Should Rachel Levine’s replacement be a physician? | Pro/Con

On Tuesday, the Biden administration announced it is tapping Dr. Rachel Levine, Pennsylvania’s secretary of health, as the nominee for assistant secretary of health and human services. If confirmed by the Senate, she would be the highest ranking transgender person ever to serve in the federal government.

The historic nomination means that Gov. Tom Wolf needs a new health secretary for the next three years — a job that arguably has never been more important and more difficult. Coronavirus is still raging and vaccine distribution a mess, overdose deaths are increasing, and that’s on top of many other ongoing health challenges of the pandemic — from obesity to lead poisoning to care access.

In the past, Pennsylvania required health secretaries to be physicians — medical doctors — but later, that requirement was removed to create the physician general position. Dr. Levine started her tenure in Wolf’s administration as the physician general under a health secretary who wasn’t a physician. But in this challenging time, should Gov. Tom Wolf prioritize a physician to lead the state’s health department? The Inquirer turned to two experts to debate.

Although Act 87 of July 2, 1996, P.L. 518 removed the requirement that the secretary be a physician, I strongly believe that another physician is most qualified to fill Dr. Levine’s shoes. Here’s why.

First, undergraduate and graduate medical training in the U.S. provide an incredible breadth and depth of experience along many aspects of the health-care continuum. Folded into the education curricula are many critical elements of epidemiology, population health, health delivery systems, and preventive care in addition to the fundamental biology of physiology and disease. This rigorous and multidimensional medical training — including meeting the needs of our sickest patients — unequivocally provides a physician with the diverse armamentarium of knowledge and skills desirable for such a critical position that can help shape the future of Pennsylvania. Whether the need is to weigh in on managing the rise in health-care-associated infections or improving Pennsylvania’s prescription drug monitoring program, the looming SARS-CoV-2 crisis, or future emergency preparedness, a physician’s unique background allows for greater understanding of and informed responses to the needs of various bureaus and offices under the Department of Health’s umbrella.

Second, physicians are uniquely positioned in their ability to provide clinical context and account for patient implications to burgeoning evidence and research results. Take the case of SARS-CoV-2, the virus that causes COVID-19. From quickly shifting evidence on the characteristics of the virus to the effect of SARS-CoV-2-associated lockdowns on accessing treatment for substance use disorders, physicians are well-equipped to understand the whole gamut of impact on various walks of life and can appropriately partner with respective bureau heads to devise innovative solutions.

“Few professions have direct exposures to Pennsylvanians adversely impacted by ... housing and food insecurity, lack of health insurance, and low health literacy.”

For example, as SARS-CoV-2 mutation variants are gaining considerable traction, a physician can synthesize what this means and then partner with departments like the Bureau of Woman, Infants and Children to come up with precautionary measures. In this way they cannot only help risk-mitigate exposures at a community level, but also speak the same language as clinical colleagues to monitor maternal/fetal health. As another example, a new physician secretary can contribute equally to SARS-CoV-2-related conversations in health promotion and risk reduction as they can around resources for emergency medical services to prepare for more transmissible virus strains.

Finally, few professions have direct (nearly daily) exposures to Pennsylvanians adversely impacted by social and structural determinants of health — such as housing and food insecurity, lack of health insurance, and low health literacy. As is our practice to better understand and help our patients navigate systems and resources that can hopefully improve their biopsychosocial needs, a physician secretary can similarly spearhead various efforts to fill in the gaps of community health systems, improve insurance and health access challenges, and innovate health technology offerings.

Historically, health professionals have helped redefine many parameters of sociopolitical “normalcy,” much as they did when they pathologized and then de-pathologized homosexuality in the Diagnostic and Statistical Manual of Mental Disorders. They can do the same to better reshape the future of Pennsylvania.

Lala Tanmoy (Tom) Das is an M.D.-Ph.D. student at the Weill Cornell/ Rockefeller University/ Memorial Sloan Kettering Tri-Institutional Program in New York City.

The U.S. experience with COVID-19 is a reminder that protecting and ensuring the public’s health has implications for the entire economy and that public health recommendations should be based in science rather than politics. Few would argue against the notion that leadership today matters more than ever, including those who lead state public health agencies. I believe (and evidence suggests) that medical training is insufficient for most challenges of leading a statewide public health agency, as Dr. Levine did in Pennsylvania. For sure, requiring a medical degree may ensure that states have highly intelligent leaders, but having a medical degree alone does not provide the necessary expertise needed to effectively lead a public health agency.

In a recent study, my colleagues and I asked current and former state health officials what skills they felt they needed most in their roles. In addition to a solid understanding of core public health science, their answers focused on navigating state political processes related to lawmaking, working with state leadership, and having administrative experience. None of these skills are part of medical training. Further, a medical degree does not provide a thorough understanding of governmental public health responsibilities.

In fact, until recent changes to medical school accreditation requirements, most programs did not cover public health topics in the standard medical curriculum. Many medical schools meet the new accreditation requirement by adding lectures on the four public health core areas — biostatistics, epidemiology, health policy, and health behavior. However, doing so rarely confers public health expertise, resulting in vast numbers of physicians with little understanding of the expectations on governmental public health. Thus, requiring a medical degree as a condition of serving as leader of the state public health agency is problematically misaligned with the job requirements.

Public health focuses on preventing disease and protecting existing health at the population-level — and requires a different mindset and orientation.

Medical doctors spend the vast majority of their time working with individual patients and treating the sick and injured. This essential work is critical and praiseworthy. Public health, on the other hand, focuses on preventing disease and protecting existing health at the population-level — and requires a different mindset and orientation.

The experiences of COVID-19 have shown that using a clinical lens for public health prevention can actually impede the effectiveness of public health response. While having a strong understanding of health is beneficial for public health leaders, medical acumen is not a substitute for public health expertise. State Health Officials need to be versed in public health science and able to navigate complex policy-making. State health officials also need leadership and management skills because in most cases they will be running an agency with a budget in the 100s of millions of dollars, with many hundreds of employees.

There are at least seven states that require state health officials to have prior public health experience. An additional eight states require that leaders have both public health and management experience. The largest portion of states, nevertheless, require a medical degree as the only mandatory criteria. The pandemic has shown how crucial public health expertise and management skills are to effective public health leadership. In the words of my colleague, Dr. Nir Menachemi, “If you have COVID-19, you need a doctor. If you want to prevent people from getting COVID-19, you need public health.”

Valerie Yeager is an associate professor at Indiana University’s Richard M. Fairbanks School of Public Health in the Department of Health Policy and Management.