Densely-populated with lots of turn-over, cities are perhaps the worst place to be in a pandemic. And yet in the latter half of the COVID-19 pandemic, people living in cities have been safer than their rural and suburban counterparts. Abdul explores why cities matter when it comes to public health. Then he speaks with Katrina Forrest, co-Executive Director of the CityHealth initiative and Chrissie Juliano, Executive Director of the Big Cities Health Coalition, to discuss the threats and opportunities facing health in cities.

Transcript

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Dr. Abdul El Sayed: Nationwide, COVID-19 cases continue to decline, down 19% over the past two weeks. Facebook whistleblower Francis Haugen blows the lid off of how Facebook knowingly harms teenagers’ mental health. The WHO approves a new malaria vaccine that could save hundreds of thousands of lives a year. This is America Dissected. I’m your host, Dr. Abdul El-Sayed.

Do you all mind if I nerd out for a minute? Who am I kidding!? You all are here because I usually nerd out for like 45. So let me take you back to the founding of epidemiology, because that’s what we do on the show. Everyone’s heard of the story of Jon Snow, “King of the North.” Nope. Not that Jon Snow. The guy who stopped a cholera outbreak in London way back in the 1800s. He had painstakingly traced the water source of people who had gotten cholera to a single water pump just downstream of where they dumped the sewage in the Thames. By petitioning the local government to take the handle off, he ended the epidemic. Voila! Public health in action. But others actually trace the founding of epidemiology back even further, to the 1300s, when a haberdasher named John Graunt stylishly started analyzing bills of mortality, or records of every single death, or at least all the ones they could count back then, in London. He found that while the death rate for most things were pretty stable, mortality to the plague came in spurts. Outbreaks. It was the first time anyone had looked at the patterns of disease at all. Here’s the thing, whether you think it was John Graunt or John Snow who founded epidemiology, it was probably founded by a dude named John who happened to do it in London, a city. Cities were important for two reasons. First, because they were so densely packed, there were the kinds of places where infectious diseases, which were overwhelmingly the leading causes of death back then, could move around. And because they were so big, they didn’t kill everyone in sight. Think about it. If an outbreak had hit a band of hunter-gatherers, it probably would have wiped out enough of them that the group wouldn’t have survived. The very means of public health, managing the circumstances around us to promote health and prevent disease, none of that happened until there were enough people in a single place, until there were cities. In America, cities have been the epicenter of the worst conditions for America’s Black and brown communities. For a long time, the very word urban itself was a euphemism for Black. Frankly, it often still is. And throughout our culture and our politics, cities were blamed for the structural poverty and racism that relegated Black folks, who had moved out of the South during the Great Migration in search of well-paying industrial jobs to the worst, most dangerous jobs and segregated them into specific neighborhoods. The racist, quote unquote “welfare queen” trope of the 1980s, the crack epidemic, and the disinvestment in basic public services of the Reagan era, were weaponized to exacerbate conditions in America’s poorest neighborhoods. The gentrification of the 2000s and 2010s squeezed the poorest city dwellers further out of affordable housing and work opportunities. And into all that came the pandemic.

[news clip] New York has become the epicenter of the outbreak in the U.S.

[clip] So Mayor Bill de Blasio, announcing that state of emergency at a press conference . . . delivered a message of reassurance, while urging New Yorkers to be cautious.

Dr. Abdul El Sayed: For the first several months of the pandemic, cities across the country: New York, Detroit, Chicago, Seattle, Los Angeles—they suffered the worst of the pandemic. But cities are nothing, if not resilient. Cities have stepped up to protect their communities. Now, rural folks in America are two times as likely to be infected with COVID than urban ones. And that was the work of thoughtful, invested, engaged public health workers, and maybe more importantly, community leaders and activists and everyday folk doing what they needed to do to protect their communities. Today, I wanted to learn more about where we go from here. Cities continue to be the locus of public health in this country, setting the standard for suburbs and rural communities in the rest of the country. Beyond COVID, there remain dozens of issues they face: opioids, diabetes, heart disease, stroke, lung disease, lead, and so on. Our guests today are leading the fight for healthier cities. Katrina Forrest is the co-Executive Director of CityHealth, an initiative toward improving local health policies in cities to improve public health. Chrissie Juliano runs the Big Cities Health Coalition, a collective of big-city health officials working together to improve health in their cities and beyond. Our conversation after the break.

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Dr. Abdul El Sayed: All right, you guys ready to get started, everybody recording?

Katrina Forrest: Yes.

Chrissie Juliano: Yeah.

Dr. Abdul El Sayed: OK. Can you guys introduce yourself with the tape, please?

Katrina Forrest: Hi, Katrina Forrest and I’m one of the co-Executive Directors of the CityHealth Initiative.

Chrissie Juliano: Hi, I’m Chrissie Juliano. I’m Executive Director of the Big Cities Health Coalition.

Dr. Abdul El Sayed, narrating: When I served as health director in the city of Detroit, CityHealth and Big Cities Health Coalition were two leaders I would look to for guidance for how to do my job better. It was a privilege to sit down with Chrissie and Katrina, their leaders, to understand how city officials are thinking about what comes next for cities as we move beyond this pandemic.

Dr. Abdul El Sayed: I’m really excited to be in conversation with you all today simply because I think one of the overwhelming point of departure that we’ve seen in this pandemic and therefore more broadly, has been the urban-rural divide on the pandemic. Early on in the pandemic, of course, this was a largely urban disease, and now we’re starting to see that it’s actually largely a rural disease— twice as many COVID-19 deaths. But then more broadly, COVID, of course, is not the be all and end all of public health. And so much of the way we think about taking on the deadliest diseases in our society really has a lot to do with the kinds of environments that people live and learn and work and play in. I want to ask you all what makes public health different in cities as compared to suburbs or rural communities?

Chrissie Juliano: The first thing is cities are compact, right? You have a lot of people living closely together. You tend to have more diverse populations. You tend to have concentrated poverty. You also tend to have a whole lot of essential workers living there. Not, again, not that they’re not in rural communities, but I think the things that you talked about early on in COVID and why we saw it in cities is because of those reasons. I think the flip side is you also tend to have strong public health authorities and leadership, and that is something unique about cities, honestly, even compared to some counties. So, you know, COVID has shown us all of the things we’ve known about cities and, as you said, many of the things we’ve known about public health. And as we’ve moved on to the pandemic, through the pandemic, you know, we’re seeing that more and more across the country.

Dr. Abdul El Sayed: Katrina, I want to ask you, I mean, the CityHealth Initiative does some amazing work thinking about the metrics that we ought to be able to engage with to take on the challenges of public health in cities. This pandemic obviously has thrown everyone for a loop, it has fundamentally changed all of the goals, all of the incentive structure, all of the attention that we pay to public health. How has this pandemic both hindered our capacity to take on other public health challenges at the city level, but also potentially also helped them, and created a level of attention and focus on issues that had sat dormant in our minds for a long time?

Katrina Forrest: Yeah, I mean, I think in terms of the hindrance, it was just diverted attention, right? City leaders were focused almost acutely and exclusively on COVID. So how do we get information to the public about who is most impacted? The vaccine started rolling out, how do we make sure that we are appropriately prioritizing who gets the vaccine? Etc., etc. And so we, from the CityHealth perspective, we saw that cities really didn’t have the time necessarily at the very beginning to focus on some of the other policy areas. But then over time, because CityHealth was founded on the principle that local action can address the key social determinants of health, we started to see things like earned sick leave become more important than ever before. Earned sick leave is one of CityHealth’s policies, and so we started seeing city leaders at the local, state—local and state level taking action to adopt whether they were temporary earned sick leave policies, or in some instances, permanent earned sick leave policies. And so I think, I think this moment has, for city leaders, crystallized the fact that health is so much more than health care. And for CityHealth, we were able to squarely then position ourselves to say, Hey, listen, we have curated a finite set of tried-and-tested policy solutions that we know work, let us help you adopt these policies to protect your residents today and down the road.

Dr. Abdul El Sayed: And Chrissie, you work hand-in-glove with a lot of big city health leaders. That’s when we got to know each other when I was in Detroit. What are they telling you about the set of challenges that they face, what are the most acute, and then how are they thinking about the future trying to recover from what has been a really challenging 18 months and beyond?

Chrissie Juliano: Yeah. You know, I think first of all, everybody’s really tired. You know, they’ve been doing hard work for a long time, not just the past 18 months, but, you know, throughout their careers. I think everybody, as Katrina says, does recognize this moment. And, you know, public health really needs to seize the moment and use this to illustrate all of the things that those of us who worked in the field have known for years, right? Katrina said: health is more than health care. Well, health is the economy and education, right, and safe housing, and again, all the things that we talk about. And interestingly, even though, you know, our members who are health commissioners from the big cities have been so in response mode, these are actually the things that we’re talking about now and what we need to do moving forward, again, to seize that moment. So, you know, when vaccines were being rolled out, it was figuring out how to reach people, where, you know? As we think about whether or not kids are going to be able to get vaccinated, is that going to be at school, is that going to be in a clinic? But really relating this to, again, all the things that we need to be doing in routine times and in crises. So making sure that we have open communication and effective communication, and culturally competent communication, you know, in communities, and making sure that public health can partner with the private sector and having support and acknowledgment from elected officials. You know, just really across the gamut how we build support, not just for COVID response and recovery, but building safer, healthier communities on the other side.

Dr. Abdul El Sayed: Yeah. I want to think a bit about some of the state-city dynamics that I’m sure come up in both of your work. You know, having been a health director in a large urban community in a state that specifically targeted our city, largely as, and because of, an undercurrent implicitly and explicitly, of rank racism—how has that dynamic shaped public health in cities, the role of systemic structural racism that has both robbed folks and leaders of basic resources, but then also created an environment where cities are held up and blamed for their own marginalization? How does that play out in the context of the pandemic, and do you feel like this moment has an opportunity to change that?

Chrissie Juliano: So, you know, I think we do have an opportunity. I think in some ways, everybody said the same thing, right? COVID has laid bare these structural issues that we all have been trying to piecemeal address for years. I think it’s given sort of an opportunity to leaders across the country, I mean, even myself as a white woman, right? Like people who maybe were less comfortable talking about all of these things, now we have to. So it’s really, I think, upped the ante a little bit. And I think also empowered health leaders to talk about this. And again, not that, not that big city health commissioner’s, you know, aren’t strong personalities with great communication skills, but it’s just become a, we have to talk about this. And for those folks who’ve had, again, the support of elected local officials to be able to stand up to state government, that’s been really important. So, you know, we have a number of members in a certain state that I won’t necessarily say, whose governor has really, you know, been really strict about what the locals can do and can’t do. And in those cities where there’s been strong local leadership, again among the elected, they’ve moved forward with keeping mask mandates in place. And if they get sued, they get sued. But they’re going to stand up for what they believe in.

Katrina Forrest: I think the sort of the undercurrent to your question is also: how do we go about solving racism, right? Which is the question of a lifetime. I want to say I think first and foremost, people of color in this country cannot both bear the weight of the nation’s oppression and the burden of solving it alone. I think, it is going to take a multidisciplinary cross-sector approach. We’re going to have to bring some interesting folks to the table to try to come up with some solutions. But I think from a public health standpoint, and Chrissie just spoke to this some, I think it really does start with naming, understanding, disrupting, and ultimately dismantling racism. I think public health leaders have been doing this, but as Chrissie mentioned, they can no longer, we can no longer ignore it. It can’t just be the elephant in the room now. It’s out there and so now we have to focus on it. I think it starts with setting an equity-focused agenda. I think committing to some ongoing cultural competence. I think where there are knowledge gaps that exist on the impact of racism specifically, public health has to fill them. And I think we also have to have public health be more engaged in advocacy for federal, state and local policy changes to address some of these issues.

Chrissie Juliano: And just to that point that Katrina made, one of the things, one of the projects we’re launching at the Big Cities Health Coalition with some partners is to think about, OK, we’ve all said racism is a public health crisis, now what? Actually saying it is important, but we need to move to action. And so we’re starting to think about how you support folks on the ground and those public health leaders who really do want to do the right thing and make the right decisions, but really need some help figuring out what that means and what that looks like in their local community.

Dr. Abdul El Sayed, narrating: We’ll be back with more of my conversation with Katrina Forrest and Chrissie Juliano after this break.

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Dr. Abdul El Sayed, narrating: We’re back with more of my conversation with Katrina Forrest and Chrissie Juliano.

Dr. Abdul El Sayed: You know, it’s been hard to watch because, you know, on the one hand, we know that so much of the disinvestment in cities and their well-being, whether it’s directly disinvestment in health departments or it’s disinvestment in everything from housing to economic opportunities or overinvestment in policing, is founded in a particular racism that tends to be weaponized at the state level against cities. And then now that health commissioners and public health have stood up and done the hard things in the cut around protecting cities, we’re watching as the same state officials are trying to take away their rights to do it. So I think about, you know, in Michigan, where the state legislature is trying to amend the public health code that was passed back in 1978 to take away the powers of local public health officers, and you’re seeing similar dynamics across the country. What’s clear is that this pandemic has deeply politicized public health. Not that public health wasn’t political to begin with, but it has certainly drawn a very clear set of lines around the politics of public health. Meanwhile, we’re watching as cities, because of the willingness to embrace things like vaccinations and masking, are suffering substantially lower rates of COVID-19 than rural counterparts. How has this moment changed the politics of being a public health official? How has it forced public health folks to sort of wade into political spaces in ways that maybe in the past they might not have?

Chrissie Juliano: You know, I think Abdul, you said it. It’s forced them to be in a space that maybe they haven’t previously wanted to be in or needed to be in. Recognizing public health has always been political, I think it’s disappointing, to say the least, that it’s now partisan, right? And there’s a difference there. And that’s the real challenge, I think, when you are, say, a big city health official when it’s just your job to keep people healthy and safe and now you’re in the middle of a culture war, right? So, you know, we talk about, and you know this, following the science and the data and using those tools to help make hard decisions and that’s the job of the health official. And then where the rest of the local government needs to come in, is to support that and understand that people aren’t asking you to stay home because they’re on one side of the political spectrum or the other, it’s because they want to protect people. And it really is that simple.

Katrina Forrest: And I think that pick up on that thread to Chrissie’s point, what we have seen are local officials supporting that. I will say there was some polling work done, and as this pandemic was rolling out, mayors and city council members were some of the most trusted voices on public health issues. Folks were looking to them. And so to Chrissie’s point, I think they have to be there to support their health officials and make sure that they are disseminating the right information.

Dr. Abdul El Sayed: Yeah, what’s fascinating and is emerging from both of the excellent points that you guys made is that, it’s not quite that public health has waded into politics, it’s that politics has thrown itself into public health. One of the political bounds is whether or not you believe in science as a way to arbitrate the truth. The very act of trying to leverage science becomes a political act, and that doesn’t bode well for any of our futures, but in particular, public health. The other thing I worry about is that because public health, as a function of the pandemic, has become so politicized, I worry about whether or not we might see politicians starting to roll back a lot of the things that we had taken for granted in the past. We talked about it in the context of state government, but even local city leaders starting to dip their fingers in things that may not actually be, may not actually redound down to the well-being of the public. What is the risk of the politicization of public health at the city level, and how do we prevent that from happening?

Chrissie Juliano: I mean, I think the risks are similar at the city level, or the county level, than at the state level, just because, you know, it’s a different level of government, doesn’t build in other protections. I do think, to clearly a smaller extent than the national dynamic, there were cities, are cities, who had elected officials who didn’t listen to the science and the data and made decisions based on, you know, the fact that they were the mayor and they were going to make a decision. Now that cuts both ways. And I don’t think we yet can have a good answer to this question, I think. Many of us talk about this a lot. You know, we talk about independent local boards of health, you know? But guess what? Health Commissioners who report to those, have gotten fired, too. Right? So I will say I don’t yet have the solution. You know, if somebody could come up with that, that’d be great. But I think we just need to figure out how we all work better within the system in which we live, because it’s not like the system is going to change anytime soon.

Katrina Forrest: I think the greatest risks are inaction or bad action. So if we are starting to politicize public health and it is filtering down to local governments, they’re either not going to do anything at all or they’re going to start to make choices that have long-term unintended consequences that are going to put us in a worse off position. And so I think those are the greatest risks, of things getting deeply politicized at the local level, especially. Especially in light of the fact, as I mentioned, we are talking about leaders that are trusted, throughout this entire pandemic this is who the public has looked to, this is who they have believe. And if they’re not able to believe them, I’m deeply concerned about what that means for our future.

Chrissie Juliano: I mean, the flip side of that is if they do believe them and they are giving the wrong information, now you have your trusted leaders doing that, right. And it’s this need for balance that I think frankly, as Americans, we’re not good at, right? We can never see the middle ground. I spent all of 2020 saying that we needed strong federal leadership, and my husband said to me, You know you’ve been talking about local independence for like years, as long as I’ve known you. And it’s true. But you know, you need this balance. And there are times where sometimes the locals need the heavy hand, and sometimes other levels of government do. We’re just not really good at mediating that, I think.

Dr. Abdul El Sayed: What you’ve both spoken to is the need for checks and balances, right? The ability to have a system that that can check itself. And the ultimate check on power in democratic society ought to be the people. And the thing I do want listeners to come away with is the recognition that you have a voice. If you believe that science and public health are political values unto themselves, that we should invest in these things and that we should empower them and we should listen to them, then raising your voice matters, because we sure as hell know they’re going to be a lot of people on the other side raising their voices. We see it every day. And the frustrating piece is that folks who believe that the idea that we should listen to science or promote and invest in public health should be a foregone conclusion, were a lot quieter. And I think it demands folks being willing to stand up and support their public health officials and support electeds who invest in and believe in science in public health. The last point I just want to leave you with, or last question I want to ask is: what have we learned in this moment about where public health ought to go? I think for a lot of us, we had opinions—those of us who’ve been involved in public health hald opinions before the pandemic about what we needed. And you know, Chrissie, you just shared a, you know, very important one. What has this moment taught us about both what’s at stake, and about where we need to go from here to be able to continue to promote and invest in the well-being of folks living in cities across this country?

Chrissie Juliano: You know, I think one of the takeaways for me is, we’ve always talked about prevention as being at the core of public health, and that’s unfortunately a really hard concept. I think today what we’re seeing is, you know, had we prevented the spread of COVID with commonsense public health—things like masks—if we had prevented underlying conditions like obesity and diabetes, if we had prevented, you know, income inequality—OK, that’s a big one—but if we had done more to address these structural things that we’ve talked about, we would have been in a very different position. You know, the fact that the United States of America has lost 700,000 people to a pandemic is insane. And so we just, we need to think more about not just preventing disease and preventing the next pandemic, but preventing the conditions that get us here in this moment.

Katrina Forrest: And just to pick up on that, I hope what we have learned is we have to invest in public health and public health infrastructure. I think—I hope—that we have learned that equity should not just be some rote talking point, but that we are actually taking steps to operationalize that. And I hope that we have learned the importance of policy. And particularly as Chrissie was getting at, upstream policy. How do we prevent the conditions from even starting before we’re down to the downstream effects of those things?

Dr. Abdul El Sayed: I deeply appreciate you all joining and sharing some perspective on the way we think about cities and health. You’ve heard from Chrissie Juliano, who’s the Executive Director of the Big Cities Health Coalition, and Katrina Forrest, who’s the co-Executive Director of CityHealth. And we really appreciate your time and your leadership, and really appreciate you sharing some thoughts today.

Chrissie Juliano: Thank you.

Katrina Forrest: Thank you. It’s great to be here.

Dr. Abdul El Sayed: As usual, here’s what I’m watching right now. Let’s start with some good news: COVID-19 cases continue to trend downward, as we hurtle into the fall. The open question is whether cases will continue to decline, or if cases will plateau and, God forbid, climb. After all, the high transmissibility of the virus suggests that it could stick around quite a while. All of this has prompted a growing concern over what more we can do to keep pushing cases downward. More people could get vaccinated, of course. On that front. Pfizer’s application for emergency use authorization for vaccines for kids aged 5 to 11 is promising. And then there’s masking. Increasingly, experts are starting to think a little bit more about what kind of masks we should be wearing. Perhaps we should be wearing less penetrable masks, given the fact that the virus’s main direction of evolution is to become more transmissible by air. We’re well beyond the early days of this pandemic, when there wasn’t enough PPE to go around, and yet our advice about masking hasn’t really changed. That is, until the CDC upgraded its guidance in September to say that the public could wear N95 or similar masks, like KN95 or KF94s—my mask of choice. Maybe it’s time to trade that fashion mask for something a bit more protective. And don’t get me wrong, I’m not saying that we’ll be wearing masks forever. I’m just saying that we should be wearing better masks when we do. That said, I’m pretty confident that this virus will continue to ebb over time. That’s because more people are now immune, whether because they did the right thing and got vaccinated, or did the wrong thing and got infected. Though natural immunity is more specific to a given strain and less durable, it does help increase our collective immunity driving cases downward.

In other news, last week, Facebook whistleblower Francis Haugen testified before Congress:

[clip of Francis Haugen] Left alone, Facebook will continue to make choices that go against the common good.

[news clip] Instagram has put on hold plans for a version of its app meant for kids under age 13. The company is facing new scrutiny after a report revealed Instagram can be toxic for teenagers.

Dr. Abdul El Sayed: And here’s the deal: Instagram is a public health hazard for kids. And it’s not like we just figured that out. Facebook has known about it for a long time. Their response? To try and create a version for even younger kids. The best analogy here is to cigarettes. For decades, cigarette companies knowingly marketed and sold cigarettes to kids for nothing but their bottom line. And guess what we did to cigarette companies? We regulated the hell out of them. Facebook needs the same treatment.

Let’s end on another positive note. This was WHO Director General Tedros Ghebreyesus.

[clip of WHO DG Tedros Ghebreyesus] I started my career as a malaria researcher, and I longed for the day that we would have an effective vaccine against this ancient and terrible disease. And today is that day. An historic day.

Dr. Abdul El Sayed: Malaria is one of the worst killers in human history. It kills hundreds of thousands of people, a disproportionate number of them kids, every single year. This vaccine could save millions of lives, and that? That is a big deal.

That’s all for today. And don’t forget, we’re doing a live show at the American Public Health Association annual meeting in Denver on October 24th. So if you’re going to APHA, make sure you plan to join us at 6 o’clock on Sunday. On your way out, do me a favor and go to your podcast app and rate, and review the show. It does go a long way. And if you’d like, I hope that you’ll check out our Crooked Media store and pick up some merch. We’ve got our new logo tees and mugs, our Safe and Effective shirts, and our Science Always Wins shirts and dad caps.

Dr. Abdul El Sayed: America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producer is Olivia Martinez. Veronica Simonetti mixes and masters the show. Production support from Lyra Smith and Ari Schwartz, and Tara Terpstra—whose birthday it is today! Happy birthday, Tara. The theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Sarah Geismer, Sandy Girard and me: Dr. Abdul El-Sayed, your host. Thanks for listening.