In Washington, D.C., Howard Koh, MD, was known simply as "the ASH," an acronym for his full title, assistant secretary for health for the U.S. Department of Health and Human Services. But for a physician who had devoted his career to battling tobacco use, to suddenly be known as the ASH — even though the title connoted respect and authority — was a bit of a struggle, a smiling Koh told attendees at a recent Stanford Health Policy Forum.
In a wide-ranging conversation with Paul Costello, chief communications officer for the School of Medicine, Koh, currently a public health professor at Harvard, reflected on his time in the Obama administration (2009-2014) — where he played a key role in the implementation of the Affordable Care Act — his background and his passion for keeping as many Americans as healthy as possible.
Frustrated and saddened after watching patients die from preventable lung cancers, Koh explained that his entrée into public policy began with an effort in the early 1990s to pass a tobacco tax in Massachusetts. He served as the commissioner of public health in Massachusetts and then at the federal level, always crusading to reduce the harm caused by tobacco.
Yet despite substantive declines in tobacco use, millions are still dying and the issue is not getting the ongoing attention it warrants, Koh said.
"People think 'Oh, this has been solved,'" Koh said. "It hasn't been solved. It has fallen more heavily on disadvantaged people and those with mental health and substance use conditions. What I'm hoping is that we keep talking about prevention."
Prevention is a critical component of any effort to address health disparities, another point of personal passion and a topic he commented on in a recent JAMA editorial.
Koh said he turns often to words from the World Health Organization's constitution, inscribed on a building at the Harvard T.H. Chan School of Public Health where he works: "The highest attainable standard of health is one of the fundamental rights of every human being."
"This is inspiring to me. [Health] is a gift that needs to be protected and cherished. We as a society need to do everything we can to protect that gift," Koh said, adding that for many people, the gift of health is not accessible. For example, as he and a co-author write in the editorial, life expectancy in Hawaii is above 81; in Mississippi, it is only 75.
"Everybody should look at this. Are we truly a United States if this is what we have for the status quo?" Koh asked. Some of these gaps are biological, but many relate to health policy — the availability of insurance, for example — or the environment, and they illustrate a need to double-down on efforts to improve population health, preventing many diseases and conditions like obesity before they develop, he said.
"Right now prevention is rarely talked about in health discussions nationwide and that really bothers me."
Koh, who frequently broke into a warm, open grin throughout the talk, admitted that transitioning from a practicing physician to a federal official was not easy. "Medical students and physicians don't like surprises," he said.
Life in the federal government was full of surprises and flexibility was a critical asset, Koh said. He tried to have a strategic plan — achieving goals on tobacco control, HIV, hepatitis, among others — while remaining "very aware and ready for the unexpected."
Koh's preparation for his high-power career began as a child. One of six children of Korean immigrants — his father, Kwang Lim Koh, PhD, was a South Korean ambassador to the United States and his mother, Hesung Chun Koh, PhD, a Korean cultural scholar.
"My parents came here looking for the American dream," Koh said. "When you are a child of an immigrant family, you don't take anything for granted. I distinctly remember my parents lecturing to us that we were lucky to be born in this country with freedom and rights."
Kwang Lim Koh told his children how much he valued his relationship with former vice president Hubert Humphrey, Koh said. "A generation later, I work[ed] in the Humphrey [building], somehow I don't think that was an accident."
"I think about my dad and what he taught us, that there was some meaning to this journey," Koh said, his voice wavering. "I think that's what drove [me] into public service."
Photo by Becky Bach