with, very brilliant, and director of tracing at the New York City Department of Health and Health and Hospital Corporation.
Thank you all for joining me today. So I'm going to open up with the question that I always open up with in all of these panels is, I kind of know where you all are. So I think everybody knows we're talking to New Yorkers, so you all are in New York City. So you don't have to say that part unless you feel like you have to, but can you just tell us how are you doing at this point? Literally for yourselves and for your family, how are you doing at this point, whatever month this is into this, the fifth or sixth month. I just want to hear a little bit about that. Any of you all can start and just chime in.
Dr. Easterling: Since you named me first, I'll just jump in and then pass it to my partners and my colleagues. I was just remarking to someone yesterday that the period of this pandemic sort of aligns with the birth of my daughter. My daughter was born March 1, and so we've been six months into this pandemic, a little bit longer. So I'm in this moment where I am certainly tired and exhausted, not only because of the pandemic, but also dealing with the racial injustices that we know continue throughout this country, and certainly here in New York City, but also I've been inspired. When I go home and see my daughter, but also working with these amazing colleagues that I have here with me on this call, and so many others. We are in one of the largest public health agencies, and day in day, someone is stepping up and doing something amazing. I continue to get this bolt of energy, but I know that we need to find some reprieves. So that's where I am, sort of in this middle of exhaustion and excitement.
Dr. Maybank: Yes. Thank you. Dr. Vora?
Dr. Vora: Thanks for having me here. It's been a period that none of us have ever experienced before. Every New Yorker has been affected, some more than others, sadly, and it's just, it's been really hard. It's such a privilege though to be able to give back and help to get the city back on its feet. For me, that helps get me out of bed every day, the mission is so important. Otherwise, I don't think I'd be standing right now. It's that mission that's just really helped to energize me. I'd also add that it's really important that we take care of ourselves right now, stay connected to our friends and family and other loved ones. It just goes up and down.
One other situation that really stood out to me back, I think it was March or something. My best friend from residency was working in a hospital and she had run out of N95 masks, or respirators. I had some from several years ago when I had done a deployment to West Africa for Ebola, and I had some leftover. I had to give her the five N95s that I had, but that's all she had with her. So to hear from my friends on the front lines and what they had to go through to stay safe while they were taking care of patients was really difficult. I'm just so grateful for so many of the people on this call who treat patients and put themselves at risk for the greater good. So again, it's a privilege to be here, and thank you all so much for this opportunity.
Dr. Maybank: Thank you. Dr. Daskalakis?
Dr. Daskalakis: Thank you. So I echo a lot of the sentiments of Dr. Easterling and Dr. Vora, and mainly the sentiment of, with an audience of folks who are in the front line of care, thank you so much for the amazing work that you've done and continued to do. I think where I am now is waxing philosophical a bit about the duration of the pandemic and remembering that at the very beginning, many leaders said this is a marathon, not a sprint, and then actually realizing that it's been a marathon of sprints. So I think really focusing on the mission and the evolution of the mission and really keeping eyes on the prize, I think there's a lot that we do every day that is sort of in a planning mode and a preparedness mode. But realizing that even though we continue to sprint, the sprint is actually one that prevents disease and ultimately hospitalizations and death.
So I think it would be disingenuous to say that I am not exhausted. I think we all are. But I think that the mission continues and evolves in a way where every day, and I think probably Dr. Easterling and Dr. Vora, and I'm sure also Dr. Maybank, would agree that every day, this is another, it's a different story. Definitely from the perspective of this pandemic, a sort of interesting anecdote is that the Department of Health here was planning for about a year before the pandemic started in March to do a pandemic tabletop, interestingly enough. So the constant joke that I have, as we go through the pandemic, is that in tabletops, we often have these things that are called injects, where people give you, throw you a curve ball, and all of a sudden you have to deal with it.
I think the most valuable lesson and where I'm at now is to say that public health is one giant, continuous inject, with curve ball after curve ball, and that biology and viruses, as well as health care and people are often surprising. So it is more likely to not have a baseline and more likely to have a continuous curve ball. My family is okay. I've lost some friends to COVID. I had a friend who died in the very beginning of March and was found passed away in his home. So I have a very personal drive to continue doing the work and pushing forward. But I think that that's where I'm at, which is tired, but still kicking.
Dr. Maybank: ...[W]ell, thanks to all of you for sharing those pieces. I think it's just important that folks know. So Demetre, just to continue real quickly, where is New York right now? How are we doing? What are the numbers and how are we doing as New York?
Dr. Daskalakis: Great, no, it's great. So all of our indicators that we use, percent positivity, number of hospitalizations that are related to COVID and eventually are found to be COVID positive, as well as the number of cases in the city continue to be in I think what we're calling low transmission. So we're not seeing a lot. So we have a couple of hundred cases a day there. We're still seeing, our percent positivity, is at this point, let's just say bouncing around one, some times well below one percent, sometimes a little bit over, and our hospitalizations are looking good.
So I think from the perspective of all of the metrics that we have, a lot of the work, which I will really attribute to the medical providers messaging as well as to New Yorkers at large of adhering to the core four, so wearing facial coverings, washing your hands, staying home if you're sick and maintaining six feet of distance, all of those along with the great work that Dr. Vora is doing along with Department of Health, in contact tracing, I think have put us into this phase that we call suppression, where we're making all of the right moves to keep the virus as suppressed as possible to avoid a second wave. As New York City opens up, we are always at risk for increasing transmission, and so we have a couple of really big things that are coming our way, including the reopening of schools on September 21. So we're guardedly optimistic, but I think have a lot of systems in place if the scenario begins to look like we have the beginning of more than low transmission.
Dr. Maybank: Thank you. I appreciate that. That's helpful. So Torian, or Dr. Easterling, I'm trying to remember not to call you all first names do your last names. It's hard. Dr. Easterling And equity, I'm going to come to you of course, with that question. I had the experience and the opportunity, I needed to get testing, as the recommendation is for asymptomatic people. I think it was about, I don't know, two or three weeks ago, I went to one of the sites in Brooklyn that was a popup site and went through one of the stations that you all had set up. The line was long, that was fine, but it moved. It was moving.
I was just impressed by the organization. I was impressed that there was somebody who was outside in the line asking folks if they needed mental health support while they were standing in the line, then entering this space and just the amount of support. It wasn't just about testing. It was about how are you connecting people, fully understanding the context of their experience as it relates to testing, but also this experience in COVID. So can you just talk about some of this work and how you all really thought about strategically prioritizing equity in this work around the response to COVID?
Dr. Easterling: Sure. I think you could talk more about us prioritizing equity. I think, as an agency, under the leadership of then commissioner, Dr. Bassett, operationalizing equity, organizing our agency to really think about how we talk about and how we normalize the conversation. We're seeing the fruits of that labor six years ago, and I think what we're trying to do now is think intentionally about one, how we're using our data and not just quantitative data, but also qualitative data to ensure that we're thinking about the historical disinvestment and how it plays out in emergency operations, and really thinking about the feedback and the input that we get, not only from community members, but from our community based organizations who we work with and we need to figure out how we strengthen and include in our infrastructure.
But just to take a step back and provide a little bit more detail to what you alluded to, in our operations, and as you heard from Dr. Daskalakis, we're in this moment during our suppression phase where we're seeing low transmission. However, we are seeing neighborhoods that continue to signal to us that more attention needs to be brought to bear or marshal for those neighborhoods. I don't have to tell you about the neighborhoods in New York City that have had longstanding disinvestment and really thinking about what more can we do to ensure that individuals know that the resources are being allocated for them, that we're minimizing any barriers and ensuring that individuals understand that this information is not being used to penalize or criminalize any individuals in New York City neighborhoods where historically that has happened.
We understand the fear of, of connecting to government resources, so we have to be honest about that, and we have to think intentionally about how we bring those resources into community. We've been seeing some neighborhoods where there has been low testing. Manhattan, at the beginning of this pandemic, everyone was getting tested. But when you look at the outer boroughs, that wasn't the case. Particularly in Black and Brown communities, that was not the case.
So during this suppression phase, we've been seeing these neighborhoods with low testing but higher percent positivity, so that's been signaling to us that not enough people are getting tested, but there could be community transmission going on, so we need to do more in those neighborhoods. We bought some interventions, and really fortunate for our agency that we already had some rapid point of care testing. That really allowed us to get results immediately, and then we can talk to someone 15, 20 minutes after they get their results and let them know what their next steps could be.
We've heard nationally about the issues around turnaround testing and turnaround times, and so how can we get the information quickly and how can we ensure that someone's getting connected to a resource navigator so they can understand what they need to do to support with isolation, and with their families, potential contacts that they would need to quarantine. But we know that there's intersections there, there's social issues. So how do I get my food delivery or prescription delivered, or other things that may be issues related to making sure that I'm able to secure my job, and I'm not going to lose my job while I am isolating.
We marshaled all these resources, and we brought it to some of the neighborhoods. We started off in Tremont, which is in South Bronx because the data really showed that we needed to be there. We partnered with a church, and so St. Simon Stock church, I really have to shout out Father Mike there. I mean, he was amazing. He opened up. First, we were on the sidewalk, then we moved into the auditorium. It was hot. We also had a tropical storm during that time, and he was just an awesome partner and really allowed us to stand up the operations.
We partnered with affiliated physicians to provide the testing. We had our staff on the ground. They were connecting people to resources. That really taught us that if we are going to really have this place-based operations, we really need to make sure that everything was lined up, not just having the testing site, but making sure that our community partners knew where they need to go out, do outreach, knocking on doors. So literally we were going into apartments, knocking on doors, "Hey, your friend's just got tested. We need you to come down." So people were just coming down in droves.
We were testing 150, 200 people a day. Sometimes we had to turn people away. So that's just the response. When we invest in communities, we will see this response. I think what you're talking about, you were there two weeks ago and you saw that in Sunset Park, but you interestingly about Sunset Park, because of the success in Fremont, when we went to Sunset Park, the first week, we were getting people from Pennsylvania, Connecticut, New Jersey, and so we really had to go out and we partnered with a number of organizations, the Academy of Medicine, public health services. So by the end of our operations, we were getting 60% of the residents who were coming out and getting tested. That's community at work, that's the investment.
Dr. Maybank: Yeah. Congratulations on that. That's quite remarkable. Very remarkable, actually. Dr. Vora. Lots of conversation, confusion sometimes about contact tracing. I just wanted to have a sense of what are you all doing to prioritize equity within the context of that? Dr. Easterling just mentioned it, but also what have been some of the pitfalls that people really need to take into consideration as they set up their systems or strengthen their systems of contact tracing, that may not be considered, or people aren't considering potentially?
Dr. Vora: So there were days in April when we had over 6,000 new cases being reported a day. New Yorkers banded together to do with social distancing and staying home to the extent possible, keeping that space, wearing face coverings. All of those non-pharmaceutical interventions had the outcome that New Yorkers were the ones who brought that daily case count down. So that by the beginning of June, the daily number of new cases was, at the very beginning of June, maybe around 3,400 new cases a day.
Since June, the beginning of June, we've gotten it lower and lower like Dr. Daskalakis was saying. Right now we're at around 250 new cases a day. Contact tracing is one of several different things that the city has been doing that has helped to keep the virus suppressed and actually get it lower and lower. We hope to see it go lower and lower. This is despite a number of factors that would have led us to believe that maybe there would be a resurgence of COVID in the city.
For example, the city started to reopen during June and July, and there was a number of protests for a lot of clearly very valid reasons. We thought that maybe some of those activities would actually lead to a resurgence of the virus, yet we've managed to keep COVID suppressed. Again, that's a combination of things such as what New Yorkers are doing with face covering and keeping physical distance and a lot of testing and contact tracing.
There are challenges with contact tracing that are very real. Like Dr. Easterling was saying, people have understandable reasons to be skeptical of government, especially when you think about contact tracing, because it's so invasive talking to people out of the blue. We're calling people up and asking them where they've been and who they've had sex with and a number of other very personal questions. It is alarming. Especially when you put that in the context of COVID taking advantage of structural racism and historic inequities in New York City.
COVID has preyed upon certain communities disproportionately, and those are the very same communities that have been disenfranchised. We've had to do a lot of work to improve our overall contact tracing operation. If you look at our stats over time, the number of cases that we're reaching, the number of cases that are doing their interviews with the us, the number of contacts that are completing interviews with us, those are all statistics that we've seen have been improving over time. So we're really excited to see that, and that suggests that our work is successful.
Some of the things that have been done include, first of all, all of you clinicians on the phone, when you tell your patients that when they get tested for COVID, and if they test positive to expect a phone call from a contact tracing team, that really helps. We're so grateful when you do that because patients obviously trust their physician, their nurse practitioner, their PA, the general public, more than a random person from government. So when they hear their provider say that, it makes a big difference. So we hope that you'll continue to do that.
We have made a very, very concerted effort to hire our tracers, our contact tracers from disproportionately impacted areas of the city. Like I said before, certain parts of the city were more heavily impacted than others. Again, that's reflective of structural racism and historic inequities, but we made a very concerted effort that when we hired thousands of new staff for this contact tracing effort, that we would put a lot of effort into trying to recruit people from those disproportionately impacted neighborhoods. Over 50% of our contact tracers do come from those neighborhoods, which means that the very people doing the contact tracing represent those communities that they're working in, which makes a very big difference. We've gotten a lot of feedback from our community advisory board, from our contact tracers about how to improve our operation. We incorporated that into our efforts and that's also made a difference.
The last thing I'll say is that equity is the underpinning of what we're doing. We can't do our job if we don't have that equity lens in mind. That also means that we have to make sure our services are available in a range of different languages. All of our tracers undergo a lot of different types of trainings, including on health equity and on implicit bias and on trauma-informed care. So those types of things I think have all led to our current situation where our contact tracing operation has been improving since the beginning of June.
Dr. Maybank: Thank you. Anybody want to say anything? Demetre, you're sitting closer to the screen, so is there anything you want to say at this moment before, I was going to ask my other question, but go ahead.
Dr. Daskalakis: I'd rather get your question. I don't have a lot beyond the excellent comments from Dr. Easterling and Vora.
Dr. Maybank: Okay. So it continues on with Dr. Vora, because as these half hours go, they go really quickly, but what's new audience, is that we have an after-show. So we're going to have 15 more minutes of conversation that you all won't see right now, but you'll get to see at another point. But just as this portion of the show does close up, what's some other key advice to other physicians who could be working in health departments or other health providers who may be on the phone, what is your advice? In terms of, in the context of your health department work, whether it's centering equity, whatever it is you feel you need to say at this moment in terms of advice around centering equity, mostly. Go ahead, Demetre.
Dr. Daskalakis: I think from that perspective, especially in the context of emergencies, really realizing that your patients who have historically had issues because of structural racism are going to have issues during the emergency as well. So I think really realizing the vulnerability that exists for other diseases and conditions is not different than what happens during an emergency. So I think that from the perspective of a provider and I still see, I see patients myself, primary care patients and people living with HIV.
During that patch where my clinical service was suspended, because there were no people going to the clinic, I really, taking a page out of my public health experience, really looked at my patient list and actively reached out to people to make sure that things were okay. I think that from our perspective, or from my perspective, from the public health/clinician perspective, I think really realizing that through these baked in inequities that both Dr. Vora and Dr. Easterling and Aletha, Dr. Maybank have talked about, that these are something that really have real clinical impact and that you should assume that when an emergency strikes or when something challenges primary care, that a specific work has to happen to focus on those populations that you know about.
For me, like my folks who are living with HIV, I reach out to them first and then I also have a whole series of primary care patients who live in the neighborhoods where we were seeing a lot of activity. So it became sort of part of, all of my spare time, part of my mission to reach out to the folks that I could, to make sure that they were okay and knew what to do in the setting of the emergency. I think that, again, to sort of address equity, you have to have your eyes open to equity and be clear to know that there are folks that you need to work and reach out to specifically, especially during an emergency. That I think is how clinical care can really help augment the work that we do from the perspective of public health.
Dr. Easterling: [On mute.]
Dr. Easterling: Yeah, not much more to add than what Dr. Daskalakis has already mentioned. I think just one quick point I'll just add is the information. I think what is being elevated is how you're using that information, looking at your patient census, because one of the things that we were doing just to support our providers, we reached out to all our providers, prioritizing neighborhoods, Black and Brown communities, low income communities, supporting our providers by making direct phone calls, just like Dr. Daskalakis is mentioning. I think that data is going to be something that we're going to need, even as we're thinking about planning and preparing for flu vaccination and even prioritizing for COVID-19 vaccine. Providers, I think this is just one way that you can begin to integrate public health practice. It's just figuring out how we can strengthen data collection.
Dr. Maybank: Great. Thank you. And Dr. Vora? Neil?
Dr. Vora: Thanks. Public health is a team sport, right? So we can't just have the Health Department or Health and Hospitals Corporation doing public health. We work as a lot of different players across a number of different disciplines, including with people on the front lines, the clinicians. Together we're going to help keep this virus suppressed. So like I said before, when clinicians tell their patients who are getting tested for COVID to expect a call from a contact tracer, that helps us do our contact tracing job.
Dr. Vora: But I hope that you all, also, if you're a clinician, that you're seeing the benefit as well. First of all, from reduced transmission in the city, because we can break those chains of transmission through contact tracing. The other thing is that as part of our contact tracing to help cases isolate and context quarantine, we actually offer wraparound services, including free hotels, we deliver food to homes, or we help to get food delivered to homes, get medications delivered, even walking pets. As you all are seeing patients who've been exposed or who have COVID, we can help you take care of them because we have those wraparound services that we have available to offer. Again, I think it's a win win situation as we together try to suppress COVID, and we're here to help and work together with everyone.
Dr. Maybank: I appreciate that. Just so folks know, also the Center for Health Equity this week launched on our website the ability to, if you have other examples that are happening across the country that you want to share with how you're centering equity, there's a link on our website. We will put that in the chat box as well, that you can submit. New York City is already up. We have about six, I think, localities across the country. New York City is one of the first ones that we put up, so check them out and check out other examples of how folks are centering equity. I believe the contact information of the people in those cities are listed, but we'll double check to make sure.
I want to really just thank you all for being on this call today and thank you all, the reality about New York City is that you all had to learn a lot of this first and really, I think, set the standard and the bar for how to respond to COVID and also in centering equity as well. I'm here in New York, it was rough for all of us. It still is rough. At one point in time, it was a lot rougher, but I just want to say that many of us recognize that and the leadership that you all have had, not only for the city, for the country, but really for the world, and continue to do that. So thank you for your contributions and thank you for participating for today, and thank you to all that have listened in and will continue to listen in. Have a great day.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.