Fighting NYC’s Ongoing Public Health Crisis — Racism

JOEL BERVELL: My guest today on The Dose is Dr. Michelle Morse. She’s the first person ever to serve as chief medical officer for the City of New York’s Health and Mental Hygiene Department. There, her primary role is addressing gaps between public health and the health care sector. In addition to being chief medical officer, Dr. Morse is also the deputy commissioner of the city’s Center for Health Equity and Community Wellness. She focuses on everything from community engagement to Medicaid policy to strengthening networks of federally qualified health centers. Dr. Morse oversees the department’s work to understand health inequities and end disparities relating to premature mortality, racial inequity, chronic disease, and so much more.

Before I say any more about her work and accomplishments, let me just say first, Dr. Morse is one of the leading thinkers and doers in the health equity space. Her wide-ranging accomplishments span on-the-ground clinical work in Haiti, time spent policymaking on Capitol Hill, and as a physician advocate and activist. She’s an internist trained at the University of Pennsylvania Medical School and holds a master’s in public health from Harvard. And she’s an assistant professor at Harvard Medical School, Brigham and Women’s Hospital. For me, Dr. Morse is a role model and I’m lucky enough to call her a friend and a fellow Afrobeats lover.

So, thank you so much for joining me on this conversation, Dr. Morse.

MICHELLE MORSE: Thank you so much for having me, Joel. It’s really an honor to get to be in conversation with you today.

JOEL BERVELL: So I just want to jump straight into the questions and ask: You’re New York City’s first ever chief medical officer. It was a newly created post in 2021 during the COVID pandemic, and I know that the city also has a health commissioner, so I’m hoping you can explain for our listeners the difference in your roles and how you came into the role as well.

MICHELLE MORSE: Thank you so much for that question. Yes, I mean, I will say it’s so fascinating to me that there hadn’t been a chief medical officer role in New York City in the past. And at the same time, what I would say is, the health department in New York City has dealt with so many health crises over the years so there have been ways, of course, to make sure the work gets done. But I do believe that part of the reason and vision for this role and the creation of it was the depth of challenges that New York City faced during the pandemic. Certainly being one of the first epicenters for the pandemic in the United States was part of it. But then what also was very, very clear was that we needed stronger connections between the health department and the health care providers across the city, both in terms of understanding health equity, where to focus resources, coordination both for testing as well as for vaccination and other prevention efforts.

And so the case I think was clearer than ever that there was a need to have even more capacity for the connection between health care and public health. And I will say one of the most exciting initiatives that I got to be involved in was one that really brought together the health care organizations, specifically the safety-net organizations across New York City, to really help them understand what we were seeing coming down the pipeline from the public health perspective and help them to prepare and get ready for the waves of challenges that were to come. It’s really extra capacity to connect with, coordinate with, and frankly also to push health care organizations to focus on health equity, to focus on place-based initiatives, and to focus on the ways in which our health care system’s fragmentation can be overcome with convening and coordination.

JOEL BERVELL: And so while the position you’re in is new, some of the challenges, like you mentioned, that were highlighted during the COVID pandemic, are pretty old. Anyone stepping into this job is inheriting a lot, especially in New York where it’s not a blank slate. There’s a lot of history, there’s built systems in place, and there’s structural race and class issues throughout the city. What was your top priority for when you began? I mean, you were instrumental in having racism declared a public health crisis by the New York City Board of Public Health in 2021. And I assume it just wasn’t about COVID, but what were you top priorities?

MICHELLE MORSE: It’s a great question. There’s no time like a time of crisis to really build alignment and to build analysis. I would also say in addition to the COVID crisis, of course, we were also dealing with a racial justice crisis, and the murder of George Floyd truly transformed the conversation. The activists and organizers that helped to lead the movement that followed were incredibly important in, I think, creating a new kind of conversation about racial justice and how every single sector in society, including government, including public health, needed to reevaluate its role. So that was a huge priority coming in.

I was also involved in doing an analysis looking at declarations of racism as a public health crisis across the country. And of course, there was an exponential increase in those declarations in the month and year following the murder of George Floyd. So I was very honored to get to be involved in developing that to, I would say memorialize in some ways, the outpouring of both outrage and action to try to change the patterns of racial health inequities specifically. And as you described, premature mortality — so this is death under the age of 65 years — is one of those things that has some of the most dramatic racial health inequities no matter where you look, but particularly in New York City. And so Black New Yorkers had the highest rates of premature mortality before COVID, and that continued after COVID, unfortunately.

Another area of priority was really looking at policy. So how do we use policy to advance racial justice and public health practices to end racial inequities? And so there’s been a lot of work happening in New York State around Medicaid and advancing the flexibilities for Medicaid to take care of social issues in addition to health issues. And so that work has also been a priority that my team and the health department have been working very heavily on.

And then we also were working on areas of institutional accountability. How can we advance institutional accountability when it comes to health equity and antiracism in public health? One of the things that we prioritized in that realm was the Coalition to End Racism in Clinical Algorithms. That’s a coalition that we launched in the fall of 2021, again, as another way to bring health care organizations to the table who were facing the same challenge of algorithms that use race in a way that is inequitable and in a way that unfortunately solidified racial inequities instead of trying to fix them and end them. And so that’s a shared problem, right? Even though our health care system is fragmented, that’s the problem that all the institutions in New York City were facing and needed health systems and operational fixes to address. And so we thought, well, there’s a great way to both advance and accelerate those institutional changes as well as ensure that there is learning and collaboration across institutions to make the change even more efficient and impactful than if each institution did it by themselves.

JOEL BERVELL: Absolutely. I’m so happy that you started off, that kind of answered the question, by focusing on George Floyd. I think so many people, that was their first introduction, especially people that were not Black, that was their first introduction to understanding how much these kind of disparities impact people not just in police brutality, but in health care and all these other spaces. And it really opened up the conversation.

I remember I was going to my second year of medical school when all those conversations are happening. It’s really what motivated me to start using my platform to start talking more about it. I think it really opened up conversations for people to feel willing to be able to take this next step. And what you’re talking about a lot of this reimagining of health care, I feel like has accelerated so much in the past couple of years. And of course this work takes more than just imagination. It takes actual on-the-ground work. I’m curious: What would you say are some of the near-term changes that you see being sent into motion? You’ve mentioned a lot of larger issues that your office is going after. What are some of the granular, step-by-step incremental changes that are happening?

MICHELLE MORSE: There’s a lot happening right now for a number of reasons. I think one of the areas that we have been looking at very closely and working on is the end of the public health emergency of course and what that means for Medicaid redeterminations. And so instead of folks who were enrolled in Medicaid just kind of continuing to have access to those benefits, we’re going back now to the phase in which each year the eligibility for Medicaid has to be reassessed. Some people no longer meet the eligibility criteria and will be taken off of Medicaid benefits and disenrolled from the program.

I would say what is challenging is, number one, that it’s going to be very difficult to make sure that we have up-to-date information about where current beneficiaries are living and what their phone numbers are because this has been a time of a lot of transition for many people and families. But it’s also happening at a time when vaccines and treatment for COVID are being commercialized. That means that for those who are uninsured or underinsured, they could face some pretty significant costs to pay for getting their COVID vaccine or to pay for getting treatment for COVID.

And I would say that the incremental work that’s happening is a lot of planning and conversation with various communities. One of the gifts of COVID was that we were able to launch a program called the Public Health Corps, which funds community-based organizations all across New York City to essentially be able to do the outreach and engagement and street-level conversations, including literally walking hand-in-hand with someone to take them to the place where they can get their COVID vaccine. But the beauty of Public Health Corps is that it uses a community health worker program that is really based in the community. So whether you are connected to a primary care doctor or not, it didn’t matter. This is massive community engagement effort, and it was done with over 100 community-based organizations, many of which were doing this outreach in over 30 different languages.

JOEL BERVELL: Wow.

MICHELLE MORSE: And so that infrastructure and connection is one of the things that we’ll build on when we’re continuing to do the outreach work and the connection work that we have been doing.

JOEL BERVELL: I’m so happy you talked about these disparities and getting access to things, but also the financial disparities that affect people too. I think a lot about a study that you were a part of that looked at what would’ve happened to COVID transmission if the racial wealth gap had been eliminated prior to the COVID pandemic. Could you talk a little bit about that for listeners? Because I think it’s so powerful what you guys found.

MICHELLE MORSE: It’s interesting because in some ways what we were doing with Public Health Core, focusing the investments in community-based organizations that were in the neighborhoods that had the most and unfair impact from COVID, in some ways is kind of what we found in this modeling study. What we attempted to do was we actually compared two locales. So one extremely inequitable, and that was the state of Louisiana, actually based on the [U.S. Census Bureau’s] Gini Index which looks at inequity, economic inequity. Specifically, Louisiana has a very, very high level of economic inequity. And we compared it to South Korea, which interestingly has a very equitable rating on the Gini Index.

So we compared the two and what COVID transmission looked like in those two different areas. We modeled what would’ve happened if there was no racial wealth gap. And for those who are not aware, the racial wealth gap is this: So wealth is very different than income. Wealth is assets minus debt, whereas income is the annual salary that a person or a family might bring in. Wealth of course reflects more of the generational dynamics of equity and marginalization or the lack or presence thereof. And so that’s why wealth is a very interesting indicator for us to look at when we’re looking at health outcomes.

When you look at wealth by race in the United States, there are profound inequities. So one study looked at Boston and found that the average white household had about $247,000 in wealth, whereas the average Black household had about $8 in wealth. That was a study by the Federal Reserve Bank in Boston in partnership with Professors Sandy Darity, Darrick Hamilton, and many others. And that massive gap, of course, tracks with health outcomes. And so what if that gap didn’t exist? What if there was not this massive racial gap in wealth?

And when we looked at that in Louisiana, what we found was that transmission of COVID would’ve been somewhere between 30 and 68 percent lower for the whole community. So it wouldn’t have only benefited Black people who had the lowest wealth, it would’ve benefited everybody. In some ways, that’s on the level of the intervention impact of a vaccine, right? 30 to 68 percent. The reason for that is because with wealth, you can of course live in less crowded housing. You can have a job that doesn’t expose you as much as an essential worker to COVID. You can buy PPE and hand sanitizer. So there are a number of ways that wealth is protective in general, but specifically in COVID, it is clearly very protective.

And so now I’m very excited that we are actually, in the New York City Health Department, we recently published a white paper looking at the racial wealth gap and health inequities and how the two connect. We’re partnering with several partners, including CUNY [the City University of New York], to do a survey in New York City assessing wealth by race across the city as a way for us to again map and track how that wealth equity or inequity tracks with health outcomes.

JOEL BERVELL: I love that. You predicted some of the questions I was going to ask about the policies that you’re working on. I’m so glad you were able to talk about that white paper that just recently came out last month or two months ago I guess now in February, at the end of February. I read through it. It was incredible work. So I mean, obviously thank you so much for everything that you’re doing.

I want to ask about some of the policy issues and initiatives that you have going on in your office as well. You’ve mentioned some already, which I love. For example, the coalition to end racism, clinical algorithms, something that I’ve also been very committed to, understanding how we even got here. And so for some of the listeners who maybe don’t understand what some of those algorithms mean, and I know you had recent study that shows most people don’t understand what that looks like, could you help guide us through what it looks like on the ground, in the hospitals? What work are you doing through that aspect?

MICHELLE MORSE: This is another one where I have to just shout out and appreciate all of the trainees, medical students, residents, et cetera. That’s how I first started learning more about this issue actually back in 2016. At the time I was involved in cochairing the health equity committee for the Department of Medicine at Brigham and Women’s, and the Racial Justice Coalition at Harvard Medical School was working on this issue. They were, of course, being taught about estimated glomerular filtration rate, this is how we calculate kidney function. And they were being taught that they’re supposed to multiply by a certain number if the patient is Black. So they were being asked — and again, this is a routine and previously standard part of clinical practice — that clinicians were supposed to dichotomize the world of their patients into Black and non-Black, which is absolutely absurd and impossible. Race, as we know and as we often state, is a social construct; it’s not a biological construct.

And so there isn’t really a biological issue, but there are, of course, physiological impacts of the experience of racism over generations and on one’s health. Now, that’s an area that I think we can get into in this conversation as well. But what was also clear was that when you look back at how that original equation was established in 1999, it actually only had just under 200 “Black” patients in the study. And Black race was assigned by the study staff, it wasn’t self-identified race. Interestingly, over time, that equation, of course, is one of the many contributors that has led to Black people having a delayed rate of referral to kidney doctors and kidney specialists when they have the development of kidney disease. It’s also been a factor that has delayed referral for kidney transplant.

But there are lots of things that are actually the true causes of racial differences in health outcomes that we can fix and have massive impact on.

So the coalition is really meant to help providers and health systems understand that and change their practices, measure and evaluate how racial inequities and health outcomes change as they change their practices around use of race and misuse of race in the algorithms, and then actually do a patient engagement plan to make sure that patients, Black patients, for example, with kidney disease, understand that actually they need to have a new calculation done to make sure that they actually get the access to the specialty care and to transplantation evaluation and transplant in a way that they deserve. And we have to be able to talk to patients about these algorithms as well.

JOEL BERVELL: That’s so powerful. This topic has actually come up multiple times in this podcast miniseries. I had on Naomi Nkinsi, who was instrumental in changing eGFR at the University of Washington. Do you think there has been a change in practice or thinking that’s significant in regards to physicians and also, as you mentioned, patients having to know about these changes?

MICHELLE MORSE: It’s a really good question. If you look at surveys of physicians about asking them, do they think that racism amongst physicians or consciousness about health equity amongst physicians is good or real? And it’s really not. A lot of the surveys out there have shown that physicians systematically underestimate and underappreciate how much racism is shaping health outcomes. So that’s a huge challenge.

Now, has there been a shift? I will tell you I have been encouraged to see some of the professional societies come out with either task forces or new guidelines, really setting a new standard, a new gold standard for how race and ethnicity could or could not be used or should not be used in clinical algorithms. So the American Society of Nephrology, for example, in partnership with the National Kidney Foundation, they have done some really important work in this realm and have supported a new algorithm that doesn’t use race, Black race specifically, and is just as accurate. So have there been some changes? I would say yes, but we have far more to go. And again, I think the more that these kinds of changes can happen at a systems level — rather than clinic by clinic, hospital by hospital, health system by health system — the more powerful and impactful they will be.

JOEL BERVELL: Absolutely. I’d like to shift gears a little bit to talk about the new report that you mentioned about analyzing the racial wealth gap implications of health equity. I guess I’m curious: When it comes to structural programs like Medicaid and Medicare, how do we begin to embed equity into these historic safety -net programs?

MICHELLE MORSE: Such a good question. It’s interesting also because I think the standard has often been that, well, if you have work that you’re doing or planning work around Medicaid, then that it’s automatically health equity, right? Because it’s an entitlement program that is specifically for people with low income, people who are living in poverty, people who are from marginalized groups. And there’s a little bit of truth to that, but it’s not the full story, right? There are ways in which programs like Medicaid can continue to even increase and deepen accountability for health equity and outcomes in health equity. I think that that’s the kind of work that’s already starting to happen. I know that CMS [the Centers for Medicare and Medicaid Services] has been thinking a lot about that. I also know HHS [the U.S. Department of Health and Human Services], for example, has issued a set of rules specifically around civil rights within the Affordable Care Act and the ACA that actually I think strengthens the guidance and the floor for what kinds of health equity changes need to happen at a policy and systems level, including around clinical algorithms, which is very exciting.

But I would say that, yeah, there’s tremendous opportunity in using benefits like Medicaid to advance health equity. In fact, I think some of the other things that we’re starting to see from Medicaid policy and many other policies is we’re starting to see the ability, again, to cover the cost of things like transportation, housing, healthy food, et cetera, because we know, of course, that these are some of the social needs and social conditions that allow for improved health outcomes, right? We know that health care alone is not going to get us to health equity, and we also can’t have health equity with social injustice prevailing, right?

We’ve been doing some work within the New York City Health Department on using and learning about public health critical race praxis, which is the methodology and an approach to really make sure that you’re centering the margins, as we know is so critical, and building interventions that are race-conscious, right? If we know that the highest rate of premature mortality is amongst Black New Yorkers, for all the cumulative historic and current marginalization and wealth and other inequity reasons we know, well then, we need to focus resources in that community in ways that address the need specifically for Black New Yorkers.

JOEL BERVELL: Absolutely. I feel like one of the communities that often gets overlooked, especially in the city of New York, is those that are undocumented. I’m curious if you can tell us a little about what state lawmakers in New York are doing right now to make sure that health insurance coverage is accessible for undocumented New Yorkers of all ages, who are often, like you’re saying, found at these margins and not centered in conversations.

MICHELLE MORSE: Absolutely. I think it’s a central health equity issue for our time, and in fact is at crisis levels. New York City as a city has received over 55,000 folks seeking asylum over the past year or so. And as was described, there are a number of serious and important health needs that we consider to be human rights for asylum seekers. One of the ways that that work is rolling out and is happening, our partners at Health + Hospitals, which is the public hospital system, has a program called NYC Cares, which is a program for folks who are undocumented to make sure that they have consistent primary care and all other health care needs as well.

And then the state right now is considering and trying to think about its approach to following suit to California, which recently passed a waiver. This is a waiver that essentially allows for undocumented folks to get access to Medicaid and to ensure that they actually have access to health insurance no matter what their documentation status is. We see that as something that of course is a huge priority. And we know that that’s still only part of the battle, right? That’s kind of just one piece of the puzzle, because there’s also, of course, the right to food, to housing, to all of these other social needs in addition to health insurance and access to health care.

JOEL BERVELL: Mm-hmm. And as we wrap up, I want to look beyond New York City to kind of your approach. You’ve had so much grassroots experience: you cofounded a global NGO, you’ve worked in Haiti as a physician, you worked at Act Up Philadelphia, you have policy experience at the Ways and Means committee, and now you’re truly on the inside. And given your broad range of experiences and insights, I’m curious: What have you found moves the needle the most, and what are your strategies for getting things done?

MICHELLE MORSE: Yeah, what works? What works? That is the question, isn’t it? I mean, I will say I’m continuing to learn more and more about the inside–outside game for sure, and strategies working both inside and outside institutions to make progress, to transform systems, to transform society. I will say that one of my most powerful experiences was as a medical student involved in Act Up Philadelphia to actually go to and attend the presidential nomination and campaign and being involved in ensuring that folks with HIV/AIDS had access to the full entire slate of health and social needs, including free access to HIV treatment, and in fact, cash transfers, essentially, to ensure that their social and health needs were being met. It’s very, very powerful to see how that kind of organizing and direct-action work can translate into policy change.

My experience, of course, being involved in supporting the passing of the resolution declaring racism a public health crisis here in New York City with other colleagues, that’s possible from the inside work as well, right? Being able to have something on the New York City books forever, essentially. So there are lots of different fruits from the inside work and outside work. And I would say no one is going to get us to a new transformed, socially equitable, racially just society. It’s going to be, more than anything else, I would say, Joel, it’s the coordination and relationship-building across sectors, social movements. It’s taking that intersectional approach that I think allows us to build power in ways that could really change the game. I would say, more than anything else, is deepening those relationships across sectors and working in coordination for shared goals that works.

JOEL BERVELL: Well, like I said at the beginning, and I think listeners will now know as well, you truly are one of the leading thinkers and doers in the health equity space. I’m so fortunate to have you as my role model. You inspire me every single day, so thank you so much for your time. Thank you for speaking with us and sharing all your insights.

MICHELLE MORSE: Thank you so much, Joel. That is beyond generous. You give me hope, and the whole entire next generation of health workers gives me a lot of hope that things can change. So it’s a real, real honor to be in conversation. And yeah, really looking forward to the next one.

JOEL BERVELL: Thank you. Take care.

This episode of The Dose was produced by Jody Becker, Mickey Capper, and Naomi Leibowitz. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. If you want to check us out online, visit thedose.show. There you’ll be able to learn more about today’s episode and explore other resources.

Thanks so much for joining me on this special season of The Dose, exploring health care equity. I really appreciated these conversations and I hope you enjoyed the episodes. We’re taking a break, but The Dose will be back this summer with a series focused on women’s health. I hope you’ll tune in.