Principles of Public Health
by Judy Wessler
April 14, 2020
This interview with Judy Wessler was conducted and condensed by frank news.
Judy Wessler is a legendary public health activist in New York City. She served as Director of the Commission on the Public's Healthcare Systems from 1985-2013, a critical period of the privatization and merging of New York hospitals, working for equal and widespread care across this city’s five boroughs. She currently chairs an advisory committee for the board.
You have worked in public health in New York for quite some time. How does that shape the way you view our current crisis?
A lot of my work is centered around working with communities and community based organizations on issues they were concerned about and affected them.
Nobody said public health, but when they talked about what it was they were concerned about, it was often very related to public health, rather than medical care.
There are just some principles of public health, like testing, early intervention, and things like that, that are totally in the toilet. They're not even being considered in what's going on. So it's very, very frustrating and upsetting.
Is this the response you expected or feared?
We have to think of it in the context of the state and the city, and the budget cuts that have happened between the state and the city. So much policy emanates out of the state and affects what the city does. For example, there is legislation called Title Six that is state matching funds for community based public health programs in the city. Last year, the state cut $62 million of their match for city public health programs, arguing that the city had access to federal dollars.
Yeah, exactly, exactly. And you know, it was not true. It was actually at a time when federal funds were disappearing for important programs.
There was a quite surprisingly excellent coalition formed after the budget was passed and the cut was made. They were trying to get the city to make up for what was being cut from the budget and also to try to influence the state budget for this year, which was impossible to do. There have been campaigns like that that have really worked.
But mostly those kinds of campaigns, at the city and the state level, have come out of community organizing and not out of the goodness of the hearts of elected officials.
I was revisiting a paper you wrote – in 1972 – from the New York City Coalition of Health. You outline three main points, emphasizing the creation of a base of power in the community. Now more than ever, public health is at the forefront of the community's agenda. If, like me, you're new to public health, how is it best to start participating – and what questions do we need to be asking?
The first question is, who has any kind of involvement or say in what the priorities are? And how do people influence the priorities and budgets set? Clearly, budgets are money, but a lot of policy is set through the budget. Being able to influence the dollar flow I think is important.
Very rarely a person alone, unless they are unbelievable, can do this. The number one thing to do is to find like minded people in the person's community or locality to come together and hash out an agenda of what people would like to see. Typically, because it’s so visual, it comes out around hospitals.
People often don't care about their local hospital, until there's a plan to close it.
Then they may have to fight. We've seen a lot of that here.
One would hope that at some point we could go back to local community health planning. There were local health systems agencies where consumers and providers sat at a table together, not with equal power, but equal ability to voice what needed to happen – and sometimes it worked. If we could go back to that scenario again, I think it could make a huge difference.
Announcement of the New York City Coalition for Community Health’s first City-Wide Health Conference, 1972. (Wessler Papers, Box 71:20, Image #C-000647)
What was the undoing of that more localized system?
I can talk about it in the context of New York City, New York state. My organization, The New York City Coalition for Community Health, was very strong and very influential in its day.
To become the local health systems agency, we, with the involvement of maybe 40 people, wrote our own application and submitted it. Which meant, when it came time to make a decision about whether it was going to be a private entity dominated by providers, or it was going to be a city agency, we were at the table. Because we were at the table, because we submitted an application, we were able to influence the final outcome. It ended up not fully a city agency, not totally private, but a hybrid agency with a lot of community involvement, including sub area councils.
Thirty-three districts were defined and had local sub area councils where consumers and providers sat together and absolutely influenced policy. There were some real serious problems, but there were also some very good things that happened. Most of all, I think people were really excited about being a part of it and having a say in their local community.
Then, two things happen. One, the agency decided there were too many local subarea councils. After a big fight, which we lost, they set up five borough councils. The entities were much larger, and reduced the number of consumers and community members involved. Sometime after that, the agency tried to stand up and influence how many specialized services there were going to be, and at how many hospitals. The hospitals got angry about this. The hospitals went to the state about not funding this agency anymore. The agency, the leadership, looked around to try and find community support, and of course the community support wasn't there anymore because they had been done away with. So that's how the agency was defunded in New York City.
In the 1980’s, The New York City Coalition worked closely with some city council people, our local form of government, and the chair of the city council health committee, and came up with a proposal for a restart of this agency. The hospital community went bonkers. They were really opposed – we didn't win on that one. That's just an example of what potentially can happen and how it also could go wrong, I guess.
What is your community focused on right now? In New York City.
It goes back to 2006 when George Pataki, the then governor, set up, what we called, The Hospital Closing Commission. There was strong organizing on a statewide basis to influence that, but nevertheless, that commission got away with some proposals in the name of revenue and efficiency that led to both hospital closings and to the consolidations of hospitals into these big mega, what I called, empires.
You lose any kind of vocal community influence in what the needs are when those institutions consolidate. Gone is the local ability to influence policy.
Most of the hospitals that closed were in medically underserved areas, primarily immigrant communities, communities of color, and certainly lower income communities. There were big losses, and there were community fights from the local community and unions. They fought against the closing, and they fought to try to get some sort of service available for people if the hospitals were going to close.
What I have seen in the racial and economic data that exists, is that low income, black, and Hispanic communities are absolutely being hit hardest by this virus. How much of that is a result of the closures you just spoke about?
There's a multitude of reasons why illness and deaths are so concentrated in immigrant communities and communities of color. It includes problems of access to care.
It's great to fight for universal coverage, but that universal coverage in no way guarantees universal access.
People in the movement get pissed at me for saying these things, but I do feel strongly about it. I was just watching a program where the president of Howard University said basically the same thing. In DC, so many people are insured, but that has nothing to do with access. People don't acknowledge that part of it.
Further, if you go on the commissioner on the public health system website, there are two surveys there. The feedback that we get from people through that, include stories of people getting treated so rudely, with such racism and anti-immigrant sentiment. They're very clear studies about the impact that racism has on access to care and the type of care that people can get.
These types of things also have such an influence on vulnerability to COVID-19, on top of underlying illnesses.
I think the official word on why this disproportionately affects underserved communities will be that it is due to underlying illnesses, but it's much more complex than that.
Do you feel like we’re experiencing a unique moment to address inequalities?
I wish – but I'm not overwhelmingly confident. There's just so many issues people are going to have to deal with coming out of this, I don't know much energy there will be, other than those that do this for their life's work. I'm not feeling confident that the energy is going to be there because there are so many issues and problems. I wish it was, but I'm just not clear.
You know, the conference calls, and the Zoom, and the video conferencing are helpful, but it's not the same thing as what I was always used to. Really sitting down for hours on a continual basis, hammering out priorities and strategies. I can't see any real planning, I mean there is organizing going on, but it's mainly around particular issues and not necessarily about, how do we go forward? What do we do from here, and how do we use this opportunity? That's not what people are talking about. Not that I've heard. I mean, I hope it's going on someplace, but I haven't heard it.
I’m weary about how we transitioned to new mechanisms to work so quickly. This feels normal, what we’re doing now, but we both know it’d be different in person. We’ve rationalized already – this is normal.
I think people are numb. I don't know what it's like in San Francisco, but it's so Kafka-esque here, you know.
The only really encouraging thing is at seven o'clock at night, people open their windows, or they go out on the terraces, or go on their roofs, and just holler and bang things to say they're alive.
To support all the folks in the healthcare system and say thank you for what you're doing. That's the only thing that is lively, that I can feel in any way.
I haven't gone out very much because I am asmathic, but I live near Eighth Avenue, which always has unbelievable traffic – and there's no traffic, it's silent. What we can hear is sirens, mainly ambulances. Somebody took a picture of the food court at Penn Station, which is always a mob, especially at lunch time, and there were two people there. It's just this very unreal feeling of where am I, and why am I here, and what am I doing and feeling?
You know that you care, but it's really hard to figure out what you can do about it.
Have you found anything that feels helpful?
The only thing is spending time and finding good information and shooting it out to 500, 600 people. Getting some feedback about the usefulness. People are calling me because they know my history – just to pick my brain, which keeps my brain somewhat active, which is very nice. And you know, helping people. I freaked out today because a former staff person went to the hospital to get tested because she wasn't feeling well, and she learned that she had the virus, but she lost her job. So she had no insurance. They told her how much it was going to be to do some kind of radiology procedure, and she left because she doesn't have money, and didn't know what to do. She felt it was because she's black and clearly very dark skinned. We spent some time walking through it all – it's good to have that anger, it’s important. But she also needed to get care. So our conversation was, let's talk about where you need to go, where we know you're going to get taken care of.
That scenario is just so pervasive in the city – in our very liberal city.
San Francisco too - so progressive the hospital was renamed Zuckerberg San Francisco General Hospital. A sign of the culture.
Wow. Yeah. There's no public hospital in San Francisco, is there?
UCSF is there. Progressive safe havens can't sort it out. It's discouraging.
And very American unfortunately.
Remember our constitution, where African-Americans were, what, three-fifths of a human being. Maybe something in what we did to the native Americans whose land we’re still on? There's good stuff, and I'm not going to deny that. We had an African American president, who many of us still look up to, because of what we have now. There are some good things that can happen, but for the most part we are a very racist country, and certainly a class based country.