Guiding New York City Through COVID-19

“The Doctor’s Art” is a weekly podcast that explores what makes medicine meaningful, featuring profiles and stories from clinicians, patients, educators, leaders, and others working in healthcare. Listen and subscribe on Apple, Spotify, Amazon, Google, Stitcher, and Podchaser.

In the first half of 2020, New York City quickly became the American epicenter of the COVID-19 pandemic, with over 200,000 cases reported in the first few months. The city came to a standstill as thousands of people died alone in hospitals and bodies piled up in freezer trucks that could not transport them away fast enough.

In August 2020, amid this cataclysm, Dave Chokshi, MD, of New York University Grossman School of Medicine, assumed position as New York City’s Health Commissioner and began the arduous task of repairing a broken city and restoring public trust among its residents. Prior to this work, Chokshi was chief population health officer for N.Y.C. Health and Hospitals and was a White House fellow at the Department of Veterans Affairs.

In this episode, Chokshi joins Henry Bair and Tyler Johnson, MD, to share the core values that drive his public health work and how he navigated the challenges of leading New York City through COVID-19.

In this episode, you will hear about:

• 3:52 How Chokshi, early in his life, came to understand the association between health and opportunity
• 7:40 A discussion of how privilege impacts the opportunities available to individuals and how this recognition impacts Chokshi’s medical work
• 15:48 How Hurricane Katrina revealed to Chokshi the flaws in our existing health system
• 19:34 Chokshi’s involvement with Universities Allied for Essential Medicines
• 24:31 An account of Chokshi’s tenure as New York City Health Commissioner during the height of the COVID-19 pandemic
• 32:31 Chokshi’s principles of effective leadership
• 37:15 Reflections on the first wave of the COVID-19 pandemic and how indebted society is to nurses and hospital house staff
• 53:48 Chokshi’s personal philosophy on maintaining a balanced sense of humility
• 57:38 Five lessons for medical trainees and clinicians on staying connected to what makes medicine meaningful

Following is a partial transcript (note errors are possible):

Johnson: So, Dave, can you begin by telling us, how did you end up being a doctor? What brought you into medicine?

Chokshi: Yeah, well, I was not one of those kids with the Fisher-Price stethoscope, I guess, is how I’ll begin. I was the first doctor in my family, and that meant that I didn’t really have role models for what it meant to practice medicine. I didn’t know the day to day of taking care of patients in that way. But what I did know and sort of observed through my childhood and young adulthood was all of the ways in which health was connected to opportunity.

You know, I experienced this personally as a kid growing up with asthma, watching how the diagnosis of diabetes affected my father and his life, and then having some early formative experiences that showed me just how tightly linked health and opportunity were. There’s one that comes to mind. It was a summer that I spent as a college student in Mumbai. Actually, all of my extended family lives in Mumbai, India. It’s where my parents grew up and I had the chance to work for a nonprofit organization called Committed Communities Development Trust in Kamathipura, which is one of the red light districts in Mumbai. And this was around the turn of the century, about 2000. And the organization was providing child care for the children of commercial sex workers in Mumbai, many of whom had been infected with HIV as a result of being a sex worker and many of whom had transmitted that infection to their children.

I thought about the lot of the kids that we were taking care of, and I thought about how little separated their life and the opportunity that they would have in their lives from mine. You know, if things had just been slightly different with respect to my family and their path, I could have very easily been in the shoes of the children that we were trying to take care of.

And I saw everywhere from that experience, from a few others that I had early in my career, that it’s not just a connection between health and opportunity, but it’s often a cycle. What I think of as either a vicious cycle or a virtuous cycle. Ways in which illness can beget other problems, often economic problems, sometimes poverty, but also the ways in which good health can beget opportunity in a positive way as well. So it’s all to say, you know, I was sort of propelled to a career in medicine because I cared about health and I found it so fundamental to people’s life prospects, whether it was in a red light district in Mumbai or where I grew up in Baton Rouge, Louisiana.

Johnson: Can I just ask, Dave, as an aside — we talk a lot on this podcast about deeper philosophical, metaphysical questions, and I feel like since we were in med school together, a term that has become very popular in the lay press and even in politics is “privilege.” And part of what I hear you saying is that it really is so striking to think about the differences in inherent privilege with which a person is born, depending on their zip code, their parentage, their social capital, their family situation, and on and on and on.

And there have been many studies recently demonstrating, for example, that one of the most determinative forces in a person’s life — in the United States, anyway — is the zip code in which they’re born. Right? Which makes sense when you think about the schools to which a person has access and on and on and on. But I guess from a philosophical perspective, that relatively early recognition that you had been endowed with enormous privilege because of where you had been born and what your parents did and educational opportunities and all the rest, that was so much greater than so many other people in the world. What do you do with that philosophically and/or how does that help to shape how you practice as a doctor?

Chokshi: Yeah, that’s a really thoughtful question. And first, Tyler, I have to say, I remember our conversations in med school so well. I actually remember we would sometimes have coffee in the bookstore on Penn’s campus and try to puzzle through some of these questions together. And I’ll just pick up on one of the words that you used, which is “endowed.” And I think that, just as you pointed out, many of us are endowed in a positive direction. We have the advantages that you described in terms of family and education and sometimes health as well.

But I think the realization that that endowment is not equally distributed and that so much of life circumstances are in some cases random and other cases represent the intergenerational transmission of things like illness or poverty, it makes me assess endowment in a different way as well, which is that it generates, it endows us with some responsibility to recognize the structural forces that we’ve talked about, but then ultimately to try to close some of the gaps that we see in our world.

One of the ways that I think about this is the difference between inequity and inequality. And the distinction that I always keep in mind is that inequity is a difference that is avoidable and unfair. And when we see inequity in that way, those of us who have the privilege to occupy spaces like we do in medicine or in other sectors, it’s our responsibility to take up those inequities and actually change the trajectory, change the direction in which those inequities cause illness and cause lack of opportunity.

For the full transcript, visit The Doctor’s Art.

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