Sunday, May 26, 2024

Mandy Cohen’s best shot

A relative newcomer to North Carolina, public health chief Mandy Cohen’s forthright manner earns respect while leading the state’s pandemic response.

In late 2019, the secretary of the N.C. Department of Health and Human Services, Mandy Cohen, was mostly just another face in the state bureaucracy, exhorting the legislature to take up Medicaid expansion, working to address the opioid crisis and warning about the dangers of the seasonal flu.

Meanwhile, a world away in China’s Hubei province, events were conspiring that would soon make her a household name across North Carolina, with the power to influence the lives of virtually every resident. On Nov. 17, 2019, the first case of what would become known as COVID-19 was detected, according to the South China Morning Post. By Jan. 20, 2020, the disease had arrived in the U.S. By March 3, North Carolina reported its first case. Less than 10 days later, Cohen was out suggesting a number of now familiar actions that could be undertaken to slow the spread of the virus.

“As we move through this, there may be a time when we, the government, have to enforce some closures. … We’re not there yet,” she said. But we soon would be, and Cohen would become the “figurative and literal face of North Carolina’s ongoing fight against COVID-19,” as the Raleigh News & Observer noted in citing her as its Tarheel of the Year. It’s been quite a wild ride for the 42-year-old who arrived in the state less than five years ago.

Having an impact “at scale”

Health care is something of a family enterprise for Mandy Krauthamer Cohen, who grew up on New York’s Long Island. Her mother, whom she cites as the inspiration for her career, was a nurse practitioner in emergency medicine; her father was a junior high school counselor in New York City. Her husband of 11 years, Sam Cohen, is an attorney with Raleigh-based Curi, a physician-owned company that mainly offers malpractice insurance. The two met when she was a resident at a Boston hospital and he was a law student at Harvard University. The Cohens have two daughters, ages 6 and 8, who attend Wake County public schools, which are currently operating under a hybrid in-person/remote-education plan. “I leave the home schooling to my husband,” she says.

Cohen’s academic pedigree reads like a Cook’s tour of the Ivy League: She received her undergraduate degree from Cornell University, graduated from the Yale School of Medicine in 2005 and earned a master’s in public health from Harvard. Cohen trained in internal medicine at Massachusetts General Hospital, though she spent only a modest amount of time in actual practice, quickly gravitating to the administrative side of the health care industry. (She’s a board-certified internist but does not hold a license to practice medicine in North Carolina.)

“I always knew I wanted to have an impact at scale,” she says.

That path took her to Washington, D.C., after medical school, where she landed at the U.S. Department of Veterans Affairs, serving as deputy director of Comprehensive Women’s Health Services. In 2008, she helped found Doctors for Obama, a nonprofit group that later morphed into Doctors for America, with a mission of promoting access to affordable health care. Co-founder Vivek Murthy became President Barack Obama’s surgeon general — and now President Joe Biden’s — while Cohen was executive director.

Five years later, and early in Obama’s second term, she joined the U.S. Department of Health and Human Services and rose to become chief operating officer and chief of staff at the Centers for Medicare & Medicaid Services, which oversees Medicare, Medicaid and the Children’s Health Insurance Program. The department also had responsibility for the Patient Protection and Affordable Care Act (also known as Obamacare), which meant Cohen had to help sort out the disastrous initial rollout of the Obamacare website,

That experience has played an important role in how she has approached the coronavirus crisis. “We spend a lot of time getting as much as we can on our dashboard,” she told an interviewer earlier this year, referring to the state’s public-facing coronavirus tracking website. “It’s not perfect, because the way we collect data is not perfect. But communication and transparency, I think, are core to being able to respond in a crisis.”

Gov. Roy Cooper appointed Cohen to her current role in 2017, putting her in charge of a department of 17,000 employees with an annual budget of $20 billion. Her salary is $206,000. Much of the work involves oversight of the 14 state-operated health care facilities and Medicaid, the federally backed program that provides insurance to nearly one in five North Carolinians. But it’s the public health role of directing the state’s COVID-19 response that has dominated Cohen’s time over the last year, giving her a much higher profile than previous DHHS leaders such as Aldona Wos or Lanier Cansler.

Cohen has received widespread praise across the state for her reassuring presence at weekly press conferences and for her management of the state’s coronavirus response. She strikes a lively balance with Cooper’s more measured style. Critics have slammed the governor for holding virtual Q&A sessions with the press rather than in-person gatherings that facilitate tougher scrutiny.

Outside those sessions, Cohen has been more accessible to reporters, whom she often calls on by name. Both Cooper and Cohen have shown a sense of empathy for victims of the disease.

Early on, the pandemic looked like a nail, so the idea was to hit it with a hammer. Epidemiologists and infectious disease experts advised the country to stay at home as a way to “bend the curve” of growing infections and increased hospitalizations. Cooper and Cohen embraced this approach, repeatedly citing a desire to “follow the science” in what became a national mantra.

On March 14, Cooper issued an executive order closing public schools for two weeks and prohibiting gatherings of 100 or more people and instituted the press conferences that brought Cohen regularly before the public eye. Dine-in restaurant service was halted, followed by a statewide stay-at-home order on March 27.

Still, key economic sectors were allowed to operate, including meat-processing plants and other agricultural facilities, over the objections of some progressive groups that contended that modestly paid, mostly minority workers were bearing the brunt of the pandemic. “We never shut down our essential businesses,” Cohen says. But they did work closely with the companies to put in new protocols to protect the workers. “We were bringing in medical-grade masks, putting up dividers, recommending staggered shifts, and introducing on-site testing,” she says. As a result, the spread of the virus slowed, and the plants stayed open.

Cohen has pounded home a simple message in press conferences and interviews: Follow the three Ws — do it to protect yourself, your loved ones and your community. If wearing a mask is an indicator of success, the strategy seems to be moving the needle. An August study found that about 60% of North Carolinians were generally wearing a mask, though the rate varied significantly from county to county. Five percent reported never wearing masks. By October, more than 80% of state residents were wearing masks in public “most or all of the time,” according to data from Carnegie Mellon University.

In prioritizing the state’s response, Cohen’s strategy has emphasized controlling infections while avoiding an overload of the hospitals. Ambulances stacked up outside an emergency room today tend to trump future mental health issues. As she puts it, “We are seeing that this virus kills, it kills quickly, and it strains our hospital systems very quickly.”

Based on mortality data, the approach of Cooper and Cohen appears to have paid off. As of Jan. 18, the state reported 77 virus-related deaths per 100,000 residents, tied for 11th lowest in the U.S. with Kentucky. Among Southern states, only Virginia had a lower ratio, at 67 deaths, while neighboring Tennessee and South Carolina reported 122 and 121, respectively.

Another important metric is contact tracing in which public health officials identify people who have been exposed to the virus. North Carolina appears to be above average, identifying the source of about 50% of its cases, according to Cohen. In this case, there may be natural limits to how successful this can be. “Some people don’t pick up the phone and talk to us,” she says. Other cases are just not possible to track. “It’s a virus. Sometimes you don’t know where it comes from.”

An innovation put in place by DHHS has been the SlowCOVIDNC Exposure Notification App, designed to notify users if they have been near anyone with the virus. It does this anonymously, without disclosing names, location or other personally identifiable information. But there’s a catch: Many people need to have the app to make it effective, and they have to self-report if they’ve become ill. The Associated Press reported in early December that just 482,000 North Carolinians had downloaded the app, limiting the effectiveness of something that depends on crowdsourcing to work.

Collateral damage

Here and elsewhere, what began as a one-dimensional epidemiological issue quickly morphed into a multifaceted social problem, with different demographic groups having widely different experiences in terms of hospitalization rates, fatalities and economic hardship. Domestic abuse, alcoholism, suicide and drug use have increased significantly during the lockdown. Remote learning has affected many students, with some N.C. public schools reporting serious declines in academic achievement. At Greensboro’s Page High School, Principal Erik Naglee told The Associated Press that more than half of students were failing at least one class during the fall quarter, more than double the pre-pandemic rate.

The American Academy of Pediatrics reports that “lengthy time away from school … often results in social isolation, making it difficult for schools to identify and address important learning deficits as well as child and adolescent physical or sexual abuse, substance use, depression and suicidal ideation.”

The pandemic’s economic impact has also been stark. More than 890,000 North Carolinians were approved for unemployment benefits during the pandemic, according to state officials, and 257,000 lost health insurance as a result of being out of work. The state’s unemployment rate peaked at 12.9% in April, the highest level since 1976, then declined to 6.2% by November.

Critics of the state’s approach to the coronavirus have mostly focused on the harmful economic impacts of the lockdown. Small businesses in the restaurant, entertainment and lodging industries have been among the hardest hit. Former Lt. Gov. Dan Forest made this a key part of his gubernatorial campaign, noting in May that “when we have over 1 million citizens on unemployment with less than half of those receiving benefits, countless medical surgeries and screenings delayed, and businesses on the brink of permanent closure, it is time to do everything possible to give people a chance to live and utilize their God-given freedom once again.” The candidate also questioned the wisdom of wearing masks as a virus deterrent. Cooper defeated Forest by a 51%-47% margin in the November election.

But dissenting voices have been getting louder as new data piles up on the long-term damage done by social isolation and economic hardship related to COVID-19. From the start, not everyone agreed that the path dictated by science was an obvious one. In a September Bloomberg opinion piece, science journalist Faye Flam wrote that “follow the science” is less a strategy than a slogan, arguing that “a strategy to deal with the pandemic needs to set priorities and incorporate values that science isn’t equipped to provide.”

Martin Kulldorff, a professor of medicine at Harvard whose work focuses on disease surveillance, contends that lockdowns have inflicted unnecessary harm on the broader population. “One of the basic principles of public health is that you do not look at one disease — you have to look at health as a whole, including all kinds of diseases, over a long period. That is not what has been done with COVID-19.”

Among other recommendations, Kulldorff advocates for a return to in-person schooling. “The lockdowns affect everybody, but they affect the working class and poor the most,” he says. While Cohen and Cooper have made similar points, they have not pressed local school leaders to expand in-person classes.
A.P. Dillon, associate editor for the North State Journal in Raleigh, has criticized the state’s willingness to share information. She says that Cohen’s department has made it difficult to download and analyze historical data used in the agency’s coronavirus dashboard, which tracks cases, deaths, hospitalizations and other trends.

For example, fears of overloaded hospitals are often cited as driving the state’s decisions, and hospitalization data is displayed prominently on the dashboard. It lists daily information on new hospitalizations, but you can’t find a side-by-side comparison of daily hospital discharges. (Though with a couple of clicks, there is a page listing the total number of those admitted who have left the hospital.)

But there is substantial turnover in the weekly COVID-19 hospital population. This would provide valuable insight into both the course of the disease and the pressure on hospitals. While it can be mostly gleaned from the dashboard, it’s not obvious to the casual reader. “When it comes to something that affects everyone you know, your state, your family, you need to have the highest level of transparency possible,” Dillon says.

Looking ahead

Before the pandemic erupted, Cohen was making progress on a key priority: the state’s opioid crisis. Opioid-related visits to emergency departments declined nearly 10% in 2018 from the previous year, before rising slightly in 2019. Unintentional opioid deaths fell by 5% in 2018. Gov. Cooper praised those results as a “major milestone for North Carolina.”

But 2020 showed a reversal, with emergency-room visits tied to opioids soaring 24%, which officials say is likely linked to higher levels of unemployment and social isolation. For Cohen, this emphasizes the importance of expanding Medicaid to serve about 1.2 million people who lack health care insurance. “COVID shines a light on the fact that North Carolina continues to have one of the highest uninsured rates in the country. When you’re trying to fight a pandemic, that puts us behind.”

Medicaid expansion, one of Cooper’s signature efforts in office, has been blocked for a decade by the state’s GOP-led legislature. Senate President Pro Tem Phil Berger and other Republicans contend the program is too expensive and poorly managed and shouldn’t be offered to most able-bodied adults between the ages of 18 and 59. Hopes that expansion would occur in North Carolina were largely dashed when the GOP held on to control of the legislature in November’s election.

To break the impasse, Cooper formed a bipartisan study committee that met in December and January with hopes of developing some type of Medicaid expansion that would satisfy both parties. By Cohen’s calculations, the state is leaving about $4 billion in federal funds on the table every year. “That’s a lot of money to help us fight COVID, to access mental health care,” Cohen says. “If we had more insurance, we’d be in better shape. Folks can’t get preventative care without insurance.” In response to rising health care costs, Cohen has promoted a collaborative approach and shown little interest in State Treasurer Dale Folwell’s push to require N.C. hospitals to publicize their insurance contracts and pricing policies.

But for now, the state is focused on getting the vaccine out. As has been the case elsewhere, the rollout has been less than smooth, encumbered by limited availability of the drugs and logistical bottlenecks. As of Jan. 18, about 1 million doses had been distributed in North Carolina, with about 302,824 administered, ranking near the bottom of U.S. states on a per capita basis.

That situation sparked unaccustomed criticism of Cohen’s work. Writing that the vaccine rollout was “one of the most anticipated world events in memory,” NC Chamber CEO Gary Salamido issued a Jan. 14 letter to members slamming the state’s performance. “The stakes couldn’t be higher, and our confidence couldn’t be lower,” he said, criticizing the failure of planners to engage the state’s private sector. North Carolina is home to world-class health care and logistical expertise, said Salamido, a former executive at drugmaker GlaxoSmithKline.

A Cooper press officer responded that the pace of vaccinations had doubled over the previous week and that North Carolina had distributed more doses than all but nine states and the District of Columbia. North Carolina is the ninth-most populous state. As of Jan. 18, the state had administered 2,887 doses per 100,000 citizens, ranking 41st per capita, according to the U.S. Centers for Disease Control and Prevention.

In truth, Cohen’s department lacks the manpower to physically handle the vaccination process, putting most control with the state’s hospitals, county public health departments and drugstore chains. She says the state is following recommendations of the National Academy of Medicine while making some adjustments to improve and speed the process including enlisting aid from the National Guard.

Preparation for crises is critical, Cohen agrees, but she points out that long-term planning advocates often go unheard because of tight budgets and competing priorities. At the advent of the pandemic, there were shortages of personal protective equipment in North Carolina and weaknesses in IT systems needed to collect data from the lab tests that Cohen says, “I wish I’d had earlier.”

Still, she cautions against excessive Monday morning quarterbacking. “You forget what you knew at the time, what resources you had,” she says.

During her years in Washington, D.C., Cohen observed how few doctors were engaged in the machinery of government. For her, the question was, “How do you combine experience in clinical medicine with policy making?” She has successfully managed to find a home for those twin interests, first at CMS and now in North Carolina, where the 2020 emergence of a novel coronavirus has provided as tough a test as anyone could imagine for wielding health care policy to impact lives “at scale.” ■

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