The Line Between Public Health and a Healthy Public

Oxiris Barbot, GME ’94, spent two years as New York’s health commissioner and headed its COVID-19 response, navigating politics as much as the viral outbreak that quieted the city that never sleeps.

By Julyssa Lopez 

Emptiness seems antithetical to New York City, home to more than 8 million people and one of the most crowded metropolises in the United States, with approximately 28,000 residents per square mile. Yet in March, as COVID-19 began its spread through all five boroughs, lockdown measures cleared out the city’s perennially packed, bustling avenues. The northwestern Brooklyn neighborhood where I live grew jarringly vacant, but there were plenty of reminders of the virus ripping through people’s lives: Sirens wailed constantly through the streets like a grim, ever-present warning. Masked paramedics wheeled a neighbor of mine out of his house one morning, and white, hulking trailers appeared at a nearby hospital—just one site of the city’s multiple mobile morgues. The number of people infected with COVID shot up at gruesome speeds: several hundred the second week of March, 10,000 a week later, more than 40,000 by the end of the month. “New York City Region Is Now an Epicenter of the Coronavirus Pandemic,” a March 22 headline of The New York Times declared.

But Oxiris Barbot, GME ’94, who was New York City’s health commissioner then, didn’t have time to feel overwhelmed by the numbers or the deluge of grisly headlines. Her version of New York in those days wasn’t a picture of eerie quiet or desolation. The department had been looking into the virus since January, and a month later, it worked to monitor travelers returning from China and recommending quarantine. Then, in early March, when her department identified the city’s first confirmed patient, a 39-year-old woman who’d contracted the virus while traveling to Iran, her days were crammed with activity as she and her colleagues “worked nonstop.” They began the process of contact tracing to identify anyone the woman had come across to assess how much the virus had spread, and they dove into more research about the virus’s behaviors. Every morning, Barbot woke up at 6 a.m. and meditated for about 30 minutes, something she’s done every single day for the last five years, since she became interested in meditation as a way of fine-tuning her concentration and ability to remain present. Then, a marathon of phone calls and staff check-ins would begin; when the office instituted a work-from-home policy, those became back-to-back Zoom meetings. She worked seven days a week, getting about three to four hours of sleep a night. And as intense as it was, Barbot—a 54-year-old woman with grey-streaked hair and a patient demeanor—channeled decades of working as a pediatric doctor and public health expert to get through the peak of the crisis.

“To a certain extent, especially in the beginning where we were so intensely focused on getting the job done, it felt like I was somewhat removed from the immediacy of it,” she says. “It’s kind of like when I was a pediatric resident, when you’re coding a kid, you can’t focus on the fact that, ‘Oh my God, this is a cute child and somebody’s baby,’ because your emotions cloud your judgment. You have to step back because your job is to save that kid’s life.”

Barbot became health commissioner of the New York City Department of Health and Mental Hygiene two years ago, making history as the first Latina to ever lead the agency. The role, which has existed since 1805 when the city created what we know today as the Department of Health, is a broad one, tasked with overseeing the health needs of the community. The job took on deeper significance amid the pandemic, moving Barbot to the center of the crisis as people looked to the top doctor in the city for guidance. She was a regular presence at daily news briefings alongside Mayor Bill de Blasio since the start of the outbreak, and to some New Yorkers, she became the face of the health department through public service ads urging social distancing and safety precautions that ran on cable and broadcast television. She was on the ground as New York City suffered its worst death tolls, eventually hitting 23,000 fatal cases, through to when infections finally began to dip in the summer.

However, even as the curve flattened in New York City, managing a global crisis came with a host of bureaucratic, political and public challenges. As early as March, media outlets reported about an aggrieved relationship between de Blaiso and health officials, who felt their advice on tougher restrictions on gatherings and other safety measures wasn’t always heard; tensions seemed to intensify when the mayor passed the responsibility of contact tracing, which the Department of Health has always handled, to New York City’s Health and Hospitals, a public benefit corporation made up of several hospitals and healthcare facilities. Later, news broke of a dispute between Barbot and New York Police Department Chief Terence Monahan, who requested a half million surgical masks for police officers (Barbot gave him 50,000 and publicly apologized if media reports gave the impression that she didn’t care about police, explaining the masks were in short supply). After that, she didn’t appear at several briefings and meetings for a few days. Questions mounted about whether the mayor had sidelined her and how leaders would leverage her expertise moving forward.

Still, in mid-July, when I spoke by phone to Barbot for the first time, she was in the health department’s offices in Long Island City, focused on examining data and mitigating a potential second wave of the virus. She was thinking about what her team had learned and also preparing for a variety of worst-case scenarios. What if a coastal storm took out electricity and forced crowds into cooling centers? What if a bad flu season came at the same time as a second wave of the virus, pushing hospitals to their absolute limit? And then, two weeks after our conversation, she resigned from the job.

“I leave my post today with deep disappointment that during the most critical public health crisis in our lifetime, that the health department’s incomparable disease control expertise was not used to the degree it could have been,” Barbot said in her resignation email, sent to de Blasio and obtained by The New York Times. “Our experts are world renowned for their epidemiology, surveillance and response work. The city would be well served by having them at the strategic center of the response not in the background.”

Barbot tells me later that leaving “wasn’t a decision that I took lightly. Serving the health of New Yorkers has been the position of a lifetime. I’m humbled by that opportunity, but it was time to part ways.”

She’s had time to reflect not just on her tenure, but about the broader role of public health amid a crisis that keeps unfolding around the country. The United States is still fighting the coronavirus, with 200,000 people dead nationwide. Some states have reopened schools and businesses, despite the risk of new outbreaks and second waves, and public health officials have continued to offer advice that in many cases gets lost amid political gridlock and wanton partisanship. On the national stage, President Donald Trump has repeatedly called into question the advice of Anthony Fauci, the government’s top infectious disease expert, and stripped the Centers for Disease Control and Prevention from data collection management. Records from the Kaiser Health News and The Associated Press found that nearly 50 state and local health officials resigned, retired, or had been fired since April, some after clashing with politicians and government figures.

But perhaps the biggest difficulty is that the pandemic has exposed how many of these public health experts are trying to work and be heard within public health infrastructure that, after years of disinvestments, is uneven—even broken, some say—and has left the U.S. vulnerable during the worst pandemic of the last century.

John Auerbach, president and CEO of Trust for America’s Health, a D.C.-based nonprofit dedicated to defending public health, says that funding for public health has been on the decline at the federal, state, and local level since 2008. He explains that public health is at a disadvantage for several reasons: When public health succeeds at preventing diseases and health crises, “nothing happens. When it’s a preventive disease, you simply don’t see the diseases, so people don’t say, ‘Oh thank goodness for public health.’ Something just doesn’t occur.” That can make stressing the importance of preventive funding difficult. Additionally, the public health system has seen an increase in the programs it deals with, such as weather-related emergencies; federally declared emergencies; deaths of despair, which are defined as deaths due to drugs, alcohol, and suicide; and other issues. Public health funding proposals often contain dozens of line items because of how many broad and complex issues departments cover, making it hard to easily summarize and thus get support for each priority. A 2012 law that slashed the Affordable Care Act’s Prevention and Public Health Fund by $6.25 billion and sequestration, which cut federal spending starting in 2013, have worsened the situation and undermined emergency preparedness in particular.

“On the one hand,” Auerbach says, “to have more limited resources and, on the other hand, to have greater need, has meant that the public health system has been crippled in terms of its capacity to respond to major public health emergencies, like the one we’re facing now, and that has resulted in preventable injuries, illness and death.”

Barbot’s own work isn’t over. In recent weeks, she’s written an op-ed for the New York Daily News, calling for a two-pronged strategy that includes wearing face coverings and carrying out comprehensive-but-targeted testing with quick results to fight COVID-19 in the U.S. She hopes that rather than listening to figures playing “armchair epidemiologist,” leaders making COVID-related decisions in the country think critically about how to best use public health tools and public health data while implementing changes that prepare the country for future catastrophes.

“The fact of the matter is that if we go back to  the status quo—the way in which health care delivery is built in this country, how it is that people access health insurance—then we’re doomed to be in the same situation again when the next public health crisis happens,” she says.

 

Barbot grew up in the Bronx’s Lester Patterson Houses, one of the largest public housing developments in New York City.

“I grew up poor but I didn’t realize I was poor until much later,” she says. “I was just surrounded by so much family and community that loved me.” Both of her parents were Puerto Rican and she grew up speaking Spanish—she still proudly refers to herself as Nuyorican. Barbot left the Bronx when she was five and moved with her mother to Belleville, N.J. She was an active kid; at 10 years old, she was the only girl drafted by the Yankees’ Little League team, and one of her first brushes with public health happened one day when she was running around outside and badly injured her knee. When her mom took her to an orthopedic surgeon, he took one look at her and said, “I don’t take Medicaid, but you can put ice on that.”

“Those experiences of growing up in public housing,” Barbot says, “being on public health insurance, relying on public assistance, I think, gave me a very intimate and personal understanding of what it means to grow up poor in this country and the degree to which systems are not designed to help poor people.”

She knew she was going to be a doctor, so she majored in American studies at Yale University—her way of getting a more well-rounded college experience. She got her medical degree at the University of Medicine and Dentistry of New Jersey and then moved to Washington, D.C., to complete her pediatric residency at the Children’s National Medical Center (now Children’s National Health System) through GW. There, she also worked at a predominantly Latino clinic in Columbia Heights, where she provided care to underserved communities. The experience, she says, made her want to take on wider issues of policy and health care parity, and she later became medical director of the Office of School Health at the New York City Department of Health and Mental Hygiene and the NYC Department of Education and commissioner of the Baltimore City Health Department. In 2014, she joined the New York City Department of Health as first deputy health commissioner. 

When de Blasio appointed her commissioner in 2018, he pointed out that she was a native New Yorker who understood “that improving the health of our city starts with keeping health equity at the center of our work.”

Issues of equity topped Barbot’s agenda, even as unexpected challenges were thrown her way: First, in the summer of 2019, she dealt with the city’s most serious measles outbreak in 30 years, which saw about 650 people infected. New York City got a handle on it by September. “I got a break for maybe two months and then all hell broke loose,” Barbot says. COVID-19 struck, and the earliest days of the pandemic were some of the most intense and confusing as public health officials raced to keep up with the virus. Barbot, like many other public leaders including Fauci, has continued to face criticism for her tweet encouraging New Yorkers to continue with their daily lives, although her messaging changed course quickly as more information about COVID-19 became available. Still, had public health experts known as much about COVID-19 as they do now, parts of the response would have looked very different, she says.

“I’ve reflected a lot on the last couple of months on what we did, what I did, and what we could have done differently,” Barbot says. “I think the thing for me is focusing on the fact that we acted on the best available scientific evidence at the time. Had we known then what we know now, obviously it would have been a very different response. But that’s part of being a leader—it’s being able to communicate that to your staff and to the  public, to say, ‘This is a rapidly evolving situation, and based on what we know right now, this is what we’re doing.’ And I think part of being a leader is being at peace with that ambiguity, and acting with integrity and dignity and urgency.”

She adds that another critical piece of what she’s taken away from her tenure is how much the country needs a cohesive, high-level strategy that works and prioritizes finding fast solutions during emergencies.

“I think the biggest lesson learned is really the importance of having a coordinated strategy that encompasses federal, state and local needs—and the fact that how at six months since the beginning of the pandemic, we still don’t have what feels to be a coordinated strategy, which I think is a huge loss for our country,” she says. “At the local level, the degree to which the mayor and the governor coordinated was good, but in many ways, it could have been better in terms of better and more quickly aligning health care resources, specifically around transporting patients between health care systems and not being constrained about how things are versus how they should be.”

 

Auerbach adds that the American public health system is made up of more than 3,000 departments that range in size from one employee to as many as 15,000, depending on the state or jurisdiction. But they’re all up against the same health threats: “They have more or less the same level of responsibility, whether they have one employee or thousands.” With funding declining over the last several years, many public health departments have advocated for infrastructure funding to build sophisticated data management systems and communication strategies that reach the public more broadly. However, year after year, those requests have often gone unheard, and when COVID-10 struck, many departments were left scrambling, with some rural offices even resorting to receiving coronavirus lab test results via fax machine and physical mail, causing lags and the possibility of duplicate or missing information.

“With core emergency-preparedness money being less than it was in 2008,” Auerbach says, “with outdated data systems and endless requests in funding to update them that resulting in little assistance, and antiquated communication systems, public health was not as well prepared as it could be for the worst emergency situation in the last 100 years.”

Barbot says that many of these gaps have been well-known for years. “I wish I could say that this was a big surprise, but this is a disaster that we all saw coming,” she says. However, there’s an opportunity in a post-COVID world, whenever that may be, to start a conversation about the challenges public health faces and evaluate what’s effective. Barbot also wants to see questions of poverty and health inequities addressed as part of a new way forward. “When we talk about, let’s say, obesity prevention, diabetes prevention—I mean, these were the folks that were at highest risk of dying. My hope is that we’ll broaden our vision of what it means to create healthy communities.”

By the first week of July, New York City was down to about 400 to 500 coronavirus cases daily. “That is still a significant number,” Barbot says. Still, by many accounts, the city was successful compared to the enormity of the first wave. “New York got hit worse than any place in the world. And they did it correctly by doing the things that you’re talking about,” Fauci said in an interview with the PBS NewsHour that aired July 18. “From the epicenter to zero deaths. Short-term sacrifice saves lives!!!” Valerie Jarrett, a former adviser to President Barack Obama, tweeted when New York City health officials reported zero COVID related deaths for the first time since March.

Yet it’s hard to celebrate when the cost was more than 23,000 lives. That’s a number that Barbot thinks about today. “These are individuals and these are deaths that we’re going to carry with us,” she says. “And I think on good days we will think, ‘Thank God we put all of the things in place that we did, because the numbers could have been even that much higher.’ And on bad days, I think we’ll think, ‘So many countless people died for no good reason.’ I think that the depths of how this virus has affected people and the number of people who have died is yet to be fully understood, but my hope is that people won’t take it as, ‘It is what it is,’ …I think that’s a disrespectful way of looking at the way in which people have lost their lives for this virus.”

At the end of August, Barbot announced that she’d taken on a job at the JPB Foundation, a private grant-making foundation established by Barbara Picower, as senior fellow for public health and social justice, which she sees as a chance to focus on underlying health inequities and building back communities. It’s fitting of what she saw for herself earlier in terms of helping jurisdictions safely implement preventative COVID-19 measures while raising awareness of social and economic inequities that have played a role in the pandemic.

“I think that my ongoing contribution will be a combination of forward planning and immediate planning for the post-COVID world as well as looking at the intersection of public health, health care delivery and social justice, and how it is that we take into consideration at the planning stages, all of the ways in which COVID-19 has ripped the scab off of inequities in this country,” she says. “We need to take this opportunity to build it back in a more just way.”