Annual Meeting keynote speaker Reed Tuckson: ‘If there is ever a time for public health, this is that time:’ Confronting challenges requires collaboration, leadership, will
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* Teddi Dineley Johnson

Reed Tuckson, MD, FACP, has spent his career on the front lines of the fight to eliminate health disparities and improve quality and access to care. As executive vice president and chief of medical affairs for UnitedHealth Group, he has been an outspoken advocate for turning off the spigot of preventable chronic diseases. As commissioner of public health for the District of Columbia from 1986 to 1990, Tuckson stepped into the national spotlight when — frustrated with city officials’ inattention to health issues — he donned his white coat and stethoscope and went into the city's poorest areas to see patients. Tuckson will be a keynote speaker at the opening session of APHA's 140th Annual Meeting in San Francisco, on Sunday, Oct. 28.

## How does your long career as a public health professional serve you today as you think about public health services on a national level?

What I have learned from my great pleasure and privilege to be involved with the health of the public is a sense of the immediacy and the comprehensive-ness of the challenges confronting the health of the nation. I think that anyone who has been privileged to be a public health officer or a public health professional has been given the opportunity to experience the epidemiology of disease that confronts the people, the families and the communities in which we live our lives and do our work. When you are made aware of that epidemiology you become so clearly focused on the causes, especially the root causes of those conditions…What you learn so clearly is that the origin of problems is so often comprehensive, so much a function of the social fabric of our community and environmental life. So I think that of all the things I have learned is an appreciation for the complexity…of the challenges and a real appreciation for the importance of working across disciplines, across dimensions, across industries, to really get at a coordinated team approach to make a responsible set of strategic interventions to respond to these challenges.

## Your deep passion for improving the health of underserved communitiess has positioned you as a national leader in the fight to eliminate health disparities. But despite our best efforts, disparities persist. Why?

I think the reason that we are struggling so hard to overcome disparities is because of the very comprehensive root causes of the problem. So many of the health challenges that confront people of color and under-represented minorities in America is because they are so deeply intertwined with the challenges that those individuals face — socio-economically, economically, education, housing. It's really intertwined so deeply in the fabric of life and so it makes it very difficult for the health community to be successful in and of itself. And so what that sort of tells me and teaches me and reminds me is that when it comes to health, we're all in this together, and we have to view it that way. That as America becomes increasingly and overwhelmingly multi-ethnic in its character, then we realize that the challenges of some populations become the challenges of the nation.

“You don't get very far wringing your hands that you don't have resources. Sometimes you just have to go and do it yourself.”

## In the movement to cover the uninsured, you were an early pioneer. What lessons did you learn, and how have they served you on the big stage?

One of the things that I learned very clearly in my time as commissioner of health in D.C. was the importance that community health centers be available, especially in the poorest parts of the city, and not only be available but be available in the evening. We needed to ensure that people who are marginally employed, who really did not have the luxury of being able to take off during the normal business day, or people who were taking multiple buses and transferring at great effort to be able to get to their work (and) had a real hard time getting back to the clinics in their community for their care — that those clinics be open at night. And we worked so hard to establish evening clinic hours. One of the frustrations during my tenure was that all the money that we had that supported our clinics in the evening were taken away because of underfunding of a growing incarcerated population. So needing more money for police and for jails, that ate away at all the discretionary resources that we were given in public health for our community clinics, especially the evening clinics. What I learned was to cut through that frustration and all the leadership of the health department. We decided to man the clinics ourselves. And so we ran our own community health center between 5 and 10 at night on certain nights during the week, and that really was a very important lesson for me… You don't get very far wringing your hands that you don't have resources. Sometimes you just have to go and do it yourself. And so, what we really learned from it though is that when you are actually running the clinics yourselves…you begin to have a very intimate understanding of what your staff is going through. And when you're the one confronting the insufficient stockpiles in the pharmacy and when you're the ones confronting the difficulties in coordinated continuity of outreach to people who don't keep their clinic appointments and when you're the ones who have to confront irritable or angry citizens or patients who don't like to wait in the waiting room, all of the sudden you start to become a much better administrator. And so I think I learned a lot from that experience about the importance of getting directly involved, roll up your sleeves and get right in there and pitch in.

## APHA partners with the United Health Foundation and Partnership for Prevention each year to present “America's Health Rankings.” The most recent report found that the nation's overall health is not improving, and that obesity and diabetes progress has stalled. What will be the path to progress?

The path to progress on trying to address obesity and diabetes will be very, very challenging and I…can't think of two more difficult problems that will be confronting the American landscape. It means you have to do a lot of things all at once and you have to do all of them well and sustained. I think clearly we first have to start with our children and we've got to make sure that our kids are learning something about the importance of exercise and have the opportunity to exercise. It is very frustrating to see how few of our children are actually getting the chance to have meaningful physical activity. The second thing, of course, is what we eat. Having available healthy foods at a price that people can afford. I fear that as fast foods become a low-cost alternative, when people have very little discretionary dollars to spend for food, that they become a too often attractive alternative for people.

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/42/7/9/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/42/7/9/F1)

Tuckson

## What do you see as the biggest public health issues in the future, and are any of them not yet on public health's radar?

As we look to the future, first and foremost, I worry about funding and resources. I think that we're going to see state governments severely challenged to have discretionary resources to do things with in public health and in education. We are seeing now so much of the budgets for state governments being consumed by their responsibilities for financing their Medicaid programs as well as for financing the health care of state employees…

And what we have not yet been able to, I think, be convincing enough is that pouring money into public health is needed at the scale it's needed can actually turn around and turn off the spigot of preventable chronic illness. I see a tsunami of preventable chronic illness continuing to pour into a delivery system that we already can't afford and whose assets we misuse terribly. And I think that those are only going to get worse in the years to come. We have an awful lot of work. I don't know how we will ever be able to medically respond to the preventable chronic illness that is confronting America. We've got to turn the spigot off. Unfortunately, the challenge that I see also going forward is an absence of will, an absence of leadership, on the prevention side to mount the level of scale and sustained intervention that's necessary to turn the spigots off. As a result, I think we have two mutually incompatible forces that are about to collide. They already are colliding.... Whether it is the continuing escalation in obesity and diabetes, the persistence of far too many people who are still smoking tobacco. Whether it is the undiagnosed or untreated risk factors such as hypertension or elevated levels of cholesterol. All of those kinds of phenomenon are either getting worse or remaining unacceptably high, which all then result in a lot of sick people who will then find a way into a medical care system that is increasingly costly, increasingly unaffordable, and this is a real challenge on the landscape of America. So if there is ever a time for public health, this is that time.

*   Copyright The Nation’s Health, American Public Health Association