Public Health Expert Harvard’s Dr. Howard Koh On Leveraging Best Weapon in the COVID-19 Fight

Dr. Howard Koh

[Music]
Female : Welcome to C onversations on H ealth C are with Mark Masselli
and Margaret F linter, a show where we speak to the top
thought leaders in health innovation, health policy, care
delivery and the great minds who are shaping the health care
of the future. This week, Mark and Margaret speak with Dr.
Howard Koh , the Harvey V. Fineberg Professor of Pra ctice and
Public Health Leadership at the Harvard T.H. Chan School of
Public Health. He's also at the Harvard Kennedy School and
F aculty C o - C hair of the Harvard A dvanced Leadership
Initiative. He talks about the inadequate federal leadership on
the pandemic, and what has led to a high death toll from
COVID - 19 here in the US and talks about how we should move
forward through the pandemic .

Lori Robertson als o ch ecks in Managing Editor of
F act C heck.org looks at misstatements spoken about health
policy in the public domain, separating the fake from the facts.
W e end with a bright idea that's improving health and well -
being in everyday life. If you have comments , please email us
at [email protected] or find us on Facebook, Twitter, or
wherever you listen to podcast. Y ou can also hear us by asking
Alexa to play the program . Now stay tuned for our interview
with Harvard's Dr . Howard Koh here on Conversations on
H ealth Care .

Mark Masselli: We're speaking today with Dr. Howard Koh, t he Harvey V.
Feinberg, Professor of the practice of Public Health Leadership
at the Harvard T.H. Chan School of Public Health and the
Harvard Kenne dy School. He's a faculty co - chair of the Harvard
advanced Leadership Initiative.

Margaret Flinter: Dr. Koh previously served as the Assistant Secretary for Health
for the US Department of Health and Human Services under
President Obama. Prior to that he w as the Commissioner of
Health for the Commonwealth of Massachusetts under
Governor W eld. He's published more than 300 papers in the
field of public health and earned numerous awards for his
service, including the Dr. Martin Luther King, Jr. Legacy Award
fo r N ational S ervice, and the Sedgwick Memorial Medal from
the American Public Health Association. Dr. Koh we welcome
you back to C onversations on H ealth C are today.

Dr. Howard Koh: Thank you so much, Margaret and M ark .

Mark Masselli: Dr. Koh, you've led a d istinguished career in the service of
public health. I would imagine that all the train ing that you
might have had, might not have fully prepared you for the

Dr. Howard Koh

unprecedented times that we're in certainly COVID - 19 has
paved the way for some new rule books to be written in the
public health arena. I'm wondering if you could put in
perspective how you think it will reshape the way the public
health community grapples with pandemics and global threats
in the future.

Dr. Howard Koh: M ark and Margaret, here we are in the worst pandemic our
country has faced in a century. P erhaps the only silver lining
out of the last number of months is that everybody now
knows what public health is. I used to tell my students here in
a very important field, it's life saving, it's c ritical, but it's
invisible. I don't say that anymore. This is really front and
center for the country and the world , a nd its importance is
there for all of us to see. I'm hoping that as we move forward,
we can learn from this, we can rally the country a n d the world
against this virus in a much more united fashion going
forward. T hen when this is past us, I hope we can learn and
vow that we should never go through this again. T he only way
to do that is to build the strongest public health system
possible. T he only way to do that is to emphasize how
important the power of prevention is , not only for us as a
society, but also for each of us as individuals.

Margaret Flinter: Well, Dr. Koh I know your career has been about leadership ,
a nd I know that's something that you've helped instill in a
generation of students and trainees as they came after you.
But we're living through really a case study of what leadership
maybe should look like during a global pandemic. W e follow
the work of other countries, New Zealand , Vietnam, initiated
well crafted protocols from the top down and led with them
and managed to significantly contain the outbreak. W e can't
help but compare this to what is going on in this country.

An article came out in the New England Journal of Medicin e,
decrying a leadership vacuum in the administration which
really has led to the failure to be able to effectively address
the pandemic. W e lead the world in bad outcomes in cases
and deaths. W hat kind of discussions are you having at the
Harvard Leadersh ip Institute to address what most would
agree is a failure of leadership in a crisis and conversely, public
health ab solutely we need , but we also need leadership so w e
have kind of failures in what we do next time to not have this
outcome.

Dr. Howard Koh: Margaret and Mark, I’ve had the great honor of thinking a lot
about public health leadership, studying it, writing about it,
and now teaching it at the Harvard Chan School of Public

Dr. Howard Koh

Health. W hen you stop and think about it, our leadership is a
fascinating topic. If you look at the literature, so much of it is
based on studies in business or in the military or even i n
sports . O ften the model are to have one person being the CEO
or the or the individual hero riding on a stallion and expecting
people to follo w him or her , usually a him actually . I n public
health the model is completely different. There is no one
person who has an answer. These challenges are enormous
and complicated, what some people call wicked problems.

T he only way to advance leadership in situations like this, like
we're facing in public health is to bring people together,
emphasize that everybody has a contribution to make, have a
united unified strategy, and then move forward and call on all
people to make contributions and even sacrifice . I think all
those themes are coming into play right now. W e could use a
lot more public health leadership in this country and the
world. That's what the New England Journal editorial was
commenting on.

Mark Masselli: Well, that's a great observation. I r eally want to pull the thread
on the leadership conversation because there have been some
questionable decisions made at the top, the White House,
maybe at HHS and CDC, and maybe the FDA as well. W e have
leading scientists like Dr. Fauci who have been igno red sort of
sideline through this. You have the former Centers for Disease
Control and Prevention D irector William Foege urging the
current CDC D irector, Dr. Robert Redfield to speak out about
the sort of colossal failure. I'm wondering, how do you really
bring people together, some of those scientists are making
enormous sacrifices, not abandoning their post . I'm wondering
how the pieces get picked up after this. I think there has been
some real concern that there's been a failure of leadership.

Dr. Howard Koh: Mark, I've had the incredible life experience of being the state
Commissioner of Public Health in Massachusetts, during 9 / 11
and anthrax, that was a very difficult period for our state and
our country and all of us in the field, then. T hen later, whe n I
began as assistant secretary at HHS in 2009, H1N1 was on the
horizon. F rom the day I started in during 2009 I joined
thousands of colleagues in federal government working
together to try to face that threat that ultimately came that
fall and beyond.

L e t me just start by saying I have great respect for anybody in
a public position right now trying to address this pandemic, it
is not easy, it's very difficult, it just stretches you to the limit.
But what you have to do is, first of all, face the facts in a very

Dr. Howard Koh

honest way, and then communicate what you know to the
public in an unflinching fashion, and put science front and
center. I f you can do that, and show the public that you
understand that this is a tough challenge with no easy
answers , o r if you're w illing to bring people together to have a
unified and u nited w ay going forward, that can help people
rally around a common mission and get to the other side.
T hat's what I'm hoping we can do.

Even now i t's very late. We're into month nine of this
pandemic response and counting, but it's not too late. We
have a potential COVID vaccine on the horizon, it's going to be
critically important to get that approval process going forward
in the most scientific and rigorous way. In the meantime, right
now we have a s easonal flu vaccination efforts going on as
well. T hese are all very important public health efforts where
we need public cooperation and trust and confidence.

Margaret Flinter: Well, Dr. Koh, it's not like we were unaware, but COVID has
certainly shone a spotlight on the disparities in health and
health care and health outcomes among our vulnerable
populations h ere in the United States over these last seven
months . Y ou recently hosted a forum at the School of Public
Health at Harvard on public health solut ions for vulnerable
populations and noted that the pandemic is accelerating,
other humanitarian crises both here at home and also abroad.
Can you talk about some of those vulnerabilities that are being
exposed by the pandemic and how the global health
comm unity is coming together to try and confront some of
these underlying challenges ?

Dr. Howard Koh: T hese issues are very important to me not just as a public
health professional and as a physician, but as a s on o f a very
proud immigrant family. W e have seen in very stark terms how
this pandemic has exposed the fault lines of our society and
really shined a light on the inequities in our country and
indeed, worldwide. W e have all seen how COVID has impacted
communities of color in disproportionate ways. T hese are
issues that are now front and center for us with respect to
racial equity, as well.

The forum you mentioned had some new data unveiled by my
great colleague, Professor Bob L inden [PH] . H e showed that
the major impacts of COVID on families in addition to health
were , of course, economics. So many families are fearing for
their financial future, even to the point of being concerned
whether they can pay their rent and keep their housing going
forward. P art of that conversation is to talk about, again, how

Dr. Howard Koh

we prevent evictions, and not risk having the current
homelessness crisis in our country be magnified in the future.

In the past, people may not have thought of that as a public
health conversation. But it is. T his is a time where we have
think about all the social determinants of health, housing,
food, transportation, education. That's the challenge. But the
solutions also come from leaders in that sector. If we can build
nontraditional partnerships with colleagues from those
sectors, they can be the new public health partnerships for the
future.

Mark Masselli: We're speaking today with Dr. Howard Koh former Assistant
Secretary of the Department of Health and Human Services .
Dr. Koh, we had one of your colleagues on our show a while
ago, D avid G ergen, and he was talking about America has this
uniquely American way of tackling challenges, sometimes to
our detriment. I think you sort of wrote about that when you
wrote about the 50 state solution is no way to address the
global pandemic. W e're still very divid ed in terms of our
approach to safety protocols, largely along geographic and
political lines . Y ou were talking about the fault lines of our
society. H ow do we address the inherent cultural dissonance
in this country so that we can do a better job in addre ssing the
crisis when they arise?

Dr. Howard Koh: Well, t hat's a great question , Marl, a nd you're right. In this
country, we have so much respect for autonomy, and in this
case, state rights. I respect that a lot as a former
Massachusetts Commissioner of P ublic Health . D eferring to
states to make public health decisions is absolutely
appropriate in usual times , b ut these are not usual times. This
is the worst pandemic we have faced in a century , a nd the
deaths and cases keep rising. I t's exactly a critical challenge for
public health leadership to say, o kay, we have to face the facts
and develop united strategy and ask all 50 states to rally
around that going forward.

We had so many moments over the last nine months, where
st ates were even competing against one another for tests,
supplies, and for PP E and , at a time, even for ventilators earlier
on in the pandemic response. T hat's not the way for a nation
to rally around a common response going forward. We also
point to the fact that there were very good crit eria put
forward by the CDC about how to reopen after the shutdown
was implemented by the P resident in March a n d April. But we
didn't hold the states to those standards , s o states opened up
as they wished, and there was no accountability, there was no

Dr. Howard Koh

coor dination a nd so we have lost many months.

T he tragedy , Mark and Margaret, is that we now look back and
also look forward with great concern about the losses that
should have and could have been prevented. One thing I
learned as a clinician for so many year s for my patients, when
a loved one dies, that's a tragedy. But when a loved one dies,
and you know that death could have been prevented, that just
haunts you for the rest of your life. W e now have thousands of
families going through that right now , a nd th at's just
absolutely not acceptable. W e have to double down on
prevention and public health right now, and get the country
ready for vaccination programs for just like the seasonal flu,
and also for COVID vaccination, which I hope can come sooner
rather th an later.

Margaret Flinter: Well, let's talk about that COVID vaccination, we're very
focused on flu right now b ut we have to be ready to move
forward with COVID vaccine as soon as it's available. But you
know from your time as Commissioner of Massachusett s and
then at HHS, and now that vaccine hesitancy is a real concern,
and it's a real concern p rior to COVID. We saw it with measles.
We've seen it with other childhood immunizations . Now with
what fairly are not as seen as the politicization of CDC and
FDA , may be even more vaccine hesitancy around the
upcoming COVID vaccine than we've ever seen before with
other vaccines. As you look at this knowing that this is the
pivot and the trajectory of the pandemic that we've been
waiting for , h ow are you looking a t strategies for addressing
resistance to any vaccine? This is a public health campaign, I
think , unlike any other and we'd be really interested in your
thoughts on that.

Dr. Howard Koh: H ere's the nightmarish scenario that we all desperately need
to avoid that sometime soon we have a safe, effect ive, life
saving, FDA approved COVID vaccine, and no one wants to
take it because they don't have trust and confidence in
government . W e just cannot allow that to happen, because if
it does, this pandemic is just g oing to go on indefinitely. I just
wrote an op - ed in the Boston Globe, emphasizing five key
steps that I think our nation needs to undertake to avoid that
nightmare scenario. First is to make the COVID vaccination
approval process a rigorous and scientific one . M ake sure that
there's lots of outside expert insights into this, and have the
science drive the approval process . T he CDC and FDA has
gotten a chair of criticism over recent months , and t hey have
to demonstrate that the approval process going forwar d is the
absolute highest standards.

Dr. Howard Koh

Now, we as a country know how to do this because we have
decades of experience with vaccine approval. I f the public
health agencies are allowed to do their job, this vaccine can
come forward and be hopefully safe and ef fective and save
lots of lives. Secondly, we have the flu vaccination efforts
going on right now. T his is a way to protect people against that
threat, and also show that there is a system of public health
working on their behalf. If we do that well this fa ll , h opefully it
could be an on ramp to the COVID vaccination campaigns to
follow.

Third, we need great communication to synchronize both
vaccination campaigns. We need top scientists like Dr. Fauci
d oing that communication. Fourth, we need to combat the
m isinformation on social media that's contributed to the social
interest in vaccine hesitancy, which is very concerning,
Margaret. W e are seeing tech companies not doing more to
block misinformation because there's so much bad
information floating out aroun d out there that's contributing
to skepticism about vaccination.

F ifth, we need a global view on this . T here's a very i mportant
global effort called COVAX to try to bring some two billion
COVID vaccines to many countries around the world by the
end of next year . R ight now that the United States is not
interested in contributing to that. But that's got to be
reexamined, hopefully by the next administration, because if
we don't tackle this from a global point of view, and just focus
on the US, this is just go ing to recur over and over again in our
country.

Mark Masselli: I want to connect the dots in a couple of things you said , one ,
about trust in science. T he COVID narrative recently took a
dramatic turn when the President held one of many public
events, rea lly avoiding all public health protocols, no mas k, no
social distancing, and generated a pretty significant cluster of
positive COVID - 19 cases among his inner circle . T he White
House seems to be blocking the CDC ’s efforts to do contract
tracing. Also, we'r e now hearing of a potential cure by an
experimental monoclonal antibody treatment that seems to
only been available to a handful of people.

If you look at this approach to the pandemic, could you
reiterate for our listeners the importance of taking all of the
preventative measures in lieu of the successful vaccine til l we
get there the end of the year or early next year . W hat's your
message to the public here? Why are these preventative
measures really the best way to save lives?

Dr. Howard Koh

Dr. Howard Koh: I f you tak e a broad view on where we are, we all want
desperately to find a cure for COVID b ut we don't have that.
We all want a life saving vaccine , w e don't have that either ,
a lthough there's been a lot of progress toward that goal. W hat
do we have that we know wo rks ? W e have public health and
prevention. We know social distancing works and c an save
lives. W e know that universal mask usage can save lives. B y
the way, we should have had a national requirement on this
months ago , b ut again, we've had a state by state process a nd
so that's led to the patchwork responses that we're seeing
right now .

W e of course, know that avoiding large crowds is critically
important. T hen when clusters arise , i mplementing contact
tracing as you mentioned, Mark, is absolutely important .
That's the only way to shut the outbreak down , and y ou got to
do that in a timely and coordinated fashion. Right now we're
seeing outbreaks to the highest levels of government. It, once
again shows how critically important public health is . W hen we
start ed , t his was viewed as a health crisis b ut we now
understand it's a business crisis. It's an education crisis. But
more recently, it's a continuity of government crisis and a
national security crisis. T he only way to solve that cascade of
challenges is to take care of the health crisis first, so that's
what we got to do. It's late but it's not too late . T he only way
to get there is through prevention i n public health until we get
cures and vaccine available for us.

Margaret Flinter: We've been speaking toda y with Dr. Howard Koh, t he Harvey
V. Feinberg Professor of the P ractice of Public Health
Leadership at the Harvard Chan School of Public Health and
the Harvard Kennedy School. You can learn more about his
very impressive body of work by going to
hsph.harva rd.edu /howardkoh or follow him on twitter @ Dr.
Howard Koh. Dr. Koh, we want to thank you so much for
joining us again today for your incredible contributions to the
field of public health for all the training that you've done of
the next generation. Thank you for joining us again today on
C onversations on H ealth C are.

Dr. Howard Koh: Thank you so much. It's a pleasure.

[Music]

Mark Masselli: At Conversations on Health Care, we want our audience to be
truly in the know when it comes to the facts about health care
reform and policy. Lori Robertson is an award winning
journalist and Managing Editor of FactCheck.org, a
nonpartisan, nonprofit consumer advocate for voters that aim

Dr. Howard Koh

to reduce the level of deception in US politics. Lori, what have
you got for us this week?

Lori Robertson: Democratic presidential nominee Joe Biden claimed President
Donald Trump's effort in court to nullify the Affordable Care
Act would “ take 100 million people with preexisting conditions
and move them in a direction where they can't ge t coverage. ”
But they wouldn't all lose coverage a s the claim misleadingly
suggests, barring highly unlikely circumstances. It's true the
Trump A dministration has backed a lawsuit seeking to
invalidate the Affordable Care Act . A decision from the
Supreme C ourt on the case isn't expected until next year and
the ACA increased protections for those with preexisting
medical conditions. D oing away with it would have
repercussions.

The ACA prohibited insurers from denying coverage charging
more or excluding cover age of certain conditions based on
health status. The 100 million figure which comes from a 2018
report by the consulting firm Avalere is in estimate for the
number of Americans outside of Medicare and Medicaid with
preexisting conditions, including cardio vascular diseases,
mental health disorders, obesity and diabetes. Without the
ACA, they'd lose the preexisting condition protections in that
law. But to be at risk of being denied insurance, they would
have to seek coverage on the individual market or thos e
without employer or public insurance by plans.

Only 6% of the population gets coverage on the individual
market, while 49% have employer based plans. Before the
ACA, those buying plans on the individual market could face
denials or higher premiums based on their health. Employer
based plans, however, couldn't deny insurance before the
ACA, but they could decline coverage for some preexisting
conditions for a limited period. Biden made his claim in a late
August interview on CNN. His campaign pointed out t o us that
the 100 million would be at risk of not being able to get
coverage, those Americans would have to be seeking coverage
on the individual market to be denied an insurance plan
outright. T hat's my fat check for this week. I'm Laurie
Robertson, M anag ing E ditor of F act C heck.org .

Margaret Flinter: F act C heck.org is committed to factual accuracy from the
country's major political players and is a project of the
Annenberg Public Policy Center at the University of
Pennsylvania. If you have a fact that you'd like checked, e - mail
us at www.chcradio.com . We'll have FactCheck.org’s Lori
Robertson check it out for you here on Conversations on

Dr. Howard Koh

Health Care.

[Music]

Mark Masselli: E ach week, C onversations highlights a bright idea about how
to make wellness a part of our communities and everyday
lives. Anxiety disorders are on the rise among the nation's
youth , and experts in the field of child psychology f eel the
condition starts much earlier in childhood, and it's far more
co mmon than previously thought, with an estimated one in
five children being affected . B ut too often these so called
internalizing disorders go undiagnosed. Unlike children with
more expressive conditions such as ADHD or Autism Spectrum
Disorder, young kids struggling with anxiety or depression
often internalize their symptoms, and may just seem like an
introvert to the casual observer.

University of Vermont child psychologist Ellen McGinnis says
the process of diagnosis for younger children is often
painstak ing and can take months to confirm. Dr. McGinnis says
the traditional method of diagnosis involves creating scenarios
that induce anxiety followed by behavioral observation by
clinicians and the results can be inexact . S he teamed up with
her husband and fe llow researcher, biomedical engineer Ryan
McGinnis to create a wearable sensor that can pick up on
physical cues that suggest the presence of anxiety using
accelerometers and simple algorithms to compare normal
stress responses.

Dr. Ellen McGinnis: The dev ice is called an inertial measurement unit s , and i t's
about the size of a business card, and we strap that to belts on
each child. W hen they did the mood induction task, it has an
accelerometer in it a nd so we're able to pick up angular
velocity speed, how much the child is bending forward and
backward. I t actually picks up 100 samples per second, so
much more than the eye can see. W e were able to see if kids
with anxiety and depression move differently in response to a
potential threatening information , a n d they do . K ids with
disorder turn further away from the potential threat than kids
without a disorder.

Mark Masselli: Their research paper shows the device was nearly 85%
accurate in making a correct diagnosis. S he says early
diagnosis is the key to avoid ing more damaging manifestations
of anxiety disorder later on . A simple wearable tool that can
assist parents and clinicians in determining if a child is
suffering from anxiety disorder leading to less guesswork and
more rapid diagnosis and treatment. Now that's a bright idea.

Dr. Howard Koh

[ Music ]

Mark Masselli: You've been listening to Conversations on Health Care. I'm
Mark Masselli.

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: Peace and h ealth.

Female : Conversations on Health Care is recorded at WESU at
Wesleyan University, streaming live at www.chcradio.com ,
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