Umair Shah’s story isn’t an uncommon one in public health. Starting out in medicine, with a career as an emergency department doctor, he said it quickly became clear that most of what impacts our health happens outside the hospital and in the community.
Today, that philosophy drives his work as executive director of Harris County Public Health (HCPH) in Houston, Texas — an agency that serves the third-largest county in the nation, home to about 4.5 million residents. In fact, Shah, who first joined the agency in 2004 and become director in 2013, said the agency’s mantra is this: “Health happens where you live, learn, work, worship and play.” Last year, HCPH became the first public health department in Texas to be selected as Local Public Health Department of the Year by the National Association of County and City Health Officials (NACCHO), which recognized HCPH for its commitment to engagement, equity and innovation.
Take for example, its work with Microsoft on mosquito “smart traps.” The traps, now being piloted in Harris County, can identify a mosquito by the oscillation of its wings and capture data on the environmental conditions at the time it was caught. The hope is that public health practitioners like Shah can eventually use all that data to predict where disease-carrying mosquitos will show up and where the agency should deploy the preventive measures that head off potential disease outbreaks.
“We’re not looking at the public health of yesterday or today, but toward the public health of tomorrow,” Shah told me. “That’s how we’re positioning ourselves.”
In July, Shah became the new president of NACCHO. He spoke with the Pump Handle last week about achieving healthy equity, the impact of the Affordable Care Act and elevating the public health narrative. (The following has been edited for clarity and length.)
Pump Handle (PH): In becoming NACCHO’s new president, you talked about changing the “invisible narrative” around public health. Why do you believe this is important and how do you recommend local public health workers go about that?
Shah: The challenge we have in the public health field is that we’re all very good at what we do and yet our work is largely invisible — like the disease outbreak that doesn’t happen — and so it’s hard to show the value of that work. So raising the visibility, drawing attention to actual work being done...that helps people value that work and then they become interested in investing in that work.
Here in Texas — because we’re such a football-loving state — I like to describe public health as the offensive line of the team. There’s lots of other players on the team that often get the recognition...but it’s public health doing all the blocking and pushing that allows the rest of the team to be successful.
We have an investment issue in our country. The vast majority of health-related expenditures go to health care delivery systems and not to public health and prevention. So we need to be thinking about how we can reframe that, and I believe the public health workforce has a role in that. We are the ambassadors of our field and when we’re willing to raise the visibility of the work we do, it translates into reframing the value proposition, if you will, of public health.
PH: Your agency has a strong focus on embedding health equity principles in everyday public health work. Why do you believe equity-focused work is so important at this particular time?
Shah: Equality really is the lens by which we approach so many of the activities we’re engaged in. At HCPH, we have a strong stance toward incorporating the social determinants of health into everything we do, from theoretical modeling to our response to Zika — we even have a health equity coordinator embedded in our multidisciplinary (Zika) response team.
We’re finding that communities are feeling that they’re being left out. …They feel like they don’t have a voice or don’t see a role for themselves in the decision-making process. Health equity really allows us to (elevate) community voices and perspectives as well as the social factors that determine health. Often, we find that it's the areas not traditionally in the purview of public health that we need to be focused on. That’s why we’ve taken such an assertive role in incorporating health equity into our work.
PH: You work in a state at high risk of Zika virus. Can put in context just how much work and coordination it takes to prepare for Zika and the possibility of a local outbreak?
Shah: HCPH confirmed the first Zika positive case back in January 2016, and it was before a lot of the interest happening around Zika domestically. That meant we had to build the plane while we were flying it.
We worked very diligently with our federal, state and local partners, and with a number of health care organizations, hospitals systems, providers, medical societies — all sorts of different stakeholders. At the end of the day, it was an incredibly instructive process in the real need for government to work together with the public in ensuring the health of our community and in preventing what could have been a remarkably worse situation.
Our department spent $1.5 million of its resources on Zika last year. We waited quite a bit of time for things to come through from the federal level and for Congress to approve a package, but we couldn’t rest on our laurels. We had to be very aggressive.
We’ve been investing an incredible amount of resources, staffing and capacity building not just in mosquito control, but in epidemiology, communications, policy work, environmental and veterinary work. This multidisciplinary approach gives us the best opportunity to respond to Zika in our community. That said, it only takes one mosquito to get Zika from a traveler from a Zika-affected area and — boom — now we have Zika in the community. We have to stay vigilant and that’s the real challenge.
PH: According to recent data from your agency, Harris County’s infant mortality rate is higher than both the state and national averages, with black families experiencing a disproportionate amount of that burden. What is your agency doing to address this?
Shah: This goes back to the health equity issue.
There’s a number of things we’ve been doing. We’re participants in Global Latch through our Women, Infants and Children (WIC) program, which is an opportunity to remind new mothers about the importance of breastfeeding. We’re members of the Harris County Child Fatality Review Team, where we review cases of children who have died through a prevention and policy lens. We operate 16 different WIC sites or prevention clinics throughout the community, where we use an equity lens approach to address the mitigating factors that impact health with a particular family.
We see this as a global issue that requires a multifaceted approach from the health department. So it’s not just an approach of our clinics and WIC sites or just the human health side; but really believing it requires a look at the (social) conditions too.
PH: How important has the Affordable Care Act been for the community you serve?
Shah: The ACA has had a great impact both in widening access and in creating opportunities for us to partner with the health care sector.
Sometimes there’s this perspective that because Texas didn’t expand Medicaid, that we haven't made any efforts, or few efforts, to improve coverage. But even without Medicaid expansion, the uninsured rate has dropped both statewide and locally. Enrollment increased in the marketplace from 135,000 in 2014 to almost a quarter-million in 2017. But we still have a good portion of our community, especially in certain communities, who aren’t aware of how to access health care coverage. We have to make sure people are aware they may be eligible for subsides.
But we also have to recognize that while health care coverage is important and necessary, it’s not sufficient. We need to recognize that health goes beyond health care…and when health care and public health work together, we can leverage the entirety of our systems to improve the health of our community.
What’s been missing in all the discussions around the ACA repeal is that a significant portion of CDC funds is in the ACA’s Prevention and Public Health Fund (PPHF) — if that fund went away, you’d have a 12 or 13 percent cut to CDC’s budget. We receive about $1.5 million through the PPHF...and so if you have a reduction in dollars at the federal level, you start to have an impact on what’s happening in Texas to the tune of about $28 million. That’s just through the health departments — the PPHF monies also go to community groups. We have to remember public health in all of this.
PH: The PPHF has become a critical source of funding for a variety of public health activities at the local level. Can you provide a couple examples of what we stand to lose if that fund disappears?
Shah: We’d lose dollars for surveillance, epidemiology, infectious disease response, health promotion. Many of those dollars aren’t just about disease, but about infrastructure and capacity. For example, when we have something like Zika or Ebola, we can chase the dollar by being reactive or we can have a system where local and state public health are well-resourced. That means we’re not being reactive to the next disease of the day, but proactively building capacity so we’re ready to respond to myriad issues.
PH: As a physician, you came to public health via the world of medicine. As such, what’s one thing you wish public health workers better understood about their colleagues in medical care? What’s one thing you wish those in medicine better understood about public health?
Shah: I don’t want to forget the importance of the public health-health care interface. What I would say is we can’t do our jobs effectively unless we work hand in hand with each other.
When you look back at Ebola, it is an incredible testament that only Mr. (Eric) Duncan (the first Ebola patient diagnosed in the U.S.) and two additional nurses were exposed. That is an incredible success story, and yet that is also the challenge for public heath. When I treat cancer in a child, I can show you a poster child for cancer treatment. But it’s much harder to show the image of the kids who were prevented from getting cancer in the first place.
At the end of the day, we can’t do this alone. We have to do it together.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for 15 years. Follow me on Twitter — @kkrisberg.
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