Opioids, obesity, syphilis — Onondaga's outgoing health official reflects on county's progress, challenges
The beginning of July marks the end of Dr. Indu Gupta's time as Onondaga County health commissioner. WAER’s Tarryn Mento sat down with Gupta to look back at her biggest accomplishments over the last seven years and which health issues still need addressing.
Q: How are these last few days going for you?
A: It's a mixed emotion, I have been here for more than seven years—to be precise, seven years and eight months. I started in November 2014, and my tenure will end on July 1, in a few days, actually. So it has been a feeling of accomplishment at the same time, a little sadness that you know, that I'm leaving. But at the same time, it's a good feeling that I have been able to accomplish a lot in the last several years.
A: As you're packing everything up and reflecting on your time. What do you zero in on?
When I started here as the health commissioner, one of the things which I wanted to do is serve our community and lead my team with the strong focus on our mission to improve and protect health of the community. With a vision, right? The vision is really needed to serve the mission of partners—community partners working together for physical, social, and emotional well being, which is the classic definition of health by WHO.
And also, we need to have values in the work which we do and those values guide our work every single day. And that is respect, excellence in our work, accountability, which means we are accountable not only by performance but also transparency, and health equity, and community collaboration.
These are the themes which I want to make sure that I lead my team, and every single program and work which we do should be guided by that pre-pandemic and during pandemic So it has been really a goal for me, and I think, I believe I have been successful in not only sort of putting it in the genetic code of this health department that we need to serve with a purpose, because that's what our job is.
Q: How do you measure your success? What do you look at, to prove to yourself that I made a difference here?
A: I will start with the pandemic, right. When I became commissioner in November 2014, I never thought that I'll be leading my team and this community through the worst pandemic of the century. That has been very stressful as well as very rewarding because I believe I was able to do something about the pandemic by working with everybody. When I say "I" that means we all work together to make a difference, and I had the opportunity and privilege to lead everybody in this one. So that's the biggest one.
But to do a good job during the most time of most need during the crisis, you really need preparation ahead of time. Preparation prevents poor performance, right? That's a very important thing for me to remember, and I remind everybody. We have a strong, functioning health department, and how do we do that? When I started I wanted to see how each and every program is doing and how are we measuring it? Without measuring, you can't improve it. So to get there If I had to get buy-in from my team, and to do buy-in, you do apply for accreditation. Because then you have to set some standard—it's not my standard. It's not some arbitrary standard, it's a national standard by the accreditation board.
I completed the application, initiated the process and 2015. A year later, I started. And it took us few years to do the whole thing: we re-imagined our strategic plan, five-year plan, did the performance management system—it means every program will measure effectively to the benchmark and achieve that and report it and do the quality improvement.
It's like the business world, right? The car companies and all businesses, food industry; they continuously look into their performance. It's the bottom line there—our bottom line is good health. So how do we do that? We need to make sure that we are measuring what we are doing, and improve that. There is a process, or the numbers. In public health, the numbers take years, so we have to make sure the process is put in the right place by not only by our department, but by working throughout the community partners who are going to be intricate part of that. Remember health is physical, social and emotional well being, so from the public health point of view, I have to look at the things from the 30,000-foot view. And that was the very driving force when we put the application for accreditation. We work with many community partners to and we were successfully able to get that in 2018, which was a big thing to do. And what it did it prepared us for very performance based data driven during the pandemic.
And that underscores the importance of our success. We were able to measure things on a daily basis and see how 'okay, what are we not doing good? What are we doing good?' Let's make a small QI.' (QI is what we call small quality improvement.) Or 'The process didn't work last week here, let's try to this week,' — whether it's a case investigation, contact tracing, because there was not a whole lot of guidance that was coming out. We have to create a lot of those things based on our knowledge and science, what was coming out. And the same thing for when we did the testing part when we did the vaccination part.
So all these things really highlighted the other thing, which when we get accredited, it means that a third body is saying that 'You're good,' right? So it gives comfort to other funders, or other programs to come out way. I was able to create new program and bring some more funding: we have a new opioid prevention program since I think 2016. We started somewhere that was state funded with a small funding and it's getting bigger. The other one was the tobacco prevention program, which we didn't have that it's a tri-county one, so that that became very, very important.
And then transparency. The way we can do, in government, transparency is in the outbreaks and in an acute situation, we do press conferences, press releases. But on a daily basis, have a transparent website with digital transformation. So this is something I worked with my PIO and graphic designer and said, 'Okay, let's, let's put things out there on a regular basis.' We put the OPR data on a quarterly basis. And we put our lead data—it takes a little time but usually it's updated every year. Whatever information comes our way, and is good for the community and for our partners who actually can use it for their operations, we certainly are going to do that. Otherwise data is useless unless we share that with everybody.
As a physician, as a commissioner, I have been engaged with other boards of directors. So one of them is New York State County Health Association, so I became president last year. I was vice president before and then president for last two years. I have been working very intensely to not only promote good policy with the state legislatures, but also with the governor's office and and health commissioner's office. So last year for the first time, we were able to secure more funding for our public health work, so most of the counties minus New York City, we couldn't get it. We tried. But I think it's something because it's a large one. Fifty-seven counties, we were able to secure about $25 million more from the state for public health work. Is it enough? No, it is not enough. But it's better than nothing. And our county will even get a little bit over 1 million. So that is a good thing, when I reflect on certain things, putting those processes and systems in place, and provide more resources will have long term sustainability. And that was my goal. When I took this position.
Q: You made progress on organization and planning. And one of the issues you wanted to address was smoking. And I see that reflected in the New York State Prevention Agenda dashboard. Looking at Onondaga County data, you also mentioned that you wanted to make progress on substance abuse, specifically with opioids, that is an area where we have not made progress. How did that happen if it was one of your key goals?
A: I would not say we have not made progress. It is not measurable by the data at this point, but the processes are being put in place. So in 2015 I saw the highest number of cases after I started. I mean, we have a peak now last year, but 2015 was the high at that time, and I mobilized the community in 2016. There was an existing district attorney's drug task force, so I became co-chair of that drug task force and we renamed it with the mission and vision what we call the Onondaga County Drug Task Force, and in which district attorney's office, as well as I, their administrative officer, and I co chair, and I was able to bring all the healthcare partners—all the hospitals, medical society, and some of our county agencies, which were not part of that. So it became quite big, including some of the community advocates. So that was good progress. In 2016 we did a big forum, which I think you can find online, that actually mobilized the community in 2016 a lot because we were talking about it. There was a media coverage about that. I presented in the schools, my team and some of the other partners went and did their job and then we started doing more Narcan engagement and trying to reduce the stigma. It's okay to use the Narcan. It's okay to have that because people were, 'No, no, no, no, no, no, we don't want to talk about that.'
The goal of the task force was based on the CDC's recommendation of prevention, treatment and crisis. So in the last few years, the progress we have made—I would like to highlight that we have more treatment in our county than it was before because of a strong collaborative effort.
Number two, we have been able to address crisis in two ways: Law enforcement is very active. We also have a overdose map, which we monitor and then engage our community partners. And the most of it is harm reduction strategies have been very prevalent. Our health department has done several trainings along with other partners that also do and engage them and destigmatize use of Narcan at every single way which we can. As we speak, we are in the process of trying to put some
Narcan in different places, so people can take that if they are in some places in the bathroom or something like that. Engagement with the partners to harm reduction is very important, and saving lives is the goal essentially so that you can put people in treatment.
Where we have not made progress is the prevention part, which is a near and dear to my heart, because prevention—whether it's a chronic disease for overweight, obesity, right food exercise and you know, take care of yourself to reduce the mental health, all these things are a bigger conversation and they cannot be just only done by not only health department, but starting from school education, workplaces—all these things have to be inserted, like become part our genetic code, right, we are part product of the environment. So the prevention part is how do we address those negative risk factors which make people uncomfortable and push them towards trying something to relieve their anxiety or depression at that point? How do we identify those individuals when they are going through rough patches? Do they have enough support? And then can the providers do the screening at that point? Or at workplaces do they have an employee assistance program? You know, reducing stigma and then the family feels empowered. That's a large conversation. That's more policy-driven, both at federal, state and local level.
Also, each and every organization can do it on their own. We can start conversation in our families, the parents, the schools can be engaged and they are engaged to some extent, but I think there has to be more. And then resources, of course, in prevention, as you know, because that's not a shiny object, it doesn't come.
Healthcare gets a lot of dollars. I came from health care. If you look at the budget of the federal government, state government—local doesn't come into the picture there. Federal government and state —17% or something of GDP goes into health care. Public health is not even 1%. So that tells you a story, as compared to some of the European countries or OECD countries, where we have much, much better health outcomes because they spend on social capital. It's not social welfare, it's to provide that, again, health equity—provide opportunity to people to thrive. Those are the things I think that there's a longer conversation. We are making progress, so we have made progress, not that overdoses are reduced, unless we do address the prevention. And I tell the state partners unless we spend money on that, unless we make policies to address that and engage everybody and people see value in it, we will always be spinning in this.
Q: On the subject of health equity, looking at the state prevention agenda dashboard, health disparities in terms of premature deaths, we're seeing a higher rate among Hispanic and Black residents than we are white residents. What is going on there?
A: So a lot of it people living in poverty, people living in certain zip codes. Access to care, and trust of the system are the key things. These are historical things: systemic racism, exposure to significant poverty and violence. All these things really impact people's health. And when they do not trust the people who are coming their way, based on previous experience, that becomes a tall order. And to do that we really have to gain their trust. During at least my tenure here, I have tried to connect to try to do my best.
We did that same thing during the COVID-19 pandemic. We went where they wanted us to go, because I understand that there was a discomfort about the vaccine also. Bo matter what I say, it's not going to go that way unless somebody from that community is going to advocate for that. So our pastors, bishops have been so instrumental in their when they hear he or she are talking about that. The community rallied behind that and we had so successful vaccinations there. And anytime when I spoke to leadership in any of the faith-based or any community-based organizations, I said, 'I'm going to come back to you about these other health initiatives,' whether we want to improve maternal and child health, or we want to do any other chronic disease initiative. We have a team here of the health educators, which working with the community and making sure that we provide them all the information from the same lens, and what the health department can do. And if we don't have that, can we connect them to those—it takes time, it really takes time.
So I believe if the pandemic has taught us anything, is there are gaps in access. I'm not talking access to care but access to information, access to resources. And if we want to do better in the future, that's true for everybody.
It's not only public health agencies, but as a county agency, at the state and federal level—we need to make sure those gaps are pretty much taken care of. So that when the next big thing happens, we won't be dealing with that one. And also, it will improve health overall, for anything, because in a stable time, we always deal with how we address chronic diseases in our community; we need to have less hypertension, less diabetes, less stroke, less cancer, less depression, or less overdoses, right? The list is long. But to do that, there are underlying factors. If we look and provide those resources for them from the beginning when things are calm and quiet, then we can weather any storm. That's how a strong foundation is needed. And the pandemic has taught that lesson, which we were saying it before now, but it has become very, very loud, and hopefully all policymakers are listening to that.
Q: We know that more than 30% of school aged children are obese, and looking at the state's dashboard, low income children two to four years old grew worse. There was funding over a five-year period of $1.5 million last summer that came to the county to address this. Is it working?
A: So yes—you won't see the numbers right away, but the process is working. How? Because even before that actually, we had a continuous funding from before, we have worked with many school systems, school districts to change the food policy. So the kids get the food in the cafeteria, they get the healthy food. We work with the Syracuse City School District very intensely and will continue to do it at this point. We expanded that further to more schools. Baldwinsville is one of them and we are working with the Onondaga Nation also, and Lafayette.
The policy change in what the kids eat is very important—having more fruits and vegetables, and having less processed food, and also promoting physical activity. Providing safe space—we also work with the schools to have some fixing some playgrounds and parks and different things. So small, small things. We also will be working with the daycare providers to part of this, to have that opportunity for the little kids to have healthy food. Don't just open the can and give it to them. There are so many beautiful ways to have kids enjoy the food, and that's something we are working on.
I would say that yes, our processes are right in place. We also worked with the corner stores in the past to the display of the food in the front. If they needed resources we provided them. We work with higher ed including, I think some hospitals also to look into their menus for low salt and also low fat diet. I provided them tools, brought in a special chef and to do training. These are good things people don't see that, but there are a lot of things that are happening in the background quite a bit. These are the things in the long term will help.
What we have seen, not so good policies created overweight and obesity, right, then to undo that, it will take several years to undo some of them, and then we will see the impact of them.
Q: We were making progress in the county on chlamydia, gonorrhea and even HIV. But then your office put out a notice not too long ago about syphilis rates tripling. How did we go from progress to such a significant increase in cases?
So Syphilis is very silent. People don't have any discomfort. So unless it comes to attention, they continue to transmit the infection, and that has been a problem not only in our county, throughout New York State and throughout our country. Syphilis should have been eradicated. It was a thing of the past, and now it's coming back with a wrath at this point. So I don't have a good answer for why it is.
What we are asking people to do is prevention. Again, prevention is the key. Using safe sex methods for any kind—whether you're using oral contraceptive, use the condom, use barrier protection to reduce the chance of it. Reducing partners I think it's important to also, and stay engaged with your health. Sexual health is very important. It's part of your physical health, and also it impacts future generations, because syphilis can impact the child. If you look at any other sexually transmitted infections, they can cause premature birth of the child. So all these things can impact the mother's health as well as the child's health in the future. So it is very important.
Make sure every provider should ask those questions. I actually have sent the provider alerts; I tried to engage our medical community here that whenever a person comes to your door, please make sure to ask for sexual history, irrespective of their social status. Because it should not be stigmatized there are certain groups of people will have it. Believe me, sexual health is very important for everyone and that should be part of the screening process wherever you have a touch point with the patient.
And for the patient, you really need to think about who your partner is, and also make sure you test yourself and encourage your partner to test. For any reason if you end up getting exposed, make sure you get treated. There are providers that can treat you, our clinic can treat you. There are many, many resources. Early detection and treatment is the best way to take care of yourself.