Dave Chokshi: Lessons from the Front Lines of the Pandemic

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.‌

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University, and we’re trying to get closer to the truth about health and healthcare. Our guest today is Dr. Dave Chokshi, but first, we like to check in on current or hot topics in health and healthcare, and Harlan, you were not available last week, and Megan Ranney stepped into your enormous shoes. She did a great job.‌

Harlan Krumholz: You kicked me off the show. You pushed me off.‌

Howard Forman: We missed you an awful lot, but I really think it’s important for people to know that—‌

Harlan Krumholz: Just because you got someone more important who could step in.‌

Howard Forman: I think it’s really important for our listeners to understand that there are rare reasons why you might have to miss a segment, and I want to hear about the trip to China, because right now, at this particular time in history, I think this is an even more important trip that you made.‌

Harlan Krumholz: Yeah, I had a great trip. You know, the last two weeks I was in Europe. I was at cardiology meetings in France, and then I came home for only a day, and then, actually, there was another meeting in China. I rarely would put a back-to-back meetings like that, but they were both important, and I wanted to make sure that I had a chance to see people face to face. So I had a nice chance to get a little more of a global view of what people in healthcare and particularly in the cardiovascular community are thinking about what’s going on now. The trip to China was great. Of course, I have decades-long collaborations in China. I built up national research networks there, had worked with a lot of people, had a lot of—‌

Howard Forman: Our listeners should know, you’ve been honored with one of the highest non-Chinese-civilian honors, right? I forget the title of the—‌

Harlan Krumholz: The Friendship Award. The Friendship Award, yeah.‌

Howard Forman: You are nationally recognized there, and you really have invested so much time, and you’re learning Chinese or have learned Chinese.‌

Harlan Krumholz: I actually gave the beginning of my talk in Mandarin. They didn’t know that I had to practice it for like a month before I did it. It sounded good at the time. But you know what’s interesting to me as you go over there, gosh, there’s such a positive energy, and you don’t get a sense of oppressive government or the constraints. The people who I’m working with have found ways to manage within their system, and the young people, from the beginning of the time I went over to China, I’ve always been impressed. You get people together, the diligence, the enthusiasm, the dedication, the aspiration to do good is really strong. When you get down to people, you get away from the politics and you actually talk to people, the commonalities are so great and what people aspire to, a meaningful life, a career of contribution, a family and friends, they’re all the same things.‌

A lot of the messaging that I was giving there was to say we’ve got to continue to find ways to work together during this period, that there may be geopolitics around but when it comes to healthcare, there should be total alignment. And I talk about cooperation and coordination. How do we collaborate continually through this? I say we’re on Team Humanity when it comes to healthcare, and so we really shouldn’t be thinking about borders or countries, but we should be thinking about, how do we race as fast as we can to relieve suffering, to figure out some of these challenges ahead, which include implementation challenges? How are we going to use AI and so forth?‌

But over there, I see continued immense investments, continued efforts to build research infrastructure and to find ways for translation into the clinics and also work around infrastructure to improve the level within rural areas and for other populations within China. So there’s a great driving energy, and I feel, still, an optimism about their trajectory that on this side feels very different, you know, that there’s a sense of fear and shrinkage of our research footprints, of difficulty within research funding, a lot of squabbling around research priorities, politicization of our research environments. And again, it’s not that they don’t have politicization or they’ve got to be concerned about political and regulatory realities over there, but just, in the discussions I had, in the talks and so forth, they were on a different frequency than I feel that we have going on now. And I hope that we can take a breath and say that we really need to all be focused on some of these challenges that commonly face us around the world and we’ve got to be able to figure out.... Also, as editor of The Journal, I’ve been trying to position The Journal to say we’re an international journal. It’s not American journal. There aren’t international, national. Good science, wherever it comes from, should be able to fairly compete for space within The Journal. We should be promoting it widely, and we should be working on how it has impact globally. And so that message resonates with a lot of people, a lot of leaders over there.‌

And my final thing is, the most important thing I think to progress are friendships, and it’s really about continuing to see us not as tribes or different countries, but how we can connect individually and think about how we can make progress together. So anyway, it was a remarkable trip. I had a great time. I especially enjoyed talking to a lot of students and getting a sense of how they were thinking about their futures and what they’re trying to accomplish.‌

All right. Hey, let’s get to our guest today. Dave is amazing. Let’s go.‌

Howard Forman: Dr. Dave Chokshi is a primary care physician and the inaugural Sternberg Family Professor of Leadership at the City College of New York. He currently chairs the Common Health Coalition and co-chairs the Health and Political Economy Project. From 2020 to ’22, he serves as the commissioner of the New York City Department of Health and Mental Hygiene, where he led the city’s response to the COVID pandemic, overseeing the vaccination of over six million New Yorkers. Before that, he was the inaugural chief population health officer for New York City Health and Hospitals, the largest public healthcare system in the United States, and was a White House fellow at the U.S. Department of Veterans Affairs before that.‌

Dr. Chokshi received his BA in chemistry and public policy from Duke, where he graduated summa cum laude before earning two master’s degrees in global public health and comparative social policy from Oxford as a Rhodes Scholar. He then received his MD from the University of Pennsylvania with Alpha Omega Alpha distinction as a Paul and Daisy Soros fellow, before completing his—‌

Harlan Krumholz: Wait a minute, this guy is way too distinguished.‌

Howard Forman: I know, it’s overwhelming. ….before completing his internal medicine residency at the Brigham and Women’s Hospital. No, I first met him a little more than five years ago, and I—‌

Harlan Krumholz: Not only that, he’s a great guy. He’s—‌

Howard Forman: That’s the important part.‌

Harlan Krumholz: You have all these accolades, and he’s a great guy.‌

Howard Forman: He’s a great guy, and I will say this. I want to start off with this because I think it’ll lead into our conversation. To me, you are a perennial optimist. You’re not afraid to be critical of the systems we have, but you always have hope. Everything about you exudes hope about our healthcare system, about our political economy, about everything. So I want to start off, I think the two main things that I’m focused on are the enterprise at City College and the Common Health Coalition, so I thought maybe we’ll start with the Common Health Coalition and hear about how you are hopeful about the future of healthcare and what your role is in that now.‌

Dave Chokshi: Sure. Well, first, let me just say, I’m so excited to be with you, Howie and Harlan, two people whom I respect deeply and admire everything that you’ve done to make our health system better, so thank you for the warm introduction and welcoming me on today. Look, these are hard times to be optimistic in, right? Let’s have a bit of a reality check in terms of the headwinds that we’re facing on so many fronts in our health system, and like many others, I’m searching for the right ways to contribute to making things better for our family members, our loved ones, our patients, the people that we serve. And so let me tell you a little bit about the Common Health Coalition in that vein.‌

The coalition fundamentally is about strengthening partnership across healthcare and public health. Frankly, this is something that we should be doing already, right? Why when we have so many challenges in our health system would we work on them with one hand tied behind our backs? Which is how I think about it in terms of the silos that too often we’ve put up. And so there were a few people who got together, really in the wake of the COVID-19 pandemic, to say we saw how public health and healthcare working together, for example in New York City for the vaccination campaign that you mentioned, there’s no way we would have been able to vaccinate over six million New Yorkers if it weren’t hospitals and clinics and pharmacists and our public health department all collaborating toward that outcome. And fundamentally, the coalition is about trying to make that business as usual in our health system.‌

Harlan Krumholz: All right, you know Howie, he gives us softball questions. I’m going to give you now some fastballs, but it actually is something I really would appreciate your wisdom about. Sorry, Howie, I know, you sneak in the fastballs so they don’t feel like them when they come by. So we live in a moment where there are a lot of people who want to say that we made so many mistakes during the pandemic, and that we, many of us, should be apologizing for what we did. I’ve heard it from many different angles. My take is that we were working under conditions of uncertainty. That beginning of the pandemic, we were dealing with a highly pathogenic virus that by the way, did mutate and so did the hosts, and things evolved over time. But I’ve always said if what hit Wuhan and what hit northern Italy and what hit the East Coast of the U.S. had stayed at that level for a longer period of time, we would have lost tens of millions, if not more.‌

But I wonder, as you reflect back, because you were at the front lines, you were really leading what I think were a lot of innovative approaches to this. But when you look back, how do you think about this and how do you internalize the sort of criticism that’s coming the way of people who were in public health as, “Gosh, you guys really failed us”? That’s a persistent message that’s being promoted right now, and I think it undermines even people’s confidence in public health as a whole. Look, mistakes, no one’s perfect, things were done, but I’m interested in your reflection on this.‌

Dave Chokshi: You described it really well, Harlan, and both things can be true at once. On the one hand, mistakes were made. The way that early masking policy was described, the fact that in some places, schools were closed longer than they should have been. Certainly when you look at outcomes with respect to health equity, we could and should have done much better for certain people in communities who bore the brunt of the COVID-19 pandemic.‌

On the other hand, and this is very much borne from my direct experience, first working in the public hospital system during that devastating first wave here in New York City in March and April of 2020, and then having the privilege to serve as health commissioner, I can regale you with countless stories of heroism of my fellow healthcare workers and public health workers. We built a field hospital in a tennis stadium in a matter of days.‌

I remember walking through Bellevue Hospital, where I practice, and the waiting room of an endoscopy suite was transformed into a fully functioning ICU within a matter of hours. And we’ve already touched on the vaccination campaign, but the plain fact is that tens of thousands of New Yorkers are alive because of the scale of vaccination, the largest, most historic vaccination campaign in the history of our city.‌

So we do have to hold both of these things together in our minds at the same time, and I do worry that in the current chapter of the dialogue, we are at risk of throwing out the baby with the bathwater. Instead of having the reckoning of what we could and should have done better, where we need to turn the lessons learned into lessons mobilized, which is a big part of what we’re trying to do through this work of the Common Health Coalition, instead of having that conversation, we are relitigating aspects of pandemic response, which unequivocally were beneficial and saved lives.‌

And the last thing that I’ll say on this is something that I haven’t heard articulated too much in these conversations about pandemic revisionism, which is to have the self-awareness for us as survivors of the COVID-19 pandemic to realize that there are so many people, a million and a half Americans alone in our country, who don’t get to be a part of that conversation because they passed away, because they are no longer with us, and therefore, their perspective on what should have been done, what could have been done to protect them is not part of our dialogue. And so part of what I think we need to do to honor their memory is make sure that we’re representing those viewpoints.‌

Howard Forman: We had Rebekah Gee on a couple of weeks ago, and she is a transplanted Louisian, you are a born-and-bred Louisian. I don’t even know how to say the word, but whatever it is. But I’m wondering, it really does inform people’s views of the world, their experiences early on in life. And you were involved in Katrina relief efforts earlier. You grew up there. You have an understanding from your time in North Carolina as an undergrad. There’s a lot that informs you. Can you tell us how that ties into your unique connection between public health, healthcare, and the political economy?‌

Dave Chokshi: Sure. Well, look. First, Rebekah Gee is such a terrific leader. She served as secretary of the Louisiana Health Department, and actually my first experience in public health was working with the then secretary of the Louisiana Health Department, Fred Cerise, who’s now the CEO at Parkland Hospital, one of the most important mentors that I’ve ever had in my life. And it was during Katrina, and I saw, again as we just talked about with the pandemic, some of the very real devastation to human lives alongside extraordinary opportunities to do good.‌

I would say my most abiding lesson from seeing the horrific devastation of Katrina on the place where I was born and raised, where I grew up, is this—people who are already living on the margins are the most likely to be further marginalized during a time of crisis. And what I’ve tried to carry forward from that is that for all that DEI has become a four-letter word these days, equity at the end of the day is about ensuring that we prioritize people who are most likely to bear the worst of suffering, both in times of crisis but also for slower-moving disasters, whether it’s overdoses or chronic diseases. And so that’s something that I’ve tried to carry forward over the years, along with other lessons from being involved in emergency response during Superstorm Sandy to Ebola, and of course during the COVID-19 pandemic as well. It’s a big part of why I think we need to knit together these disparate elements of our health system so that we can operate as a more unified whole.‌

Harlan Krumholz: Dave, I wonder if you would just take a few minutes to talk a little bit more about your origin story, especially this piece about how you found yourself pretty rapidly in positions of leadership that had profound implications for the population. I think a lot of people who didn’t know you were like, “Wow, this guy’s pretty young. How did he end up in this position, and who is he?” And people listening here might want to understand the kind of serendipity and what unfolded that puts you in a position where at one of the nation’s most challenging moments, you’re in New York City leading a response that is highly consequential, highly politicized, extraordinarily contentious, and consequential, and how did you end up in that position?‌

Dave Chokshi: Well, it’s one of the hardest things I’ve ever done, maybe one of the hardest things I’ll ever do in my career, and you’re right to point to serendipity and just plain luck in terms of how that was all lined up. The short version of the story is that I’d been at the public hospital system, New York City Health and Hospitals, for about six years when that—‌

Harlan Krumholz: And just for people to understand, what is New York Health and Hospitals? Because not everyone will appreciate what that system, that humongous system, is.‌

Dave Chokshi: Yeah, thanks for the reminder. So it’s the public healthcare system of New York City. So places like Bellevue, which is the hospital where I see patients, but also King’s County Hospital, Elmhurst, Lincoln Hospital in the Bronx, the safety net for New Yorkers, including those who are uninsured, many who are on Medicaid. The system as a whole takes care of over a million New Yorkers each year, and I had risen through the ranks, for lack of a better way of describing it, over the six years that I was there. I used to say “with a team of zero,” but someone reminded me that I’m on my own team. So I started with a team of one and gradually took on some more responsibilities and primary care transformation and population health, until eventually I was asked to serve as the first chief population health officer for the system, and grew my team from seven—‌

Harlan Krumholz: And I’m just going to pause you one more second. What is a “population health officer”?‌

Dave Chokshi: Yeah, yeah. So population health is one of these terms that’s a little bit eye of the beholder. The way that we thought of it was population health is about a more proactive approach to avoidable human suffering, and so that means doing things to make prevention much more a reflex in terms of the care that we’re delivering to patients. Also looking after social needs. For example, if someone is homeless, taking care of patients differently because of that. And the common thread through all of it is trying to be less reactive, not waiting for patients to show up in duress in more advanced stages of their disease process, and try to move further upstream with respect to how we’re taking care of people.‌

So I’d been there for six years when that first wave hit and had actually been thinking about a transition at that point professionally for myself. Just to give you a sense of the texture of this, I actually announced that I was stepping down from my role in, for me at least, an emotional all-staff meeting in February of 2020. And literally two weeks later, it dawned on me and many other people that COVID-19 was something different, and so I called another all-staff meeting and said, “Just kidding, I’m sticking around, at least until we figure out how we’re going to get through this.”‌

And during that first wave, and there were so many people at Health and Hospitals and other places around New York City who just stepped up in many, many different ways, and so I tried to do my part. And I found, interestingly, that part of what I was called to do was to serve as almost an interpreter of sorts between people who were trying to translate the science, which was evolving very rapidly. You guys remember, in March of 2020, we were making rounds in the hospital and seeing that patients with COVID were suffering from clotting disorders and we didn’t know why. We didn’t know whether we should anticoagulate them or not, so just piecing together all of those scientific and clinical aspects, and then also thinking about what it meant for capacity with respect to our hospitals actually being able to shoulder the load of so many sick patients coming through our doors.‌

And so part of my role became essentially as an interpreter of all of those very rapidly moving parts into the policymaking apparatus, and so I spent a lot of time at Bellevue Hospital, at Elmhurst Hospital, but also at City Hall, and became a bit of a known quantity with the mayor and some of the top staff at City Hall, such that when there was the need for a health commissioner just a few months down the road in August of 2020, I was one of the people that they considered for that. So yeah, that’s the short version of the story.‌

Howard Forman: And they were lucky to get you. I would be remiss before we get to the end to not talk about your current role, and to point out a couple of things. One is that you could have gone, as many people in your position would go, into a well-paying private job. You could have gone to be a dean at any of the Ivy League schools in and around New York or at NYU. It’s just so many elite-type jobs you could have had, but you went to my alma mater where I went to college, where I have tremendous pride to this day, City College. You’re physically inside the building where I took many, many classes right now, the North Academic Center at City College on Convent Avenue. And you chose that, and you’re now running the Health and Opportunities Leadership Institute, which in my mind is something so essentially necessary in the City University system, not just City College. I want to hear your vision for what you could achieve in New York with such a center.‌

Dave Chokshi: Thanks for the opportunity, Howie, and I think the fact that you’re a City College alumnus is all we need to say about how distinguished this place is. But for those who aren’t as familiar with City College or the City University of New York, which is the system that the City College is a part of, it’s the public university system for the city, and so my students, our students, half of them are the first in their families to go to college. Eighty percent are students of color. This is a place that was founded in 1847 as a free academy, a place where people have taken seriously for almost two centuries now the transformative power of education to unlock opportunity for people and for society. And so I was really thrilled to have the opportunity to come here and start to build something, and I guess I’ll just connect it to some of the things that we were talking about in terms of what our health system needs.‌

If I had to distill it down to one data point, it would be this. The average American spends a single birthday in good health after the traditional retirement age of 65. Is there anything more American than that? We work our entire lives and then we only get to celebrate a single birthday in good health after the age of 65, whereas so many of our peer nations have what’s called a health span or health-adjusted life expectancy of 70 or even approaching 75 years. And so I think about this as the notion of lost. We like to jargonize things in health and medicine by talking about years of life lost, but really, this is about the lost birthdays of the people that we care about and love the most in our lives. And a big part of that has to do with all of the problems in our healthcare system, yes, but it’s far broader than that in terms of how we are structuring our society in a way that unleashes opportunity for everyone who wants to live a fulfilled life.‌

And so one of my hypotheses, or I guess the thesis of what we’re trying to build here, is that we need new leadership and we need a multigenerational movement to change the things that underlie that statistic, the single birthday in good health after 65. And so that’s really the motivation of trying to build a leadership institute at a place like CUNY where, too often, people who are from affected communities are shut out of opportunities in leadership when they should be the ones who are closest to the levers of power. And so this involves a few different things, but fundamentally, it’s about empowering students and particularly the students in a place like CUNY to take what is very inherent in terms of their passion to change our health system, and equipping them with the skills, the networks, the knowledge for them to be able to do so.‌

And I guess one thing I’ll just mention is that talking to both of you about this feels particularly apt because this is what both of you have dedicated so much of your careers to as well, is investing in human capital. When you light that spark, when you are able to shape the clay of a young person’s imagination, it’s an extraordinarily powerful tool to drive change in the world. And so yes, this is about students, and it is about a place like City College, but it’s also about the broader transformation in society that we need.‌

Howard Forman: You give me a lot of optimism, and I think we and they are so lucky to have you, so thank you.‌

Harlan Krumholz: What an amazing thing, Howie. You teach leadership, and one of your students goes back to your alma mater and sets up a center to help—‌

Howard Forman: He’s not my student; he’s just my friend.‌

Harlan Krumholz: In some sense, Howie, we’re all your students.‌

Dave Chokshi: Indeed, indeed. We have all been at the feet of Howie Forman and—‌

Harlan Krumholz: That’s exactly right.‌

Dave Chokshi: Yeah.‌

Harlan Krumholz: That’s exactly right. And Dave, what a pleasure. You and I have circled each other a lot, we have similar interests. I’m just so excited to have the chance to have you on the program to listen to you and look forward to doing anything I can do to support you and help you in your continued success. I think it’s so important.‌

Howard Forman: Thank you very much, Dave.‌

Harlan Krumholz: Thank you.‌

Dave Chokshi: Thanks to both of you.‌

Harlan Krumholz: Hey, that was great interview, Howie.‌

Howard Forman: Oh, I love him. He’s such a good guy.‌

Harlan Krumholz: Such a good guy. Such a good guy. All right, let’s get to one of my favorite parts, the Howie Forman part of the podcast. What do you got for us this week?‌

Howard Forman: Yeah, it’s not the first time I’ve talked about rubella or congenital rubella syndrome. As some of our listeners know, my mother was infected with rubella as a teacher in early 1958, and my then in utero sister was born with congenital deafness as the singular result of her congenital rubella syndrome. My sister is a highly successful professional, a mother, a grandmother, a wife, and much more. But many other children are born with much worse symptoms of congenital rubella syndrome. They’re not as lucky, some with heart defects, cognitive effects, not to mention that those that aren’t born, those that are stillborn, and by the way, deafness is still an impediment to certain enjoyments.‌

Rubella vaccination has been an enormously successful program, essentially eradicating bad rubella outcomes, principally because our vaccination levels in the United States are so high and rubella as opposed to measles has a somewhat lower herd immunity level. So whereas you need immunity in the 92 to 94% and above level of a population to stop the spread of measles, you only need about 83 to 85% to stop rubella. And so while we do have regions in our country that are well below those levels, they’re generally few in number, far between, and we’ve otherwise been lucky.‌

But today, I want to focus on a paper out of the CDC brought to us from a group of vaccine experts at global health and vaccine organizations, and what they showed me, what they taught me was that there are 19 lower- and middle-income countries in the world that still do not have a rubella vaccination program in place. And I could try to explain why this is the case but I don’t think I could do it justice, but suffice it to say these countries are still struggling to get high measles vaccination rates, and that’s part of the problem. Twenty-four thousand congenital rubella cases occur in these countries, representing 75% of worldwide cases. And remember, rubella is considered eliminated from the U.S. at present, with only sporadic cases that come from international visitors.‌

Over the next 30 years, one million such congenital rubella syndrome cases are expected to appear in these countries in the absence of a vaccination effort, but with an active effort through the modeling of this paper, 95-plus percent are expected to be eliminated. Ninety-five percent of the one million cases would go away. Prior to this paper being published, really just prior, World Health Committees, particularly the World Health Organization’s Strategic Advisory Group of Experts on Immunization, or SAGE, have concluded that waiting for greater than 80% measles immunization rates no longer can be defended and that plans to introduce rubella-containing vaccines should begin, as well as supplemental immunization programs for those who would otherwise be missed.‌

I bring this up because we do take for granted how effective our own vaccination programs are and often forget how many millions of individuals still suffer worldwide from vaccine-preventable diseases, and here’s an area where fairly immediate impact seems within reach, and these authors have laid out the case for doing this.‌

Harlan Krumholz: Wow, what a powerful segment, Howie. You speak from personal experience, and it really drives home this point. I think what drives us nuts as physicians and people who are so invested in health is when there’s preventable illness, easily preventable illness, suffering that could have been averted with simple interventions. And there’s lots of areas, gray areas, things we can talk about that are contentious, controversial, but then there are areas that are just so straightforward. We can just do so much good by doing the right thing, and it’s not that hard, and the benefit-to-harm ratio is just so—‌

Howard Forman: It’s fantastic. Yep.‌

Harlan Krumholz: ... so large. So yeah, we got to keep pushing for that. This sort of know/do gap. We know what can make a difference, but we don’t do it. Things that impede that, we’ve got to get over that hump because it’s just such a shame. People can still overcome these challenges, but they could have avoided them all together.‌

Howard Forman: And I think it’s important for us to keep talking about it because we’re almost 60 years out from rubella vaccine introduction to the United States. Most people alive right now don’t really know from rubella anymore. Unless you had someone in your family, you just don’t know from it anymore.‌

Harlan Krumholz: Yep. Thanks so much. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.‌

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, email us at health.veritas@yale.edu, or follow us on any of the social media, including LinkedIn and Bluesky.‌

Harlan Krumholz: And we love feedback. Feel free to rate us on the programs or write to us individually. It always helps us to learn what people are thinking, and we always try to respond.‌

Howard Forman: We appreciate it. If you have questions about the MBA for Executives program at the Yale School of Management, reach out via email for more information or check out our website at som.yale.edu/emba.‌

Harlan Krumholz: Health & Veritas is sponsored by the Yale School of Public Health and the Yale School of Management, and we have a spectacular team supporting us.‌

Howard Forman: We really do.‌

Harlan Krumholz: We have Tobias Liu, the amazing undergraduate, Gloria Beck, another amazing undergraduate, and Miranda Shafer, our superstar producer, and I get to work every week with the incomparable Howard Forman, the Howie.‌

Howard Forman: I am lucky to have our entire team. We really do have a good group, and I love working with you all.‌

Harlan Krumholz: All right. Hey, talk to you soon, Howie.‌

Howard Forman: Thanks, Harlan. Talk to you soon.‌