Abstract
I have always been gratified that my career as a physician, first in academic medicine and then in public service, has allowed me to help people and work for the common good. I spent decades in academic medicine in pediatric and adolescent medicine at Mount Sinai in New York and at Penn State Health and the Penn State College of Medicine in Pennsylvania, focusing on the intersection between mental and physical health for children, adolescents, young adults, and their families. I served as the chief of the Division of Adolescent Medicine and Eating Disorders and then the vice-chair for clinical affairs for the Department of Pediatrics and a professor of pediatrics and psychiatry at the Penn State College of Medicine. In 2015, I was honored to join Governor Tom Wolf’s administration as Pennsylvania’s physician general and then the secretary of health for Pennsylvania, where I am proud of our efforts toward reducing opioid overdose deaths, improving maternal health and increasing childhood immunization, advancing access to care for LGBTQI + Pennsylvanians, establishing a medical marijuana program, and leading the state’s response to the COVID-19 pandemic.
During my tenure as the 17th assistant secretary for health at the US Department of Health and Human Services (HHS) during the Biden-Harris administration, I heard firsthand accounts in communities across the country about the public health challenges faced by frontline colleagues at the local, county, tribal, and state levels. The impact of climate change on health, increasing vaccine rates, and the People and Places Thriving approach are three areas where I found tremendous opportunity to advance health equity. 1 The opportunity to serve as the Assistant Secretary for Health, overseeing 10 public health offices, several presidential and secretarial advisory committees, the Office of the Surgeon General, and the US Public Health Service Commissioned Corps, utilized a health equity lens in every stage of work to reliably and meaningfully deliver on the public health imperatives and needs of people across the United States. 2
Health equity: An essential approach
Health equity, defined in Healthy People 2030 as the attainment of the highest level of health for all people, has long been a central principle to public health. 3 For the first time in many years, this definition has recently been changed and the very idea of health equity has been politicized as somehow woke or divisive, but health equity and its longstanding definition are fundamental to public health. The acute phase of the COVID-19 pandemic revealed the depth and breadth of the health disparities in our nation. We know that low-income families and historically underserved communities bear the brunt of climate-induced health risks because they live in areas that are vulnerable to climate change, have limited ability to relocate or rebuild after a disaster, and have limited access to quality health care. 4 In a visit to the Northeast Kingdom of Vermont after massive flooding devastated St Johnsbury, I learned first-hand about the importance of health care system resilience and the challenges facing local clinics; many did not have the technology and systems in place to be able to stay open during and after the adverse weather events. Achieving health equity requires intentional, sustained efforts to end inequities, eliminate injustice, and improve health outcomes for everyone. Sadly, the HHS Office of Climate Change and Health Equity and the HHS Office of Minority Health, both of which advanced this work, have since been disbanded.
Our work in the Biden-Harris administration across the Office of the Assistant Secretary for Health aligned with the HHS Strategic Plan Fiscal Year 2022-2026 5 and the HHS Equity Action Plan. 6 We used a health equity lens to evaluate programs and policies, produce inclusive public health communication, and involve the communities most affected by our actions. For example, I focused on reproductive health in the face of the Supreme Court’s Dobbs decision, which overturned the landmark Roe v Wade case, effectively eliminating the constitutional right to abortion in the United States and allowing individual states to regulate or ban abortion access in their jurisdictions. 7 We worked to restore access in all 50 states to Title X family planning and reproductive care services for low-income individuals and families, managed the evidence-based Teen Pregnancy Prevention grant program, and released the 2024 revision to the National Recommendations for Providing Quality Family Planning Services.8–10 Since January 20th 2025, much of this work has been eliminated or reversed. The Office of the Assistant Secretary for Health has worked on nutrition security, in partnership with the US Department of Agriculture, to consider both access to and nutritional quality of available food, and promoted the concept of Food is Medicine. 11 In a visit to East St Louis, Illinois I was astonished to see corner stores with soda, chips, and liquor while the nearest grocery store with fresh foods and produce was more than 10 miles away. I saw food deserts in the Navajo Nation, where only a single grocery store was available in a long stretch of land. Health equity was also a cornerstone of the National Syphilis and Congenital Syphilis Syndemic Federal Task Force, which I stood up and led from 2023 until the end of the administration. This task force leveraged and directed federal resources to address the highest number of syphilis and congenital cases nationwide since the 1950s and the highest rate of syphilis among American Indian communities in the Great Plains since 1941—before penicillin was available as treatment.12,13 Using the health equity lens, we also saw the syndemic of syphilis and HIV and the need for more attention for the population of gay and bisexual men and other men who have sex with men. 14 The HHS mission to enhance the health and well-being of all people in the United States is essentially a message of health equity. 15 Throughout all of this work, I found that health equity underpinned each of my public health priorities. 1
Climate change and health equity: Crisis and opportunity
One of the most pressing public health issues of our time is the effect of climate change on health. We tend to think about the health effects of climate change as something distant, far in the future. But it is here now, and the manifestations of climate change are causing great suffering, particularly to the most marginalized and medically underserved among us, such as racial and ethnic minority groups, older adults, people with disabilities, children, and low-income communities.
In 2023, greenhouse gas concentrations, the global temperature across land and oceans, global sea levels, and ocean heat content all reached record highs. 16 2024 was the hottest year on record. 17 In my official travels, I heard stories and witnessed the profound effect of extreme heat on human health and survival. I heard from young farmworkers in Orlando, Florida working in extreme heat environments about them developing renal insufficiency and failure. I saw the effect of rising sea levels and the loss of freshwater sources in New Orleans and communities along the Mississippi River. Severe flooding in Vermont, powerful atmospheric rivers in California, and storms and hurricanes rapidly strengthening from Category one to Category five storms in the span of 24 hours have caused catastrophic floods, damage to property, and death.
In addition, I saw the real threats to homes and food security for rural, Alaska Native populations as they watch the permafrost melt under their feet and lose access to traditional hunting grounds. Vector-borne diseases from mosquitoes and ticks expand their geographic range, timing, and intensity to threaten new, susceptible human and animal populations. The effect has been felt from New York City to Seattle, from San Jose to Albuquerque, and from Orlando to Miami—in Native American lands including the Navajo Nation—and everywhere in between. Climate change is harmful to physical, mental, spiritual, and community health and well-being. 18 As leaders in the public health and health care fields, we have opportunities for engagement on this global threat to human health.
The US health care system alone—hospitals, health centers, suppliers, health insurance companies, group purchasing organizations, pharmaceutical companies, and more—are responsible for an estimated 8.5% of national greenhouse gas emissions. 19 And, as of November 2024, more than 1200 federal and private sector hospitals, representing more than 19% of US hospitals, have signed the Health Sector Climate Pledge, a voluntary commitment to climate resilience and emissions reduction that includes cutting greenhouse gas emissions by 50% by 2030 and achieving net-zero emissions by 2050. 20 To get there together, the now-disbanded HHS Office of Climate Change and Health Equity managed a Catalytic Program which leveraged the Inflation Reduction Act to support the healthcare sector invest in clean energy, building efficiency, building resilience, and more. 21 Unfortunately, much of that funding and federal support has been eliminated. In addition, the National Academy of Medicine, recognizing the critical need for health sector leadership, launched the Action Collaborative on Decarbonizing the US Health Sector, a public–private partnership of leaders focused on the supply chain and infrastructure, health care delivery, health professional education and communication, financing, policy, and metrics. 22 Despite the federal changes, we must continue to work across sectors to reduce the health sector’s contribution to climate change and protect the health and well-being of those most vulnerable to climate-related health effects. These efforts are good for communities, for business, and for public health.
Promoting trust in vaccines
The development of COVID-19 vaccines was a remarkable advance in vaccine science. Vaccinations and immunizations are critical to preventing an array of once common infectious diseases. People no longer remember the scourge of polio so rampant in the 1940s through 1950s. Thanks to the development of effective vaccines, whooping cough, tetanus, measles, and rubella, which caused morbidity and mortality especially in children, have been substantially reduced. 23 We have been able to almost completely eradicate smallpox. As a medical resident, I remember when the Haemophilus influenzae type b vaccine was developed, preventing an untold number of cases of meningitis and associated brain injury–related complications and death. 24 And we now have vaccines for older adults, such as respiratory syncytial virus, pneumococcal conjugate, and shingles vaccines.
Unfortunately, these advances in public health are now being challenged by vaccine hesitancy, public mistrust—as evidenced by the resurgence of measles and other vaccine-preventable diseases—and widening health disparities. My office developed, in collaboration with federal partners, a Vaccines National Strategic Plan that has a listed goal of countering vaccine misinformation and disinformation. 25 Health communications messaging and social norming campaigns that create dialogue to correct public misconceptions about vaccine effectiveness and safety will be essential to reestablish trust in vaccines and public confidence for future public health endeavors.
People and places thriving approach for a happier, healthier, more resilient nation
While many public health challenges exist, including the dismantling of the federal public health infrastructure, increased housing insecurity, lack of transportation, nutrition insecurity, environmental injustices, climate change, and lack of access to comprehensive reproductive health care, we cannot solve all needs within the traditional public health framework. Instead, we must collectively understand our relationship to these needs and how our collective resources can help create enduring cross-system solutions.
I want to share an approach my colleagues and I developed at HHS and called the People and Places Thriving Approach. 1 This approach takes a holistic and realistic perspective to address human needs. It is an evolution of the concepts we have often referred to as the social determinants of health. The social determinants of health are the mechanisms we use to drive meaningful change. The social determinants of health are the conditions in which people are born, live, learn, work, play, worship, and age. 1 These factors influence health, functioning, quality of life, and associated risks.
As I traveled across the country as the Assistant Secretary for Health, I have seen the ways in which the health and well-being of the people I met are influenced by issues beyond the immediate scope of federal health agencies. Communities need reliable transportation, humane housing, economic justice, environmental justice, and climate justice. They need an increased sense of belonging and confidence in exerting their civic muscle. Improving our nation’s health and well-being requires addressing these needs.
Focusing on the vital conditions of health requires a philosophical shift in how we work and what we are trying to realize. First, this work encompasses a whole-of-government approach. While I served as the executive champion during my time as the assistant secretary for health, the People and Places Thriving Approach was co-created and is endorsed by nearly 50 federal departments and agencies. The breadth of active interagency partnership was a testament that the People and Places Thriving Approach is different from what has come before. It is a testament to the value of fostering the right shared ethos, of building a structure that rewards proactivity and innovation, of building connections, and of aligning work across diverse federal agencies.
Second, to address the root causes of health inequities, it is critical that we expand and diversify the federal agencies and economic sectors working to realize a more equitable society. The underlying framework of the People and Places Thriving Approach is known as the Vital Conditions for Health and Well-Being. 26 This framework provides a roadmap for realizing a broader and more inclusive approach to public health. It provides an asset-focused and actionable organizing structure designed to yield complementary, synchronized, cross-agency delivery of goods and services.
Third, the People and Places Thriving Approach is focused on the long game. Specifically, it seeks to equitably address enhanced long-term resilience during the next decade and beyond. This consideration of long-term needs of a community deliberately differs from a focus on immediate recovery from a disaster, such as restoring power or reopening a school. Efforts toward near-term recovery are critical, but they are not sufficient to achieve improved, sustainable resilience for individuals and communities or meaningfully address deeply rooted health inequities.
Finally, the work of the People and Places Thriving Approach intentionally shifts our language to be transparent. It aligns with how communities understand their needs and prioritizes acknowledging shared assets. As leaders who are a part of and engage with our communities, we need to use community-driven language.
All of us are critical partners to help ensure the success of the work ahead. The primary focus of the People and Places Thriving Approach is on actions that federal partners can take to better align and maximize their departmental and agency resources. However, it also provides shared concepts and language through which the federal government can better engage civil society. Through the framework of the Vital Conditions for Health and Well-being, we can all understand the needs of communities and align the resources of the federal government to best meet those needs.
There is incredible uptake and leadership across the country from state public health leaders, local governments, and civil sector organizations to focus their resources on building long-term system capabilities that increase equitable thriving. A growing number of states, including California, Delaware, and West Virginia, as well as jurisdictions such as Palm Beach County, Florida, and Fox Cities, Wisconsin, are investing in solutions to vital conditions, including humane housing, belonging and civic muscle (ie, having fulfilling relationships, social support, and community engagement), basic needs for health and safety, reliable transportation, meaningful work and wealth, lifelong learning, and a thriving natural world. 27 Several states and communities are finding inspiration in the recommendations of the People and Places Thriving Approach and taking action to implement recommendations in their communities, such as Healthy Communities Delaware; Empower Upper Cumberland in Tennessee; and Wild, Wonderful & Healthy West Virginia.28–30 This growing momentum is powerful. I am committed to supporting and partnering in that expansion, to align the work, and to share this ethos of thriving.
I would like to invite you to join me in sharing a commitment to thriving for all people and places in our nation. We have an historic opportunity to reposition our collective resources and expertise and to move our focus beyond health protection and health recovery. We can collectively support all people, in every community, as they achieve and sustain well-being. I hope that the complex and deeply rooted health inequities that we see across communities can be clearly defined and addressed so that we all can work together more effectively.
I believe in a fundamental truth: that we need each other; that our happiness and survival depend on our connection to one another and our community; and that the spirit of community is what we need now more than ever, and we must call upon it again. I believe we can, and must, build these connections and opportunities to realize health and well-being. We can do this in a manner that enables us to truly support equity in engagement, access, and outcomes and build a society in which all people and places thrive, with no exception.
We can do better, we must do better, and with your help, we will do better.
Footnotes
Acknowledgements
The author thanks the political appointees who served on her team in the Biden-Harris administration and assisted with the projects outlined in this article: Sarah Boateng, MHA; Maura Calsyn, Andrès Argüello, Adrian Shanker, Arsenio Mataka, Lynn Rosenthal, Jess Marcella, Ana Mascareñas, Adam Sarvana, Max Lesko, Steven Lopez, Melea Atkins, Jonathan Moore, Madeline Ambscome. I also acknowledge the dedication of the hundreds of career public health leaders who worked at the Office of the Assistant Secretary for Health during my time in office, and the 5500 commissioned officers of the United States Public Health Service. . Rachel L. Levine served as the 17th U.S. Assistant Secretary for Health.