What Is Public Health? An Interview With Former Governor John Kasich

This is a transcript of my interview, conducted on January 11, 2022, with former Ohio governor John Kasich. I have added the subheadings.

Alfredo Morabia (AM): Thank you very much for accepting to be interviewed by the American Journal of Public Health. I’m Alfredo Morabia, the editor in chief of the journal. I was really intrigued the other day when I heard you in a webinar talking about public health and how the public understood what public health was. So, I wanted to ask you what, for you, does public health mean?

John Kasich (JK): Well, it’s really pretty simple. It’s doing the things in the community that keep the community healthy, and it can range across many different areas, which is what a lot of people don’t understand. It’s vaccinations, making sure that our restaurants are good and clean; it has to do with keeping an eye out that everything that affects the health of the community is being looked after, hopefully nothing left out. And so, it’s a broad range and something important that at times we take for granted.

IT’S ONLY WHEN IT DOESN’T WORK THAT WE PAY ATTENTION

AM: Why do you think that a lot of people don’t understand what public health is?

JK: I’m not sure anybody’s ever been educated about it. Nobody articulates what it really means and why it’s important. So, it’s a term without a definition. If you don’t tell people what something is, they gloss over it. It’s not their fault. It’s really the fault of people who are connected to public health. I’m not blaming the people who run public health, but the community at large does not talk much about it. When you go to a place like Flint [Michigan] and see the problems with the water—all of a sudden, people really understand public health. But as long as public health is working, we don’t pay much attention. It’s only when it doesn’t work that we pay attention. The problem is that it is not always funded to the amount of money that is needed for public health officials to carry out their mandate; we have to make sure that we can always have enough resources to enable the quiet heroes in our communities to do their jobs.

AM: Many people seem to think that public health is actually health care for the poor; and they don’t make the difference between public health, as you defined it, and medicine. How would you suggest we should explain that medicine is one thing and public health is something different?

JK: It is really in the areas where the public intersects with the public health community. We have to be able to explain what we’re about, and it’s most important that that comes from the bottom up. If you have street festivals, for example, why aren’t public health people manning booths with volunteers who can talk to the public, maybe offer them some public health services to show people exactly what it is and why it matters. Because if we can show how important these officials are, then people will like and appreciate what public health officials do. It’s bottom up and it’s also for public health officials and their advocates to begin to get farther up into legislatures and of course into Washington [DC] and into Congress. It is a massive undertaking because nobody’s done this before, but it would be a fun challenge to explain to people how your family and you are kept safe by public officials who get up every day and figure out how we can have safe communities.

WE SHOULD, ONCE A YEAR, HAVE A PUBLIC HEALTH DAY

AM: Do you think the name, “public health,” is a problem in itself? Should it be named differently? Because the opposite of public health is private health. Do you think we should use a different term or keep it the same because of its history?

JK: I don’t know. The problem is not so much in the name; it’s in how we define it. We have to do a better job of defining what it is for people. In my hometown, usually on Friday afternoon, many families go into the city center, and this ought to be a place where people get told about what public health people do in an interesting way. Perhaps we should, once a year, have a Public Health Day where people can hear about it. It’s just been very quiet. It really reflects the humility of people who are in public health, because they’re not out there bragging about what they do; they just do their job in a quiet and effective way. But maybe we need to be louder.

PUBLIC HEALTH IS PREVENTIVE IN NATURE

AM: Traditionally, in this country, public health has been the prerogative of the states and not so much of the federal administration. Do you think this is something that should change, that we should have a stronger federal input?

JK: No, I don’t think that things would get better if we just turned it over to the federal government. It is fundamentally a local issue. The federal government provides funding priorities, resources to combine with resources at the state and local levels. Accountability is very, very important and is something I feel strongly about. Here is the problem: When you just use the term “public health,” people’s eyes glaze over, even decision-makers, because there’s always something else that’s more urgent that needs to be funded. But when there is an acute problem in the community, then all of a sudden, everybody says, “Oh my goodness, we need to do something about it.” Think about public health as something that is, in some sense, preventive in nature. We have to explain to a lot of the decision-makers that, when we’re doing our budgets, we just have to make sure public health is in. When you buy insurance, you don’t brag about it. But when you have a problem, the first thing you do is to take a look at your insurance provisions. If you didn’t properly insure something, it’s a disaster, but if you did, you get a sense of having done the job the right way. The same is true for public health. It has to become a priority. Just as you don’t stop paying your insurance, we should keep the funding for something which fundamentally is an insurance called public health. If that makes sense to you.

PUBLIC HEALTH HAS TO BECOME A PRIORITY

AM: Certainly, that’s a great analogy, actually. It’s very convincing, and this leads me to think that currently instead of prevention, we use medical care and emergency centers as the first response when we have problems, and billions of dollars are wasted on medical care without any benefit for the patient. Do you think that some of that money should be reinvested in prevention and public health?

JK: Well, I don’t know. If you want to talk about the problems of the United States health care system, we could be here for a century and probably talk about it and never quite figure it all out. Public health needs to be considered as a priority when city councils are doing their budgets, legislatures are doing their budgets, the federal government, Congress, do the budget along with the President. They just need to make sure that this area is adequately funded. Are there areas in the government where there’s waste? Of course. Having been budget chairman and governor of a state, I know there are always areas where you can trim, combine, improve. The problem is there aren’t many people running around saying that we have to take care of public health. That’s the problem. It’s a quiet area. We just need to explain it better and more emphatically. We need to have our heroes; we need to have our champions, particularly at the local level, and I’m hoping that as we head through 2022 that we’ll have sort of an awakening of what it is that public health is all about. But it starts with the people who deliver it and their advocates, their volunteers, because we don’t want to have a Flint-type situation in anybody’s community.

AM: But, how can we do this? You say it’s a quiet sector, but then you don’t think that we should move funds from the medical sector toward prevention.

JK: I don’t know what that means. Moving funds to Medicaid and Medicare? I don’t think so. It’s a separate priority and a separate line item, and there’s money inside of all budgets that can be moved. In other words, can we spend a little less on X? Then we can spend more on Y. That’s how budgeting works. What are the priorities? What really matters? Does every program work efficiently? We don’t need to have a war inside of health care to have this as a higher priority. In fact, we need partners in the community in both the public and private sectors to talk about the fact that this is a terrific program that has to do with providing insurance for all of our communities to have safer, cleaner air, safer water, all of those kinds of things.

PITTSBURGH WAS CLEANED UP

AM: What would you say are the major achievements that public health has done over the last one or two hundred years? What would you use as an example that you think would be convincing?

JK: Clean water, cleaner air. I grew up as a kid in Pittsburgh [Pennsylvania], where the steel mills were belching really dangerous material. It is a long story, but the community at the urgings from the public health officials decided to clean this up. They didn’t go to Washington to get it done. They just said we’re going to have a higher standard in our community, and over a relatively short period of time, Pittsburgh was cleaned up. If you go and visit Pittsburgh today, it’s a remarkable city because business leaders, community leaders, public health officials all worked together to make sure that the public is well served. For our food supply, when there is a story of salmonella or whatever, public health officials are on top of it quickly. Public health means safer food, cleaner restaurants. I’m not a historian when it comes to public health, but as a regular old citizen, I know that it has contributed terrifically. Our schools are in better shape and safer. It is an effort to promote safety for our citizens.

AM: Absolutely. And what would you say would be the main goal for public health in the coming years? Which objectives could rally people around public health?

JK: After the pandemic, if we recover from the current politicization, people are going to ask whether there were things we could have done better or sooner. Like in Flint. Are there things they could have detected earlier? We need to be able to communicate in creative ways about the historic gains, as you mentioned earlier, of what has been done and about the goals that are to be set locally to improve things. This does not have to be boring. Creative people can come in and capture the imagination of people as to how we can continue to make progress, that we don’t have outbreaks, that we do have cleaner water. People are aware of the pandemic, but they are also increasingly conscious about the environment. We want a cleaner environment, we want cleaner air, we want cleaner water. That’s good for everybody. The goal has to be to continue to up our game and provide excellence.

EQUALIZATION HAS TO BE A PRIORITY

AM: Public health needs to be all-inclusive to be effective, and it cannot divide the population and act for some groups and not for others. Do you think that the role of public health in reducing inequities is important?

JK: Health equity is a growing concern. In business today we see ESG: Environmental, Social, and Governance. More businesses are aware that we have to deal with the problem of health equity and of food deserts. We have to be concerned about groups of our fellow citizens who are not getting the same kind of treatment, the same kind of good conditions that we have in areas where people seem to have more power. There has to be a concerted effort to make sure there is some equalization. It has to be a priority that we don’t have areas where people are not being treated as important citizens, as important parts of our communities.

AM: But in most other countries, this is done by a central ministry of health; there is some federal or central governmental authority to lead this change. What do you think?

JK: Well, I don’t want to live in any other country. Some of them are just a fraction of the size of the United States, but the idea to turn this over to the federal government is not acceptable to me. I don’t like that idea because it is a one size fits all, often, when it comes to the federal government. Priorities should be established by leaders at the state and local levels working together. I don’t buy the idea that somebody is going to swoop in from Washington and care about me more than the people that I see at the grocery store. The federal government has a fundamental role in providing resources and some basic goals. But I don’t want to turn public health over to Washington because in 10 years we will still be talking about how a one size fits all doesn’t work. It’s a philosophical difference, but being a former legislator, a former governor, a former congressman, giving more power to Washington doesn’t make sense to me.

AM: What about the public health dashboard, tracking infections, food insecurity, etc.? Aren’t these things part of the role of the federal government?

JK: Yes, the federal government’s in a position to set some standards and to take a look at places where there are egregious violations or goals that are not being met. That’s appropriate.

“HOW ARE WE DOING ON PUBLIC HEALTH?”

AM: Governor Kasich, is there anything else you’d like to add? I don’t want to take too much of your time.

JK: What’s important is that we’re all in this together. It’s really about finding people who are or can become advocates for public health and to turn them into important folks in our various levels of government: a congressman who goes to work and says we need to make sure that public health’s taken care of in a real way, a member of the legislature who says how important it is, people at the city council level who ask, “How are we doing on public health?” We need to reward those people for their interest and efforts. Right now, if I were to try and go to recruit members of the legislature and get them interested in public health, it’d be real work. However, if all of a sudden, as great advocates of public health, they made a name for themselves, began to make a difference in the lives of people and were recognized for it, you’d have a winner, and that’s what we should focus on.