The Mission of Public Health: Q&A with David Fleming, Seattle and King County in Washington State
This week, David Fleming, MD, MPH, stepped down as public health director of Seattle and King County in Washington State after seven years leading the public health agency. Over that period, among many other accomplishments, he led the department’s efforts to sign up more than 165,000 residents under the Affordable Care Act and oversaw a 17 percent drop in obesity rates in partnering schools.
NewPublicHealth spoke with Fleming about his views on the mission of public health.
NPH: How has public health changed since you began your career?
David Fleming: The mission of public health has not changed—and that's to prevent unnecessary illness and death—but what has been changing is what the nature of that prevention is. Increasingly, it is in chronic diseases, injuries and, importantly, the driving force of underlying social determinants of health. So public health has changed from being more of a direct service agency where we have frontline public health workers who are out there providing treatment to people and preventing infectious diseases, to really more of a collaborative kind of agency where we need to be working with a wide range of partners outside of the traditional domains of public health to help them implement the changes that need to happen. It's a fundamental shift, I think, in the business model of public health that we're in the process of witnessing today.
NPH: When you point to some of the achievements that you've had, whether they're specific changes in the state or specific models of examples that you've given to other states, what would you point to?
Fleming: First off, I think it's important to say that public health is a team sport, and so when I talk about accomplishments, I'm talking about accomplishments of the department in which I work on this and the staff that work here. I think that we have been successful at pivoting to that future that we were talking about a moment ago, at looking at how health departments can attack the underlying social determinants of health.
Increasingly, it is health disparities that are driving poor health in this country. We have been successful here in beginning to figure out how to partner with other sectors—the education sector to reduce obesity in our poorest school districts, for example. We’ve also worked with the community development sector to begin making investments in our poorest neighborhoods to increase the healthiness of our communities, so that people who live in them can be healthy, as well. At the end of the day, I think that we have been trying to lead this new path where public health is a partner in communities with all of the other entities that are capable of influencing health and figuring out how to make that happen.
NPH: What are things left to be picked up by the team, by your successor, in order to keep making a healthier population?
Fleming: When we talk, we talk about us trying to pivot to the future because the future never gets here. There's always work that remains undone. I think that the opportunities and challenges relate to forging a more effective partnership with our clinical care system as this country undergoes health care reform and as we move from health care to a health system. In addition, I think we're at the beginning stages and need to do more to build those partnerships with the community development sector and with the education sector to really have this cross-siloed approach to improving health.
NPH: What would you say to somebody who was starting an MPH now or even starting to study public health at the undergraduate level? What would be some of the most important things that they could look at now?
Fleming: In addition to getting a great background in public health, I think increasingly our new entrants into the public health field need to have exposure to other disciplines that will be critical in moving health forward. So having a business sense and thinking about models of delivering health that have a sustainable element to them would be one. A second would be to understand the community development field and the non-health-related financing that is in essence going to the poorest neighborhoods. A third would be thinking more directly about how we can ensure that, in our health system of the future, at an individual level the human and social services that people need to be healthy—such as housing and employment—are routinely available regardless of which door patients walk in.
NPH: Are you optimistic that we really can make some of these changes and make our nation healthier? That we can end or reduce disparities, make people pay attention to physical activity and change smoking rates? Are you optimistic as we all head into the future?
Fleming: Oh, I'm absolutely optimistic. Public health is a field that if you look backward, we have continually made progress in increasing life expectancy and improving quality of health. That is something that absolutely will continue on in the future. There will be bumps in the road, but we are on the right course, and we have this huge opportunity in front of us to learn from each other in this country and from other countries about how to make progress moving forward.
>>Bonus Content: Read a previous NewPublicHealth interview with Fleming.