By Matt Nathan, M.D., and Susan Carney Lynch, Dr.PH
Dr. Howard K. Koh is one of the most influential healthcare leaders in the world today. He is the Harvey V. Fineberg Professor of the Practice of Public Health Leadership at the Harvard T. H. Chan School of Public Health and the Harvard Kennedy School. His credibility as a longstanding practicing physician coupled with senior leadership roles as a former Assistant Secretary of Health in the Obama Administration and former Commissioner of Public Health for Massachusetts have been pivotal to health care policy. Dr. Koh is a fierce advocate for disease prevention, education, policy implementation and policy funding. His influence has impacted areas ranging from the Affordable Care Act to cancer prevention and tobacco cessation programs, vaccinations, and eliminating avoidable disease and injury for patients and populations alike. Dr. Koh is a graduate of Yale Medical School and completed residency and fellowship training at Boston City Hospital and Massachusetts General Hospital, serving as chief resident in both hospitals. He holds Board Certification in Internal Medicine, Hematology, Oncology, and Dermatology. As a Korean American and a member of an immigrant family, he is passionate about promoting care and policies across the demographic, racial, ethnic spectrum to assure all people receive access to both preventive care and necessary treatment.
Matt Nathan: What was it in your life that took you on a journey from medical school to medical practice to leadership in healthcare policy and academia?
Howard Koh: There are many ways to answer that question! I'm the oldest son of a proud immigrant family from Korea -- my parents took great risks to come to this country to find the American dream. From the time I was a little boy, they would lecture to us kids regularly about how fortunate we were to be living in a country with rights and democracy. They told us how lucky we were to speak English as our first language. My late father Dr. Kwang Lim Koh always encouraged us to keep a broad perspective on life -- “be broad like the sky!” he would exclaim. My parents, while sacrificing to send us to the best schools possible, made it clear that they had high expectations for us to make something of ourselves. They stressed that we had to use our education to give back to society in some fundamental way.
I became the first physician of the family. It was a privilege to care for patients over several decades. In training, I met my physician wife Dr. Claudia Arrigg -- I am eternally grateful to her and our three grown children for supporting me every step of the way. But over time I felt somehow increasingly drawn toward disease prevention and policy -- looking back I can understand that public health has been a calling for me that I simply could not ignore. I now realize that much of this came from my father, a lawyer and political science professor. As one committed to public service, he was also Ambassador to the United States from South Korea, representing a historic but short-lived democracy in South Korea that was overthrown by a military coup. Even though he passed away several decades ago, I think about him almost every day. I now understand that my commitment to public service came from my Dad -- it is in my blood.
My famous brother Harold Koh is an international human rights lawyer, former Dean of Yale Law school and former Legal Counsel in the State Department under Secretary Hillary Clinton. He and I served together in Washington DC as two of the highest ranking Asian Americans in the Obama Administration. That was an incredible joy and privilege -- needless to say, our Mom was proud! He and I often share that it was our destiny to serve together, after being fundamentally shaped by the way our parents raised us.
Nathan: We can understand your pride in your family and their pride in you. So a new president comes to you and says, “Dr. Koh, you know your reputation is legion for disease prevention and your passion for eliminating disparities -- especially in health -- among people of different ethnic and racial groups and the underserved. What should I consider my most significant accomplishment in healthcare over the next four years?”
Koh: We have to rebuild and revitalize our public health system -- at the national, state, and local level. The absolute devastation caused by COVID-19 is the result of a fast infectious disease pandemic fueled by a slow pandemic of chronic preventable conditions -- like obesity, heart disease, and lung disease. The impact on communities of color is not unexpected but totally unacceptable. Furthermore, no one should find acceptable the level of preventable conditions long causing harm in our society -- tobacco dependence, obesity, the opioid epidemic for example -- that has prevented people from living their full potential for health. For too long, public health has been under resourced and overlooked, such that the U.S. has the most expensive health care system in the world without the outcomes to match. Also, after 9/11 and anthrax, national leaders established emergency preparedness programs and vowed to never have such threats paralyze our country ever again. But funding for them has been cut over time. In short, we are living the agonizing manifestations of chronic underinvestment in public health. We must reverse this.
In my years in public service, I've regularly advocated for more attention and programs for disease prevention. The frequent reply from policymakers is that there is not enough funding for that. Such a short-sighted response now rings hollow when COVID-19 has required trillions of dollars in national relief funding. And we will need trillions more. We must ramp up our public health and prevention infrastructure so that we don't ever go through a crisis like this again.
Nathan: As the Assistant Secretary for Health, you oversaw the U.S. Department of Health and Human Services (HHS) Office of Public Health and Science, the Commissioned Corps of the U.S. Public Health Service, and the Office of the Surgeon General. What are your thoughts on bolstering the public health domain in the country by the creation of a federal volunteer Health Service Corps -- s
Koh: I like that idea. In fact, in 2002, the nation establishedWhy not make it easier for young people right now to commit to public health as a noble profession to serve their community and country? Currently we make it difficult. Students who decide to attend public health schools like ours are almost guaranteed to take a pay cut over their ensuing careers. Then in a time of crisis, when they try to implement lifesaving prevention policies -- mask usage during COVID-19 for example -- they are
Nathan: Many people argue that the only way we're going to eliminate disparity in healthcare is to change the way that we insure and provide care for patients in this country. What are your thoughts on the advocates for a “Medicare For All” system which some would say is analogous, if not identical to, socialized medicine?
Koh: Everyone deserves good health insurance coverage. But how best do we reach that goal? Here in Massachusetts, our state was the first to pass health reform in 2006. That led to a drop in uninsured rates to 2-3%, the lowest in the country. Then starting in 2010, as Assistant Secretary for Health, I had the unforgettable experience of helping HHS implement the Affordable Care Act (ACA) after it was signed into law. We can now say that over 20 million Americans have gained the health insurance they need and deserve. And the ACA did much to reduce disparities in health insurance coverage, while advancing prevention and population health too. Those gains did not come easily. There were so many challenges including litigation that went up to the Supreme Court. And this story is far from over. Just last week, oral arguments were heard before the Supreme Court about the ACA’s future. In my view, as we await the Supreme Court’s decision, the best way to go forward is to build on the ACA’s success. President-elect Biden has proposed a public option that could expand the foundation of coverage established by the ACA while also lowering Medicare eligibility to age 60. We will have to see if a new President and Congress can make that happen.
Nathan: If you and President Obama could go back, do you think there'd be anything you could have done in the ACA architecture that would have made less contentious to those who criticize and challenge it.
Koh: I know that what resonates with people in our general population is talking about protecting health, not about trying to understand the often arcane complexities of health insurance. Understanding Medicaid eligibility or the different types of insurance marketplace structures across 50 states can frustrate everyone. And frustration opens the door for confusion and contentious debate. Today, over a decade after ACA passage, we explain its importance by emphasizing how it protects many millions of people with preexisting conditions. That's a bedrock principle that everyone supports. No one wants to strip that away. The more we focus on explaining how the ACA helps people access the good health they need and deserve, the better off we will be in helping everyone put this law into proper historic perspective.
Nathan: Many would argue the fee-for-service system incentivizes physicians and healthcare systems to provide more care in the form of procedures, tests, visits, etc. rather than health. If true, how do we craft a system that rewards hard working providers and systems for health outcomes?
Koh: Among many other things, the ACA helped advance efforts by HHS and the Centers for Medicare and Medicaid Services (CMS) to move away from fee-for-service toward care that improves value for patients. That’s what value-based care and value-based alternative payment models are all about. Continuing to explore these strategies is critical to caring for the whole person and improving true patient-centered care. I remember when former Yale Chaplain William Sloane Coffin used to warn us doctors not to view patients “as an uninteresting appendage to an interesting disease”! Rewarding health professionals and health systems for value, not volume, can restore some humanity to our medical efforts while hopefully lowering costs. We need to keep that momentum going.
Nathan: Let's talk about what you have centered much of your policy work and personal passion in regard to preventive healthcare and education. For example, decreasing tobacco use. There is no question over the last fifty years great progress has been made. However a lot of use continues. What else needs to be done?
Koh: As a young clinician, I saw too often how tobacco caused so much preventable suffering and death for my patients. At the time, I was so anguished and frustrated by it which pushed me to explore additional ways of keeping people healthy. That’s how I found public health. We now know that tobacco use represents the leading cause of preventable death in the world. No other condition is projected to cause 1 billion deaths worldwide in the 21st century. Too much of that death burden will fall on low-income communities everywhere.
When I was training in medical oncology, I first learned that the 20th century witnessed the rapid rise of lung cancer, previously rare, to become the number one cancer killer in our society today. How could that happen? The tobacco industry produced and glamorized use of addictive products to rapidly become the social norm. So over the last half a century, a public health approach has led to efforts to deglamorize and denormalize this addictive product. We have made progress in reducing tobacco use rates but not nearly enough. Meanwhile vaping has been on the rise, particularly in youth, which has dramatically complicated the landscape.
On a personal note, tobacco control has had impacts on my life in remarkable ways. In one major example, on Friday June 19, 2009 after waiting for several months, I was informed that the U.S. Senate had confirmed my nomination by President Obama to be Assistant Secretary for Health. That following Monday June 22, I went to HHS and was sworn in. I was then amazed when I was then asked to head immediately to the White House as part of the HHS delegation to support President Obama as he signed the Family Smoking Prevention and Tobacco Control Act into law. Doing so established authority for the FDA to regulate tobacco for the first time in U.S. history. When I entered the Rose Garden, I recognized so many of the approximately 200 attendees as we had all worked on tobacco control issues together for years. It was all pretty astonishing.
Overall, we have made progress in tobacco control but not enough. One vision advanced by former FDA Commissioner Scott Gottlieb is to establish a regulatory framework where the tobacco industry is required to produce products with nicotine content below addictive levels. Doing so could theoretically remove the threat of addiction and truly make tobacco use a choice. This landmark proposal will require much more attention. Meanwhile, there's just no reason why we should just accept generations of young people getting hooked now and paying for it later. So we have much more work to do.
Nathan: So vaping was originally thought to be a way for cigarette smokers to make a softer exit from tobacco, but it really has not worked out that way.
Koh: Theoretically, in a tightly regulated and carefully constructed oversight system, e-cigarettes could potentially represent an avenue for harm reduction for cigarette users otherwise unable to stop using. That’s the long-term hope. Other countries, like England, for example, have explored this concept vigorously. But what is deeply concerning right now is that in the U.S., e-cigarettes have so far served as a devastating new avenue for drug dependence for young people. Young kids are getting hooked on them and disrupting their lives, their schools and emotional wellbeing because yet another product can make them dependent on the nicotine. The FDA didn’t gain authority to regulate e-cigarettes until 2016 and initially exercised “enforcement discretion.” Recently though, they have started requiring more data from existing companies as a condition for them staying on the market. So we have to watch this area carefully.
Nathan: Another existing crisis exacerbated by COVID is opioid addiction and use. Lots of awareness and legal actions as well as provider scrutiny. Are we on the right track?
Koh: The only way to make progress in this area is to view the opioid epidemic as a health crisis, not just a criminal justice crisis. It will be critical to have public health and the criminal justice system working together. If we do that, we can keep start removing the stigma that stops people from coming forward to get the treatment they need and deserve. Too many with substance use disorders still live in the shadows because they don't know where to turn and don't want to confide in others. That needs to change.
I can offer one concrete way for all of us to help reduce the stigma. Several years ago, Michael Botticelli, the Director of the White House Office of National Drug Control Policy in the Obama Administration, and I co-wrote an article in JAMA to encourage everyone to change the language of addiction as a way to eliminate stigma. For example, we can all regularly substitute the term “substance use disorder” for what has been long referred to as “substance abuse.” Doing so can remove the sense of judgment about this medical condition. I also deeply respect people in recovery who publicly come forward to share their struggles to regain a normal life. They and their families have been tremendous spokespersons for the need for prevention. I admire them so much.
Nathan: Recreational Cannabis is now legal in Massachusetts. What are your thoughts on that specifically or the debate over legalization of marijuana for recreational use across the nation?
Koh: We all understand that medical marijuana can be useful for treatment of some people with certain health conditions. But recreational marijuana is more complicated. My concern is that young people are already facing a sea of potentially harmful substances like alcohol, tobacco, e-cigarettes, opioids and other drugs. Why add yet another one that can hurt them? We also know so little about the strength and safety of the cannabis products out there.
Despite this concern, even in the last number of days, more states are legalizing recreational marijuana. So it is critical to monitor and carefully evaluate what the public health and public safety outcomes are. For example, issues of “drugged driving” -- driving under the influence of cannabis -- need to be tracked closely. We need to know exactly what is occurring state by state and nationwide to assess how these developments are impacting the next generation.
Nathan: May we speak about the difficult subject of costs and end-of-life-care? A large percentage of public and private healthcare dollars are spent on aggressive interventions for elderly and gravely ill people, often hospitalized, who have low expectation of extending meaningful or quality life. Is there any better way to decide the often difficult, emotional, and certainly controversial aspects of how much care is enough when there are limited funds for all?
Koh: This is a tough area. I would urge that we better understand what matters to people throughout their lives and particularly at the end of life. Doing that would put these costs into better perspective. Also the area of health and spirituality is a fascinating one that I am exploring with some great academic colleagues. We all need to learn more about what gives people comfort, meaning, purpose and solace in their last days? A better understanding would put issues of expenses and quality of life into a more informed patient-centered point of view.
Nathan: Let’s conclude our discussion about pandemics. If the President were to call you up and say “Dr. Koh we'll have to work our way through this current pandemic, but what do we need to be doing for the next one?” -- What would you say?
Koh: As we speak, we are awaiting an effective COVID-19 vaccine and cure. But by revitalizing, rebuilding and renewing our disease prevention and public health system, we can not only get to the other side of this pandemic but also assure that we will never endure such devastation again. So much of the suffering we're witnessing now could have been prevented. We have to get through this threat but also understand that the next threat is just around the corner.
I was the Massachusetts Commissioner of Public Health through 9/11 and anthrax in 2001. That was my first immersion into public health emergencies. At the time, I helped lead the state’s public health response. Then when I became Assistant Secretary for Health in 2009, I joined thousands of federal colleagues in tackling our previous pandemic from H1N1. So I've been in the trenches for such emergencies at both the state and federal level. All of this has only made me even more passionate about public service and the need for good government.
Threats, natural and unnatural, come with great regularity -- they are “expected surprises.” The American people deserve a better system for protecting them and helping them live their full potential for health. My patients have taught me that when a loved one dies that’s a tragedy; but when a loved one dies a preventable death -- that’s a tragedy that haunts you forever. In the time of COVID-19, we are witnessing this terrible theme all too often. So investing in disease prevention is worth it. Because when prevention works, absolutely nothing happens -- and what you have is the miracle of a perfectly healthy, normal day.
Nathan: Sir thank you for your time and for the difference you make every day in people’s lives.
About the Authors:
Matt Nathan, M.D., is a Harvard ALI 2020 Fellow, previously the 37th Surgeon General of the Navy and most recently a Senior Vice President for a large tertiary care healthcare system.
Susan Carney Lynch, Dr.PH, is a Harvard ALI 2020 Fellow and Editor in Chief of the Social Impact Review. Prior to ALI, Susan spent 20 years at the United States Department of Justice as Senior Counsel for Elder Justice, where she led federal civil long-term care quality prosecutions nationwide and elder justice policy work. Susan has also had adjunct faculty appointments teaching health, law, and policy at law and public health schools for the past two decades.
This interview has been edited for length and clarity.