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Public health dilemma: unlimited priorities, limited funds

By Hope Green

Hospital closings. Bioterrorism. West Nile virus. AIDS. Substance abuse.
As the Massachusetts commissioner of public health, Howard Koh goes from crises that dominate the headlines to festering problems that get less media coverage but still have a lasting impact on the public's well-being.

Howard Koh speaks on Tales from the Trenches: A Commissioner's View of Public Health at the February 13 SPH Public Health Forum. Photo by Kalman Zabarsky

Now on the job for four and a half years, Koh (SPH'95) described his mission and challenges in a recent Public Health Forum, part of a monthly series of lectures held at the Medical Campus.

As commissioner, he told the approximately 100 faculty, staff, and students, "you have the incredible privilege of seeing health care from a broad societal, statewide, national, and sometimes international perspective. You get to see policy at work, and sometimes, whether you like it or not, you're part of politics."

A noted skin care specialist and a professor at Boston University's Schools of Medicine and Public Health, Koh was appointed commissioner by Governor William Weld in 1997. He is the commonwealth's first Asian-American health commissioner and the first Korean-American to hold such a position in the country -- factors, he says, that make him particularly sensitive to the health concerns of minorities and the poor.

When he took office, Koh had a master's degree in public health from Boston University, an M.D. from Yale, and board certification in four specialties, internal medicine, hematology, medical oncology, and dermatology. In retrospect he wishes he'd earned an MBA as well: the job entails supervising 3,200 employees at 18 sites, including four public-health hospitals and a state laboratory.

"Of the many courses I took as an MPH student here," he says, "conflict resolution is one that I use all the time."

He is responsible for a $750 million budget, with state taxpayers footing $520 million and the federal government supplying the rest. While thousands of constituents clamor for funds, Koh has to provide leadership to set priorities.

"We have some advocates who have come together to create a group called United We Stand for Public Health," he says. "They're going to say for the first time, we don't want to be pitted against each other for the shrinking health-care dollar. We are going to stand for all public health, not this program or that cancer or that body part. I am thrilled to hear that."

One of Koh's first actions when he took the job was to lead his senior managers on a retreat to draft a public health mission statement. Topping the list of goals is the credo, "We believe in the power of prevention." Koh has played a leading role in the state's successful antitobacco education program, which he considers "the best cancer vaccine in the world."

But sometimes crisis management competes with his agenda for long-term prevention strategies. The recent anthrax scare was one such ordeal. The Department of Public Health received more than 3,000 samples of suspicious white powders and had each of them tested. All were false alarms, but at the peak of the scare, in October, public health officials were working around the clock with police, the FBI, hazardous materials teams, and postal workers.

"The good news is that I don't think I've ever seen government working more intensely and more closely together," Koh says. "These are all amazing public servants who protect the public in times of threat."

In light of heightened concerns about bioterrorism, a Cambridge firm has received federal contracts to produce millions of extra doses of smallpox vaccine. A task for Koh's agency, he says, will be to determine a feasible strategy for distributing that supply.

An ongoing public health crisis in Massachusetts has been overcrowded emergency rooms turning patients away at the door. Koh chairs a statewide task force to address the ER issue. Another panel is looking at the underlying problem: hospital shortages.

Koh says he is "very concerned" about CareGroup's intention to close Deaconess Waltham Hospital. "We have come to learn," he says, "that the emergency room is at the center of an entire health-care system under siege and in crisis."

There are now one-third fewer hospitals in Massachusetts than there were 10 years ago, he notes, and two-thirds of those remaining have budgets in the red. A consensus is building, he says, that deregulation of the hospital industry has harmed rather than helped these institutions.

Despite his agency's high profile in the news -- whether it's addressing the hospital crunch or finding ways to prevent medical errors -- Koh would like to see more people understand the role of a public-health infrastructure in their lives.

"Public health protects people from threat," he says. "It's not some abstract, academic thing. It's concrete, and it protects everybody 24 hours a day."

22 February 2002
Boston University
Office of University Relations