EP105 New York City’s COVID-19 Journey with Dr. Ted Long

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EP105 New York City’s COVID-19 Journey with Dr. Ted Long

Aman: Dr. Ted Long. Welcome to the "I AM GPH" podcast.

Ted: Thanks for having me. 

Aman: How are you doing today? Is everything going well in your world?

Ted: Yeah, it's a beautiful day outside, cases of COVID are going in the right direction, that's all we can ask for.

Aman: I love it, I love it. Cool, let's hop right in, let's hop right in. So since I started researching and reading about you, you have a very impressive career and journey, it's fascinating to read. From the Rhode Island Department of Health to Centers of Medicare & Medicaid services to New York City Health and Hospitals. And more than that, looking back, I'm just curious about, if you can walk us through that professional trajectory, how one area and one aspect of interest led to another in your life for you?

Ted: Yeah, no, thanks for asking, and I hope it doesn't seem like too many sort of random events that came together, though I think we all feel that way at times. You know, for me, my guiding light has always been, I'm a primary care doctor in my soul through and through. And I've always, I went to medical school to practice medicine. Throughout COVID, I've always seen my patients and I always will, but I've always also thought about how I can take what I hear from my patients and really try to make the world a better place. You know, immediately coming out of my medical training, I did the Robert Wood Johnson Clinical Scholars program to give myself that sort of academic bent and piece, which has been really important to me in terms of how I see and interpret the world and how I communicate. And then I wanted to dive right in, so I went to Rhode Island to be a medical director there at their state department of health. And being there, I think one of the things that was interesting for me, and my most important takeaway was that I listened to people on the ground and I would go to the primary care doctors on the frontline, I'd say, "What's your number one problem?" And they would say, "Number one, two and three are staff, staff, staff, we don't have enough doctors, we don't have enough staff." Then I looked at the data and the federal government believed at the time that we not only had enough primary care doctors, we had a surplus, too many, and I at least knew at that point that both of those things can't be true. And with my guidance, I'd always been being a good primary care doctor, a good listener, I decided to do something which arguably you could only do in a place like Rhode Island. The only way to really know how many primary care doctors you have and what if they're actually practicing primary care and all that good stuff is to ask. You actually can ask every one in Rhode Island, which sounds crazy, but that's what I did, put a team together developed a strategy for it. So we actually were able to pinpoint, like, to the point something, the number of actual primary care doctors and effort we had in Rhode Island. And doctors on the ground had it right, we actually went from being the declared as having a surplus to declared as a shortage area. And we could only do that by me starting off and really listening, and then we were able to apply for all the grants needed to really get the state to where we want it to be. That was overall a really positive outcome for me. And I sort of, I felt that, but then I started to think more about what's going on nationally and how can we do this sort of same thing? What if we could do this on the national level? So at that point, I went to the Centers for Medicare & Medicaid services, I became the senior medical officer for quality measurement at CMS. And that was a part of all of these programs that really had this national impact and being able to drive our hospitals to make changes so that patients that have to be readmitted get readmitted a lot less often, so that our hospitals can provide higher quality and primary care doctors like myself could be incentivized to do the right thing for our patients and actually get paid what we needed to do that, to be able to hire that extra social worker, we need things like that. And it was really a phenomenal experience. CMS it's a great place to be, I would definitely recommended it to anybody thinking about jobs on the federal side of things. But there was always a part of me that was thinking, well, I kind of miss being on the front lines. I've always treated my patients and then throughout being at CMS, every Friday I'd be in clinic. But there was an opportunity to come to New York City Health and Hospitals. And as my current boss, Mitch Katz, told me when he was first talking to me about this, "Do you want to come to the largest public health care system in the country? We have a $1.8 billion structural deficit, we have to save the day. The system can't go on like it is and let's use primary care to save the day." I said, "Wow, sign me up, that's all I've ever wanted to do." So I came to New York City at that point. Again, my patients, I see every week are in the Bronx, I listen to them, they guide me. And in the meantime, in New York City, we've done some pretty amazing things, which we can talk more about today, including through my office and New York City Health and Hospitals creates what is soon to be the largest universal access program, NYC Care so that anybody in New York City will get the healthcare that's their right, that they deserve, and be able to meet their primary care doctor. We've been able to decrease wait times, deliver care to so many more New Yorkers, which is really our mission. And then we've forayed into new things now too, like how can we think about what kind of care homeless people need and how can we help New York City to continue to fight COVID? It's been a pretty amazing experience. New York City is a special place, but it really is. And New York City is special because the people here are special. They deserve the credit for everything we've done I know in fighting COVID. It's not me that, I can't force somebody next to me to always wear a mask, but you look around the street, people are doing it, you look at other places, that's not the case. New Yorkers really come together, and that's always the most heartwarming thing for me to see.

Aman: And that was a very heartwarming journey for me to listen to it as well, thanks for sharing that.

Ted: Yeah.

Aman: One word that sticks out to me is "listening", this word you mentioned, and it seems like a skill that's not spoken of much in reality, even in schooling for that matter. How have you cultivated this skill for yourself of listening, is it a natural thing? And how would you suggest folks to even think about that in their own practice or in their own journey going forward in public health?

Ted: Yeah. Well, I mean, what I tell everybody on my team, my mantra is that "I don't have all the answers, I will never have all the answers." Maybe there are some people that do, that'd be amazing, maybe we'll hire them. But I don't have to have all the answers, 'cause everybody in my team has all the answers. They know their jobs better than I do, better than anybody does. So, my job in New York City Health and Hospitals is to listen to my team members and empower them. They are the amazing people that have done these incredible things for our city, from developing new models of care, bringing patients in that previously haven't seen a doctor in 40 years. I mean, this is real stuff that really matters, but the full credit goes to my team members. And my job is not to tell them what to do every day it's to listen to them and see what they need, 'cause they're the ones that are truly making the difference out there. And the way I see that is that collective action is more than I could ever do. Even if I had all the answers, I could never have the collective impact that the hundreds of people on my team, they feel like they can really do anything in the world with my support, that's what makes a difference.

Aman: I love it, I love it. So let's hop into your roles, the roles you have held in government, because what was fascinating is you have held at a city level, at a state level, and at a federal level. So throughout your career, you've kept these strong connections, despite all of this, you have kept your strong connections within academics and research. So how are those connections in this world that you're in, that has been growing and you've experienced different layers of it, how has the academic world helped you? And why is academics and research so important to you to intermingle these worlds?

Ted: Yeah, actually it goes back to the word you used, which is listening. For me, I'll start with my mantra. My mantra is that "Good communication would solve 99% of the world's problems" and I encourage anybody listening to me think about the last five problems you've had and if good communication would have solved them you'd be surprised that you would. And to me, academics is always a way to communicate. It's our way of, one, understanding what a phenomenon is or understanding what intervention is done and then to be able to communicate that across the country, across the world. And it's my way of talking to people in California that may be struggling with the same issues that we're seeing here in New York City. Academics is our way of saying here's what the facts show, interpret them as you will. And if we didn't have academics to be able to have that sort of those objective facts we could put forward with peer review and then be able to use publications and journals to communicate that, we wouldn't be able to talk about these important interventions that we've done in New York City or in other cities that we could draw over here. And I'll give you a good example of this. So one of the things I'm really proud of is that at the beginning of last year with COVID, so I'm thinking like July, August, September of 2020. We in New York City set out and said "We're going to be the only big city in the country to reopen our schools for in-person learning." And at the time, I'm a father of two kids, you know, there is nothing more important for my kids than their education, and there's really no replacement for in-person learning. But people said, "Is it safe?", "What if COVID spreads in the schools?" All of these things. And we put together a sophisticated layered approach where we did random sample testing in every school, we did change the ventilation system, social distance, a whole layer of safety measures. But the upshot of all of that is, did it work? So we in the Journal of Pediatrics, in last winter of last of 2020, where I think we put the paper out where we basically found the key finding that students and teachers in New York City during the pandemic that were in remote learning had the same, if not higher risk of contracting COVID than our students and teachers in-person in school, making schools one of the safest places to be. But if we studied that, found that that factual conclusion, and then use that the Journal of Pediatrics in this case to disseminate the findings. I get emails from people in cities, across the country about this. This made a difference, this is one of those things that changes the world. But we couldn't do it without, I think for me, the communications that academics affords. And that's the reason I've always been very excited about supporting in continuing the academic path myself.

Aman: That's a great example of that. Wow, cool. So let's move on to some more work oriented stuff and research in your world and in your life power, how it's going to take in place for you. What have you learned from contact tracing? Cause we spoke about COVID quite a bit in the beginning, but I'd like to go more specific since you have been in the trenches from day one, and I'd love to hear about that from you itself. And what have you learned about contact tracing as a public health tool in the fight against COVID? How have we adapted to it and make it effective in New York City?

Ted: There's two big things that I think about a lot with contact tracing that I've learned. By way of background, contact tracing is where we call a case or somebody that is recently diagnosed and has a lab test for COVID. And then we ask them who they directly exposed when they were in their contagious window to COVID, and those people would of course be at the highest risk of themselves having contracted and then becoming contagious. So if we can get them to quarantine, it breaks chains of transmission by tracing those contacts, if you will, all New Yorkers that have been exposed. One thing is, and this is at the outset of contact tracing is there was a concern that will people be willing to share contacts with us? Put your yourself in the situation, you're a case, you find that you have COVID, you find you have symptoms, let's say you've exposed your grandmother to this. At the time, remember also June of 2020, we didn't know what we now know about COVID, it was very scary time. It's not easy to talk about cause you don't want to hurt your grandmother, but you may have actually, if you live with her exposed her to this life-threatening global pandemic virus, not an easy thing to talk about. So other places in the country and in the world had contact tracing been done by people that would call you, they may not necessarily be from your community city or even in some ways they may be several states over to ask you who you could have exposed. And I felt early on that that's not how New York City works. We have at New York City, our communities are tight. And I felt really strongly that I wanted all of our contact tracers to be all people from our communities, disproportionately from our communities that were hardest hit. So if you get COVID, the person that's going to call you in New York City will be somebody from New York City, from your community that knows what you went through with the horrors of March, April of 2020, because they went through the same thing in your community so they can relate to you in a way and can gain your trust, and it's all about trust. Because again, these things, aren't easy to talk about whether you exposed to your grandmother, your children, even coworkers. It's not something that anybody wants to talk about, but it's important we talk about it, we get you to talk about it cause that's how we break the chains of transmission. Today, we've actually been able to identify well over one million close contacts in New York City, in a city of over eight million people. That's a lot of close contacts we've been able to identify. We call them all, we see how we can help them. But our secret ingredient in terms of our effectiveness of being able to identify that magnitude of people is our tracers who are New Yorkers that when they saw what happened to their communities, and again, March in April of 2020, they were the people that raised their hand and said, "Yes, this cannot happen again, I want to help, sign me up." And they did, and they've done an incredible job. The other thing I've learned from contact tracing too, and I take this away from listening to my patients is whenever I tell my patients, "You have coronavirus or you've been exposed to somebody with coronavirus", every single time, I get the same single question, always the same question it's this: "Oh, Dr. Long, this is the virus I've been hearing about in the news, so what do I do?" And they pause. And in New York City and other places, there's actually not an answer to that. Whereas in New York City, we've put so much effort, and contact tracing is that big front door we've thrown open to be able to be the people that engage you and talk to you and say, "You're not alone here, you can come to our free hotel program, we'll pick you up for free in a taxi even give you free pajamas when you walk through the door. Free food. Free medical care while you're there. We'll connect you to monoclonal antibodies, we'll come to your home to give you a free vaccination, we'll come to your home to give you a free test, which we offer to anybody that's been exposed in New York City. We even had a grant for direct cash assistance, so you didn't have to make the choice of going to work, to support your family, putting up your community at risk versus making the right decision, but then you might risk losing the apartment for your family. In New York City, you haven't had to make that hard choice because we've had this direct cash assistance, we've paid sick leave, we'll help you to navigate too. So the second thing again, that I've learned very clearly about contact tracing is that you have to think of it in addition to the surveillance piece in identifying close contacts as the way to have a caring group of people directly engage you to help you to get through this. And I think that that help has been one of the things that's enabled New York City to have the level of safety compared to other places in the country, given a complicated set up we have to begin with, I think that there's a lot to be proud of there.

Aman: Silent applause from under my table right now. Love that. You mentioned the word community and community health workers specifically, and their relationship to primary care, so I'd love to hear about how you define a community health worker and what does their job look like?

Ted: Yeah, so for me in primary care, and this is to be honest with you, this vastly predates me coming to New York City, I've always felt this way. But always has been the biggest challenge for me is when my patient leaves the door of the four walls of my office, I think to myself what's going to happen? And I know my patients that struggle to get their medication, struggle to take their medications, have all kinds of other competing priorities. And then always has gotten to me that I just want to do more as a primary care doctor, but I can't — I can't follow them home. But actually, a community health worker can literally follow them home. They can go to their home, figure out what the issues are with taking the albuterol for asthma, figure out what the issues are with getting their refills on time, figure out if they qualify for any social services. All of the things that I've wished I could do in primary care, we can literally from the vantage point of your home, do in your home with you, with our new community health workers. And the icing on the cake, which makes it incredibly cool for me is that these aren't people that don't have any experience doing this sort of thing. The backbone of this are our actual contact tracers who have spent the last year and a half fighting COVID in our communities, getting further to know the communities where they live in our communities across New York City, they're going to be the ones doing this. Who in the world could be better at being an effective community health worker than somebody who's been working with our communities, either on the phone or in-person fighting COVID in the most sensitive moments of our city's history in the pandemic than our contact tracers? So they're going to be the backbone of this new program, they're going to solve what I consider the perennial challenge, I always wished we could solve in primary care, but I've never been able to, now I can. And I'm just real excited about.

Aman: Love it. That's awesome for the future and everything that's coming with regards to that. So at NYU GPH, we have alumni all over the world and that's where most universities as well, there's global alumni diverse communities. And some people connect health efforts across countries and continents. And I think New York City in its own way is also just as a very diverse place with different backgrounds, different needs and things like that. So how do you think about connecting these health efforts with regards to diverse and complicated situations that take place in New York itself?

Ted: Yeah, well, I think one of the big lessons we've all learned from COVID is that we need to work with our communities, we need to figure out who are the trusted voices are. Maybe it's community leaders, maybe it's religious leaders, maybe it's community-based organizations, or more often than not, it's all of them. And we need to have all of our efforts be focused on not just building a big testing site in New York City and hoping people will come do it, but rather bringing testing to your doorstep in your community, or actually now we literally bring it through your doorstep, into your home, in vaccinations, into your home too. But the way that we do that has to always be grassroots. It's the same principle behind making sure our contact tracers are from our communities and same with our community health workers. But even with where we brought testing in New York City, today we've been to more than a thousand locations just through the test and trace core we brought testing. But none of these are my personal decisions. We ask the communities, we ask community-based organizations where do you want testing? Not just like where generally do you want, like which corner, where do people live their lives? And that's, I think in terms of the complexity of the different communities in New York City being able to listen to the right trusted voices and then deliver on our promise to make a difference, like making sure that testing you unit it shows up or that vaccination unit shows up. That's I think enabled to build trust from our communities about what we can do. And then the end result of all of that is from a testing perspective, we in New York City throughout the pandemic have done more per capita testing than almost any other country in the whole world. But again, testing is a choice. I credit it to I think our ability to keep things grassroots and New Yorkers identifying that this is what they need to do to keep their community safe. That's why we've been able to do as much testing as we have. But I think it is acknowledging that we need to always have the community voice be at the center of it all, and that's how we get our communities to move.

Aman: It's all about the community. Love it. So what do you think is coming in the next 1 year, 2 years, 12, 24 months we have ahead of us, and challenges and opportunities you see about our New York City. What's on your mind right now?

Ted: Yeah, I mean, the biggest open question is how much longer will and I'll use my words here, we have the pandemic, as we know it. Now, New York City, we're being very effective right now in getting a tremendous number of New Yorkers vaccinated. That's probably the most important thing right now in terms of us securing the safest path forward, but we're not out of the woods yet. And one thing that I find encouraging is that New Yorkers still are taking this very seriously and that's not something I say lightly. Look, we all wear the masks, not a single person enjoys wearing a mask, but we do it and not a single person who enjoys getting tested, but we do it. And not only do we do it, we're getting tested right now in New York City at the same level that we were at the height of our second wave. So New Yorkers are still coming out in droves to keep their communities safe. So I think for me, we have to keep that, we have to keep using testing as our line of safe, we have to keep contact tracing as very, very important and heavy layer of protection that's kept our city as safe as it has throughout. We need to keep getting people vaccinated. On the other side of that, we've all been humbled by the virus and its variants. We know that we don't know what COVID has in store for us with respect to variants moving forward here. But we have a lot of effective tools in our tool belt that we're growing every day. So it's a battle, but I think we're ready for it. And I think there will be a day where we emerged from the pandemic as we know it. And what makes me excited about that is that when we emerge, we are truly going to emerge stronger than when we went in. Now we've talked to our community health workers, I mean, that's a game changer, this is the biggest changes to primary care that I've always wanted to see in the last 10 years. But in addition to that, we have tele-health. I mean, we did a handful of telehealth visits before now I can do so much for my patients, from the comfort of their homes: on the video screen, on the phone, we've just set up these systems to be able to meet people where they are, and that's my mantra there that we dreamt of, but couldn't have possibly done before COVID. So we are going to get through this, and we're going to have more battles, I believe strongly, we're going to win those battles as we have throughout New York City. But when we get to the end of the tunnel here, I really do think we're going to come out stronger than ever before.

Aman: Excited to see that myself as well. I'm sure we're on a great path and positive trajectory going forward as well. So we've been involved in academics quite extensively as well, and we spoke about that earlier. How would you advise since this podcast is usually viewed by current students, prospective students, people in the academic world as well? What would you advise them to do in order to find their path, their public health? How can they be impactful in this society?

Ted: No, it's a good question. You know, when I think about being myself, the city level, state level, the federal level, as you said earlier, there's so many different ways to make a difference for the world. And I think you got to sort of map out, try different things. For some people being on the front lines is what makes them excited, and that's what they want really dig into. For others, being able to take a very global perspective on the world and be able to think about making federal policies that has a ripple effect across the board is what really invigorates them. I truly believe there can't be a right or wrong here, it's really just a matter of what excites you the most. And I've personally found that experientially, and I guess that's why I've been at all of the levels experientially seeing what each of these types of levels means for me has enabled me to land at the place where I'm just the most excited to get up and go to work every morning. So my advice would be to try different things out, see what works for you and also to seek good mentorship. I've been fortunate to have really great mentors throughout my career. And at NYU, I have people like me that can be your mentor, so you should come to NYU.

Aman: Lovely. Where do you find this motivation to do what you're doing everyday: balancing the academic world with your professional life as well? What fuels you? What fuels your work to do this?

Ted: Yeah, well, for me, it's a combination of seeing, again, when I'm in clinic, seeing the effects of what I've done. Because for me, what I love about primary care is it's like a little snapshot of the totality of life. I've patients, 20 years old and 80 years old, I've patients that are employed, and they make middle wage earnings. I have patients that are undocumented immigrants that are worried about possibly being deported one day. I see all walks of life experience and all different types of things. And what unites everybody together is that we've all been affected by COVID. What unites everybody together is that everybody wants to have a doctor they trust that they can see for anything going on in their lives. And for me, when we're able to move the needle in different ways for example, I saw a patient, this is about a year ago now, but she hadn't seen a doctor in 40 years, 43 years to be exact, I remember so specifically. And she was able to make an appointment with me through the NYC Care program, which is our universal access program for New Yorkers. Seeing her that day, and she started crying and said she didn't feel like she deserved medical care before she came in to see me, and the NYC Care was the only way she'd ever felt comfortable getting medical care. I mean, that's why I'm here every day, and that's what motivates me, and that's why I get up every morning. You know, imagine if we could do that for everybody in New York City, be able to make them all feel like they deserve the care, is their human right. I feel like we're making progress in New York City too. That patient of mine, I've seen others just like her. But if we hadn't existed, if we hadn't done what we had over the last three or four years, my patients, it'd be 44 years now, she still would've never seen a doctor and that's unacceptable. And if I can make my small difference to be, to bring her into to finally get the care that's her right, it's good enough for me.

Aman: Would that scintillating smile that fuel inside him, one lesson or two lessons we can take is that old time listening and community are the past, they're the present, but they're also the future. Thank you for sharing your message, Dr. Ted Long. And it has been lovely chatting with you on the podcast.

Ted: Thank you for having me. It's an honor.