Reducing health inequities across NYC
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Well, hello and welcome to The Lancet Voice. It's November 2024 and I am Miriam Lewis-Saban, The Lancet's North American Senior Executive Editor based in New York City, along with my co-host Matthew Gilbert, The Lancet's U.S. Outreach Editor. Welcome, Matt. Thank you, Miriam. It's great to be here.

So your regular hosts, Gavin and Jessamy, will be back next time. This week, we have the distinct pleasure to talk with Dr. Michelle Morse, who is the Acting Health Commissioner and Chief Medical Officer of the New York City Department of Health and Mental Hygiene. She leads the agency's work in bridging public health and health care to reduce health inequities and serves as a key liaison to clinicians and

and clinical leaders across New York City. So welcome, Dr. Morse. Thank you so much for having me. Well, we thought that we would start our conversation today asking you a little bit about New York City's health landscape for our global listeners all over the world. We were wondering if you can give us a bit of an epidemiologic snapshot of health in New York and what

What you face as the health commissioner, how it varies from community to community and by various locations and by health disparities.

Thank you so much for that. New York City is an incredible and also complex city to work in and to be inhabitant of and also to try to protect and promote the health of all New Yorkers for. So it's been a real honor to get to step up in this time as the acting health commissioner, building on my experience as chief medical officer over the past three and a half years.

And I'll start just by saying that New York City is one of the most global cities in the world. It's part of the reason I'm so honored to serve here. I spent the past 20 years or so in my career as an internal medicine and public health doctor working all around the world on issues of global health equity. And so to be here in New York City, where we have literally hundreds of languages spoken regularly, where we have

literally, again, also people from just about every country in the world represented. And unfortunately, we also, of course, see the legacy of our country's history of systemic racism, enslavement, settler colonialism, and other dynamics, including things like more recent

phenomenon like redlining. These things all continue to shape the geography, the health outcomes, the social needs and social equity challenges for New Yorkers. And there are about 8.3 million of us. And it's a very complex place to do public health. And yet it's also one of the most important places to do public health. So what I'll also say is that

A lot of what I find to be very powerful and important about New York City is that there's really no time in recent decades in which there hasn't been racial health inequities and life expectancy and premature mortality.

And that, of course, is not natural. And I think that that's one of the most important epidemiologic phenomena for us to focus on. In addition to that, of course, we are still in the era of recovering from the pandemic. New York City was hit early and hard by the pandemic in 2020. And what we saw in those early data in 2020 also was racial inequities and geographic inequities in cases, hospitalizations and deaths.

And that pattern, again, is human-made. It's about our choices in society. It's about policies. It's about our history. And so all of these things are not immutable. These are all things that are actionable, that are solvable. And part of what I'm

what I'm honored again to get to do here in New York City is continue the legacy of people really trying seriously to impact those inequities and make changes. We did do that in some ways in New York City during the COVID pandemic. After a couple of years, we saw a significant narrowing in racial inequities in mortality specifically after the initial part of the COVID

the COVID vaccination campaign. So we know that we can be successful in changing these inequities. And next, of course, is the frontier around life expectancy. So I'll be talking more, I'm sure, in this conversation about Healthy NYC, which is our campaign really to change the dip in life expectancy that we saw in New York City during the pandemic.

And that just happens to be my next question. Regarding Healthy NYC's ambitious goal to increase the life expectancy of New Yorkers to exceed 83 years by 2030 through improving outcomes that are risk factors associated with increased mortality, can you please explain how you chose life expectancy as the primary indicator? And can you please give us a description of the plan and how the city will track its progress?

Thank you for that question as well. You know, life expectancy, of course, is an indicator that is very complex. It is driven by many, many different factors at the social and societal, behavioral and individual level. And so part of the reason that life expectancy was chosen as a focus is because we did see losses in life expectancy overall and by certain racial and ethnic groups during the pandemic.

And we wanted to set the goalpost and set the future for New York City to get the city back on track. Our mission, again, as the New York City Health Department is to protect and promote the health of all New Yorkers and also to focus on health equity. The life expectancy in many ways is kind of a net

indicator that allows us to look across lots of different factors, sectors, spaces, geographies, communities, and groups, and kind of have a net sum indicator of the overall health. Now, there are complexities with life expectancy. It's not the perfect indicator. But again, it really is one where if we were to achieve health equity and racial equity, we should see no differences between

in life expectancy across geographies or different places in New York City or across racial or ethnic groups or other areas. And so part of the reason that that goalpost of, you know, getting back to 83 years by 2030 was chosen was because that tells us, okay, net sum,

all of the different ways in which we do public health work, programs, policies, narrative change, in net sum, is that adding up to an equal chance at longevity for all New Yorkers? And what we found during the pandemic was it wasn't.

And even in the lead up to the pandemic, life expectancy had been improving in New York City. Although, again, inequitably, there's no time in New York City's history in which Black New Yorkers had a life expectancy equal to the average of New Yorkers. And that's also true for Indigenous New Yorkers. And so we do have work to do.

And part of the reason that we chose 83 years by 2030 is, again, because we saw a dip down to 79 years during the COVID pandemic. And we want to see improvements across the city in longevity at health.

You know, one of the really nice things about this program and focusing on healthy longevity, life expectancy, is that it really aligns with what is trying to be done globally also within health. And, you know, 2030 is when the sustainable development goals are set.

supposed to show that we've either, you know, we've, we've either gotten to where we need to be or not. And so the idea of having New York city as a leader for this in this area, I hope it sounds to me like you will perhaps be able to, you know, teach, teach others about some of the lessons that, that you'll be learning here as well.

Well, I will say New York City's health department is the largest in the country, if not the world. We have 7,000 employees who spend all day, every day committing themselves to, again, protecting and promoting the health of New Yorkers. And many of them are here because not only do they believe in that mission, they also believe in advancing health excellence.

equity in the city. In fact, our agency staff, these 7,000 folks represent all the communities, languages, experiences, identities that I was just mentioning. And so not only is it important for them personally as New Yorkers,

But it's also, of course, for them as a part of their public health mission. And I would also say that even though we are one of the largest health departments probably in the world, we also know that we have a lot to learn. No city in America has figured out how to end the racial inequities in life expectancy. And so even though we do believe in taking a leadership position in public health,

Here in the New York City Health Department, for so many reasons, we also come to this campaign around improving life expectancy with a lot of humility and acknowledging that we are battling hundreds of years of policy choices, of disinvestment, and of other social dynamics that have created the racial inequities in life expectancy that we see and the differential impacts of the pandemic on various racial and ethnic groups in the city.

You know, related to that, I was wondering if you could talk a little bit about how you reach people in the community who may be difficult to reach, difficult to find with your programs, you know, who are not connected to the Internet, who are, you know, migrants perhaps or homeless, but also others who've been living in communities, disenfranchised communities for a long time where, you

20, 30 years ago, maybe it was very difficult for them to sort out how do I even get a mammogram or a pap test or basic screening test or vaccination. Things have changed over time probably, but it would be very interesting to hear a little bit about how that's changed and where you see the city needs to be going.

Well, I will say those are our people. Marginalized New Yorkers, New Yorkers who are experiencing unfair, avoidable, unjust health outcomes, those are the New Yorkers we prioritize and focus on. And there are a number of different approaches and strategies that we've used to make sure that those New Yorkers are at the center of our focus. That is what equity is about, right? It's making sure that there is a fair chance for everyone to achieve their full health potential. And

And we know we aren't there yet in New York City. Most places are not yet there yet. So part of one of the most, I would say, important investments that this agency has made in exactly what you're describing, community engagement, following the lead of the communities that we know need to be the priority communities, that has been done in multiple ways over years. In fact,

We just celebrated the 100-year anniversary of the East Harlem Action Center. And that action center was established in 1921. And it was really focused at that time on the major health and social concerns of the East Harlem community. A hundred years later, we're still focusing on many of the same concerns, which is, you know, maternal health.

health of neonatal infants, health around tuberculosis and other infectious diseases. So it's interesting in that way that we've made so many gains in public health, and yet in some ways we're still dealing with a lot of the same health and social challenges. And I would also say that that investment in infrastructure around focusing on both place, so the geographies, the communities, the locations,

that need reinvestment and need to be prioritized. We do so also with race. And the Center for Health Equity and Community Wellness was established by former Commissioner Bassett about 10 years ago as one of the real ways to not only build that infrastructure internally in the health department to advance anti-racist and health equity-oriented practices, but also to serve the priority communities. So

We have action centers in East Harlem, in Tremont in the Bronx, and in Brownsville in Brooklyn. These are three neighborhoods and community districts that have the most unfair health outcomes.

And half for decade upon decade, unfortunately. And so we know that we need to reinvest. We need to focus. And part of the way that the action centers do that work is by actually being one-stop shopping for those communities to get the health and social care and access that they need. So that's just one of the many ways we do it. The final example I'll just mention is

During the pandemic, of course, we were facing this very acutely. It was very clear that it wasn't exactly going to be people with health department T-shirts and banners and posters that were going to be the most trusted communicators for how to protect yourself against COVID and how to get vaccinated.

And, you know, we had to just accept that reality and adapt. And part of the way we adapted was we were able, in partnership with the city, to fund about 100 community-based organizations.

in 2021 and 2022 to really support disseminating information that was reliable in the language that communities wanted it in, in the spaces and places that they wanted it in, and at their own pace. So that was incredibly important. And that

Public Health Corps continues to this day and is really about partnering with community-based organizations who themselves know community priority communities best and supporting them to be able to be frontline public health workers and protectors of public health for the communities that they serve. So that's a huge part of our approach as well.

So among the long lasting health issues and one of the most striking examples of the disparities and inequities you've been discussing is maternal mortality rates among black women, which have been disproportionately greater as compared with other races and ethnicities in the city since long before COVID-19 made everything so much worse.

Beyond reducing disparities in access to obstetric care, how is NYCDOH working to meet Healthy NYC's goal of reducing maternal mortality among Black women by 10% by 2030? And how does NYCDOH engage with community-based organizations to support pregnant and postpartum Black women outside of their health care providers' offices beyond the expanded communications and educational programs you just briefly described?

Thank you for that. It's one of the most important inequities that we're focusing on because the depth of the inequity is so profound. And what we see, of course, is that Black women and birthing people, unfortunately, are dying at significantly higher rates and that the majority of those deaths are preventable. In fact, about three in four of those deaths are preventable.

Whereas for white women in New York City, about 40% are preventable. So there's a selective way in which we're protecting the health of women and birthing people. And it tracks directly with the pattern of racism that we see in so many health outcomes, unfortunately, across the city. So protecting the health of women and birthing people in New York City has been a priority for this health department literally since its inception. And there's so much more we can do now than we could in the past.

But part of what we see as important is not only focusing on the hospital side. We have to partner with our health care institutions. They have incredible work and opportunity in terms of protecting the life of women and preventing things like hemorrhage, preeclampsia and cardiovascular outcomes.

And then we also have to focus on things like overdose and suicide that happens after women and birthing people go home and are discharged. The rate of, you know, peripartum, you know, anxiety and depression and mood disorders, among so many other things, including overdose and substance use, we know are also preventable drivers of, you know, unfortunately mortality amongst women and birthing people in the city.

So our approach really is using the data to guide us. We have a maternal mortality review committee that looks in depth at every person who dies during pregnancy or within a year after pregnancy and really tries to

to understand more deeply what the cause of that unfortunate event was. And then we're also working with community-based organizations and directly impacted people themselves as well to make sure that the strategies we're developing are not ones that are devoid of the voices or separate from the voices of the people who've either been through this or the communities that have

expertise and experience. And also part of what we're trying to do is really leverage things like Medicaid. There's a Medicaid waiver that's focused on health equity and social needs. And we're using health policy tools like that to really focus on populations like pregnant people who, again, we should be prioritizing and whose life and safety has to be central to our mission.

You know, you're raising something really important in what you're talking about, aside from the, you know, the catastrophic medical costs of racism related to Black women who sadly will die in childbirth or their infants. But it gets me thinking about social support more broadly.

And I'm sure I'm not saying anything that you don't know in that social support programs, which are so important for people who need, you know, a variety of services to help support them, not just when they're in the hospital, but once they go home. But we're also talking about people with chronic diseases and all sorts of different areas is generally really, you know, poorly funded programs.

What does that look like in New York? And how do you try to manage bringing in the importance? I mean, first of all, reminding people that these various social support systems are so important in people's health outcomes. And to sort of advocate to get the funding that you need in the city for those. Yeah.

Well, I think it's a phenomenal question. And I think in the U.S. overall, this is a challenge. Our social safety net could be stronger. And I do think that, you know, again, data is our best friend in many ways. We are able to show over and over again that health outcomes improve as socioeconomic status improves. And we have to continue to find ways to lift that up so that

Again, elected officials and other policymakers are able to really center that in their planning and policy proposals. I would also say that the racial wealth gap is an area of priority for us. We're doing quite a bit of work in the New York City Health Department to better understand wealth in addition to income and wealth relationship to health as well, which is distinct from incomes relationship to health in many ways.

And the final thing I'll say is just that for pregnant people, what we see, in fact, across Black women,

women in New York City specifically is almost regardless of socioeconomic status, we see unfortunately unfair outcomes. And so maternal mortality is one of those areas of health equity focus that is unique in some ways in that it's not as clearly about more than socioeconomic status because we see these birth outcomes even for women who are

higher in social and economic status. And so that's another, it's not to say that we don't need serious anti-poverty policies and investments. It is to say that some health inequities happen regardless of socioeconomic status, like Black maternal mortality in the city. And I think the final message I was just to leave you all with is that there is no better time to be in leadership in public health than

I think we've proven over and over again with the pandemic being the most recent, the COVID pandemic being the most recent and dramatic example that public health must be prioritized and funded to protect the health of all communities. And I know that we are entering into a new era with a new administration at the federal level. And all of us are doing a lot of planning on how we continue to protect community health workers,

restaurant inspectors, tuberculosis case managers, all of the frontline public health workers who are out there every day protecting and promoting the health of New Yorkers. And we know that that's true for health departments all

all across the nation. Our work must continue. And here in New York City, we will continue to protect the health of all New Yorkers to the best of our ability. And we are committed to continue that work no matter what happens. Thanks so much for listening to this episode of The Lancet Voice. If you're interested in hearing more about health in the US, we've got a special issue coming out on December the 9th. So look out for that.

Otherwise, we'll see you back here next time at The Lancet Voice.