Rhode Island Interim Health Director Dr. James McDonald is stepping down later this month. He spoke with Health reporter Lynn Arditi about the pandemic and challenges that lie ahead.
[This transcript has been edited.]
Arditi: Dr. McDonald, your decision to step down as the Health Department’s interim director comes at a time when we’ve seen an unprecedented wave of healthcare workers during the past 12 months or so leaving their jobs – and that includes dozens of people in your own department from leadership down to the frontline staff. What can and should state leaders do to ensure that we have an adequate and sustainable public health workforce in Rhode Island?
McDonald: For me, this was a family move. It wasn’t about anything more than that. It wasn’t like more money would solve the problem. It wasn’t like anything else would solve the problem, just like I need to be back next to my extended family. However, I think you’re raising a great question. And I think looking at compensation is really important. One of the things I think you have to look at if you’re going to recruit a permanent director [is it’s] probably best not to be the lowest salary in the country. You might want to look at the reporting structure. So the Health Department is actually part of the Executive Office of Health and Human Services. So the state Health Director actually reports to the Secretary of Health and Human Services. So that’s different [from] other states, where they usually have the state Health Director report to the governor. We’re not really a direct service agency…so it’s just something to think about, like maybe the state health directors report right to the governor. That’s what you see in most other states.
Arditi: So we’re seeing hospital leaders and union workers clamoring for a larger share of the state’s $1 billion in unspent federal funds under the American Rescue Plan Act known as ARPA funds. Has the State of Rhode Island invested enough in public health as a state? And if not, where are the most critical needs?
McDonald: It’s time to reference Humpty Dumpty, because why not, right? But I think this is indicative of where we are as a nation. We spend a lot of money giving all the king’s horses and all the king’s men trying to put Humpty Dumpty back together again. And that’s now just to the hospitals and hospitals are very important. We’re fortunate to have them. But what we really need to do is invest in prevention, like Humpty Dumpty shaped like an egg. Where were the people next to Humpty Dumpty saying, ‘Look, you’re shaped like an egg, you shouldn’t be sitting on a wall!’ If you’re gonna sit on a wall [use] protective equipment. And far too often what I see in Rhode Island, as well as other states, is because people are sick and it’s so needing to help them right then and there, we’re spending a lot of money doing that. And that’s okay. But we sometimes do that at the expense of primary prevention. In other words, what can we do to prevent the problem in the first place? This isn’t necessarily filled by just dollars, though. Some of it is how you spend things to improve your social determinants of health. In other words, why do we need neighborhoods that are safe? Why do we need schools that are effective? Social determinants of health like this – so people have jobs with health benefits – these improve peoples’ long term health outcomes. Housing that’s stable. And this is where money should be invested in. You know, eliminating the problem of people with homelessness would be a big thing to reduce the drain on the healthcare system.
Arditi: After years of leading the nation in policies to address the opioid addiction epidemic, Rhode Island’s progress appears to have stalled. Drug overdose deaths in the state have spiked 42% during the last two years (which is 2019 to 2021). And that includes the year prior to the onset of the pandemic. I know you’ve helped lead the state during the opioid crisis, and we’ve won a lot of recognition for that. What do we need to do now that we aren’t already doing?
McDonald: I think the first thing I would do is get a harm reduction center open in the state. You know, we have the law passed, the regulations written. We need a municipality to say we want one. So I think one, getting a harm reduction center opened would be a very good thing to stop deaths, the sooner the better. I think the second thing you do is work on some of the things we talked about. What are things that are upstream, social determinants of health, that if you solve those, you get long term success? Those are things like fixing the housing problem in our state, which is eminently fixable in a small state like ours. I think other things to look at are like what we do to make sure our neighborhoods are safe and really places that people can walk. Walkability in the neighborhood helps so many other things. And the other thing I would look at is our schools, are they effective? Having effective schools [is] very important. The final thing I’ll just mention really quickly is finding full time jobs for people with health insurance. That’s a really good thing. When people have a full time job with a predictable schedule with health insurance their life gets more stable.
Arditi: So I know you’ve talked in the past that we’re now at the point and then pandemic where it’s a more of an endemic situation than a pandemic. And things have, in many respects, gone back to normal with some bumps. I’m wondering, are you concerned for the longer term as we’re facing new variants, and questions about long Covid and who is vulnerable to that, [given] the medical questions that have not been answered about long Covid?
McDonald: Yeah, it’s a national issue. So we’re in the endemic state, it’s going to be here for years. You know, one of the things that I think has undermined the nation, as far as Covid is, is disinformation that Covid is a minor illness and it doesn’t matter if you get it or not. Covid attacked everybody. And it really was one of those things where you can’t predict who’s going to have long Covid, who’s going to have the problem long term. And when you can’t make that prediction, you have this whole population of people at risk. And yeah, the elderly people and those with comorbidities are at higher risk. But this wasn’t survival of the fittest. It was survival of the advantaged.
Arditi: Dr. McDonald, you’re a pediatrician. And it looks like in terms of diseases, Covid is now the fifth leading cause of death in children. How should the state be trying to address the issue of vaccinations in children?
McDonald: One of the things I’ve just seen in my practice as parents that made the decision about the vaccine without me, which to me is just remarkable. When it came to Covid, really the threat that’s out there right now, you made that decision [with information] from strangers on the internet. A vaccine for kids under five is coming out at the end of this month, already you’re seeing that a majority of parents are like, well, I’m not so sure what I’m going to do with this. And that’s concerning a little bit to me that people are sort of so willy-nilly saying I think I’m gonna take a pass on this. Because a small percentage of everybody ends up being a big number. That’s what overwhelms the healthcare system. That’s what shut the country down.
Arditi: So what would your advice be to parents as they’re looking to consider [when] this vaccine comes out and becomes available what should they do?
McDonald: I would talk to your pediatrician about what you should do for your child. As a pediatrician I know my patients. Generally I see them when they’re two, three days old. I’m highly invested in the outcome of these kids. You know, and I know all about their stories, and about their families. I know what’s best for them. I’m happy to talk to parents about it. I think you should just talk to your pediatrician about it. Because quite frankly, your pediatrician knows what you want. But they actually have recommendations for you. I’d go ask them, see what their opinion is.
Arditi: Dr. McDonald, if you were to have one thing to say to Rhode Islanders in terms of how public health and the work you do and the department does impact lives in Rhode Island in ways that are not always seen. What are the sort of life saving impacts of public health that people in the state don’t know about or don’t see every day?
McDonald: Public Health literally saves your life every day. So in other words, if you had clean water to drink today, [if] you went to a restaurant and had a healthy meal, if you actually had air to breath that was clean, if you went to a health care provider who was competent – [those are] just a few examples of how public health saved your life today. Public health is invested in keeping you healthy. We’re the ones who actually say to Humpty Dumpty: Don’t stand on the wall dude, you’re shaped like an egg. No good outcome coming here. And you know investing in people who actually speak the truth honestly and objectively is in everyone’s best interest.
