April 14, 2021
Sanjula Jain 0:03
Women make up 70% of the healthcare workforce, but only 20% of its leadership. On Her Story we’ll explore the careers of bold and influential women, from Silicon Valley to Capitol Hill and learn how they’ve overcome the odds. I’m your host, Sandra Jane. And this is Her Story, a program where we explore what’s beyond the glass ceiling. This special edition is guest hosted by Lynne Chou O’Keefe, Founder and Managing Partner of Define Ventures and founding member of the Her Story Advisory Council.
Lynne Chou O’Keefe 0:35
Karen, thank you so much for joining us at Her Story where we talk about leadership and healthcare. There is not a better person to talk to than you about this in terms of your long accomplishments, in terms of being a physician, being in government, and then also as a public health commissioner and then also at Google. We have so much to cover here, so thank you so much for your time today.
Karen DeSalvo 1:03
It’s good to see you. I’m delighted to be here. I can’t wait for our conversation. These are difficult times for so many people around the world, but it makes it even more important to make sure people have the chance to share and hear stories from others, so I’m happy to share a little bit of mine.
Lynne Chou O’Keefe 1:17
Thank you, Karen. What’s been so phenomenal about Her Story is people starting from the beginning. Many of us have been influenced by how we grew up, our family. I’d love to hear about how that’s shaped your vision of leadership and how you’ve progressed in your career.
Karen DeSalvo 1:37
I have a very scrappy origin story. We were quite poor. I was a free lunch kid. My mom raised us—there were three of us, I’m the middle child—she raised us after my dad left when I was five, and she did that pretty well on her own. She didn’t have family support for a variety of reasons and was just a remarkable woman. She didn’t have a college degree, so she started working on what she could do. She was a housekeeper, basically. One of the jobs she had for a while was, when people moved out of apartments, she would go in at night and clean them. Our neighbor would spend the night at the house so somebody was watching us and then she could go to work all night and she was awake all day taking care of us. She was the kind of person that put others before herself and found a way to help us get out of poverty by encouraging us to get an education. It very much shapes the way I think about the importance of doing for others and putting the community first.
Lynne Chou O’Keefe 2:34
You’ve done so much work around health equity, how you think about social determinants of health. Has having this type of perspective been a driver for you?
Karen DeSalvo 2:45
It’s interesting. I say a lot that my poverty was not dangerous poverty. We were poor and we had food insecurity. My mom had mental health issues, and so did my father, so there was a lot of instability in the circles around us, but I didn’t have threats in the life-and-limb kind of sense. I also had the advantage of growing up in Austin, Texas, which at the time was a relatively small town of 300,000 people, but it had a very strong infrastructure to support kids in poverty. We had a public transportation system that was reliable and safe and allowed me to get to after-school programs and go to dance and theater classes at the Austin Recreation Department Center. After school, we would go there because my mom was working and that was the way we had further personal development, a safe place to be, and it was basically free. We had parks, we had outdoor theater movies. The reality I had programs like a recreation department or green space and safety makes me think a lot about how important context is to people’s development. It wasn’t just that I had a mom who said “education is your way out of poverty” and “think about others because someone’s always struggling more than you are, no matter how much you are.” I’m grateful because I had this social infrastructure and I don’t think a lot of kids have that. When I was the health commissioner, it was a very stark contrast for me because when you’re the commissioner for an urban environment like New Orleans, you spend a lot of time in low-income communities. That’s when the contrast became clear for me that, because I had all that built environment support, there was more opportunity for me. One of the many ways we have to drive equity for kids in communities is to see that, not only that they have strong education and parenting, but that they also have those contextual factors and social infrastructure that can provide support for them.
Lynne Chou O’Keefe 4:42
Your mom sounds like an amazing woman and influence in your life. Did you have other influences or mentors as you went in? How did this progress into healthcare and how you started your career there?
Karen DeSalvo 4:57
My peer group and my mentors came a lot through that dance and theater I did as a child. It was a really good, safe outlet for us and that was an important counterweight to some of the other stressors and it drove some discipline into our lives that we might not have otherwise had as kids. I had a couple of teachers in high school. Coach Patrick was one of them. He told me I was intellectually curious. No one had ever told me that before. It felt cool that somebody recognized an interesting talent or characteristic I had and it inspired me to want to continue to learn and improve myself. He happened to say the right thing at the right time. He was the social studies teacher. Somewhere in about that same time, when I was in eighth grade, I was still dancing a lot and thinking I was going to go on that pathway professionally. I’m not saying I was that good, but I thought that in my head at the time.
Lynne Chou O’Keefe 5:51
We’re lucky in health care then, that you didn’t become a prima ballerina, because we need you in this space.
Karen DeSalvo 5:58
I did a little due diligence. “I don’t want to be a dancer because that sounds like a difficult life. What are the things that I like? I like helping people, I like science.” Then I did a book report on radiation therapy and got to go visit some radiologists in their practice. I thought, “Well, this seems like a nice marriage of all those things. I think I’ll be a doctor.” It was that naive. I didn’t know any doctors. My parents hadn’t been to college. Later my mom did graduate from college, she went back to school, but I didn’t have any idea what I was getting into. That’s thematic of many things I’ve jumped off the cliff for in my life. I’m like, “This seems like the right thing to do. I’m just gonna go and learn along the way,” but I’ve never looked back. It was not easy for me to get into medicine. Statistically, I’m not the kind of kid that should have gotten in, especially back in ’88 when I started med school. Poor kid, single parent, nobody in the family was a doctor and I was able to get into the Tulane School of Medicine, which gave me a chance. Then I was able to get a scholarship from the National Health Service Corps to pay for school. Otherwise, I would have been in crazy debt. As everything worked along the pathway, it was the right school for me to be at, it was the right city here in New Orleans, and HRSA (that program that drove me toward primary care) were the right mix of things to build out a career that I love.
Lynne Chou O’Keefe 7:14
Amazing. You knocked it out of the park getting your MD, your MPH, you went to Harvard. There are so many things you did. How did you then become Commissioner of Health for the city of New Orleans versus practicing medicine? Was that also accidental? Or was it intentional in terms of how you thought about your next step?
Karen DeSalvo 7:37
Backing up before I became Health Commissioner, I joined the faculty at Tulane when I finished my residency as an intern. I had in my head that I wanted to do hospital quality work, so I was doing that for free. I told the chair of medicine that I’ll do all this other work, but I also want to do this work. He said, “Fine, but I’m not paying you to do it,” because he didn’t understand what I was trying to accomplish. I did that work. However, a few months in, he said to me, “Karen, starting July 1 next year, you’re going to be the director of the resident internal medicine clinic.” This is where the trainees see patients and we teach them. I said, “Thank you so much for the opportunity, but I’m not interested in running an outpatient clinic. I like hospital work.” He said, “I don’t think you understand. Starting July 1, you’re going to be running the resident clinic.” I was like, “Oh, I see what’s going on here.” It was such a gift. I didn’t want to do it. I hated the clinic. I thought it was a broken environment where you never had the records of the patients (this is back in the paper days). You didn’t have continuity. It was difficult to teach in that environment. I liked the pace of inpatient medicine, etc, etc. What he gave me as a gift were many things. One was a leadership role where I had essentially free rein to redesign a system for Charity Hospital (our public hospital) because there was no one else paying attention to it. We got to implement electronic scheduling. We began looking at electronic health records even way back in 1999. We did a lot of quality improvement work, essentially, to make it so that when people arrived at the clinic, instead of it being 15% of the time that they had a record there, it was 90% of the time. We were able to improve continuity and change the wait times from 12 months to the next available appointment to two weeks and hold it there. I got so excited about the fact that you can take a broken system, do your root cause, work with teams, and make a better system for the patients but also for the people who were there in the learning environment and in the care environment. That spurred in me an interest to do more than take care of patients in front of me, which I did for 20 years. I love the practice of medicine but, if you want to level the playing field, to raise the floor and eliminate the median, you have to have a better system. I got really excited about the system in not only that environment but, as time went on, going back to this idea of context and the systems in which we live, learn, work, and play. That’s public health. I wanted to expand what I was able to do to help my patients and my community beyond what happened in the healthcare environment and into their everyday life.
Lynne Chou O’Keefe 10:14
It’s amazing. Let’s flash forward to when you were there. I’d love to hear about one of the things that happened, I believe at this time was Hurricane Katrina, and what it meant to be in that role as a leader during that crisis. Did that shape how you think about things? We’ll fast forward and get to COVID, but I’d love to hear about that early experience in public health crises.
Karen DeSalvo 10:57
When Katrina happened in August of 2005, I was actually still on the faculty at Tulane. I had a line job. I was the Chief for General Medicine and about three-quarters of my time was research-oriented. I was on a pathway of trying to change the world one paper at a time because I was doing this very academic thing. Some people, like Francis Collins who runs the NIH or Tony Fauci, can change the world one paper at a time. That was definitely not going to be my path, so the occurrence of that catastrophe was a moment in time when I had to reflect on where I could make the most difference. Because of my experiences with, knowledge about, relationships with, and passion for the health of my community, I decided to put down my more academic pursuits and step into the community. It’s a long story, but the long and short of it is that, from the time after the storm passed until the time I went to Washington (so about 10 years), I worked on rebuilding community health and public health in New Orleans. The reason I tell you I wasn’t the health commissioner is so you can understand that for me that experience was about influential leadership. We had a vacuum. We had no local public health leadership and the community was struggling and flailing and trying to figure out what to do. One of the roles I had was to bring people to the table who came from community health, mental health, social care sector, academia and who didn’t have a discreet role or responsibility but who cared deeply about rebuilding a better New Orleans. We did this in health but it was a similar story in the education system and the criminal justice system and even the levees, that citizens stepped forward and said, “This is broken. It needs to be fixed and the leadership we have right now isn’t capable of doing that, so we’re going to find a way to not only stand up the new structure but stand up a new governmental infrastructure that can better support the community going forward.” That is one of the reasons I became the health commissioner. I had done all this work through my academic chair and we built out community health and made a lot of progress, but I didn’t want to leave a city without a strong public health department, without real statutory public health leadership. Every day I woke up and said, “Today my responsibility is the health of everyone who lives, learns, works, and plays in my community. How can we bring forward that vision of a truly healthier New Orleans?” Because it’s not only going to happen from healthcare. I knew we needed to have a stronger public health enterprise. That is the high-level, happier story about how we got to improving health and public health in the community. We built a network of community health centers that serve about a quarter of a million people, which is about a quarter of the city of New Orleans. At the time, most of them were uninsured. Now they’re insured through the Affordable Care Act or Medicaid centers, receiving care and patient-centered medical homes that are high quality across the city and enabled with health IT. We’re all very proud of the work we did. It’s an accredited public health department, but none of that was seamless or easy. Frankly, it required a lot of me getting up day after day after day saying, “I’m not going to let this defeat me. It’s the right thing to do for our community,” and just being tenacious about wanting to overcome that big crisis. Then realizing there were all these little crises everybody in my community was facing every day and we needed to find a way to smooth that out for them, too.
Lynne Chou O’Keefe 14:31
One thing in that experience—which would be great to hear because there are so many individuals listening to this—is it sounds like a tumultuous time. You had to be influential at times, then it sounds like you had more line authority, but you still had to gather different opinions and leadership, I have to presume when you talk about community health. How did you as a leader galvanize people to a vision and then to action? Were there certain things you learned that we could each take as leaders to understand that? Because that’s a particularly difficult situation that every leader sees. I’d love to hear if there were ways or strategies or methods that you thought about.
Karen DeSalvo 15:15
I think there’s just generally good advice for being a good human. One is to listen, but more importantly to listen with humility. I actually started learning that from my patients even before the crisis. Over the course of all of these years, even into today, I find that if I can listen with humility and be honest about where my knowledge begins and ends, that people are more forthcoming. It’s a trust-building exercise at the root. In medicine, trust is job one. If you don’t trust me as your doctor, we’re not going to get very far together in your health and your health outcomes, so a lot of my patients helped me understand listening. There’s also this thing about listening that I’ve had to continue to learn to hear. I’ve had so many patients trying to tell me they’re taking their medication but their blood pressure is still high and it’s not working for them. I had this one woman in particular. Over the course the time, as I continued to build a relationship with her and listen, I learned that she was in an abusive relationship and she was compliant. She was under so much adrenaline stress all the time from this physically abusive relationship. That’s the help she needed. She didn’t need me to keep hammering on her about taking her meds. With our help, she was able to get off of her hypertensives. Her story—and there are so many others—where it was looking past the first layer. Listening and knowing you don’t know the answers, not going into it with the solution but listening for what’s really their problem, is the first part. The second is being able to find common ground. This is one of the things I love to do at work and in a time of crisis when you’re trying to bring people to a shared vision, to get over the hump. When you’re trying to get people to develop shared policy (work I’ve done at the national level) or just solve a thorny problem that feels more mundane. There’s always common ground. The Venn diagrams always overlap. To me, it’s such a sweet spot when you find that moment and you’re like, “Oh, what you’re saying is this and what you’re saying is this. Does this make sense that this is the thing that we can all do together? Yes? Okay, then let’s move forward on that.” Maybe one of the reasons I like doing it is because it feels so joyful when you find that place of common ground, even for people who think they have nothing in common.
Lynne Chou O’Keefe 17:37
We need so much of that right now. It’s so powerful. I’d love to delve into the patient-human relationship with the physician you just said and then you did it on a community level and then you went on a national level at HHS. It sounds like a lot of those principles held true, but did they further in some way? Did you learn new lessons from that?
Karen DeSalvo 18:02
It was so hard to do federally, and there are a bunch of reasons. When you’re working in the federal hierarchy there are these appointed positions and you’re a principal, so then you have a ring of people around you that are dictating your schedule and telling you where to go. It would be very easy to live in that bubble and have people telling you what you want to hear and you only see things that they want you to see. I had a moment when I came back to New Orleans for a weekend. I was driving around with my friend who had become the health commissioner after I left. We were going to an event in the community, a really low-income community, and I looked at her and I said, “I haven’t seen poverty in months. This is not good. My job is to make policy for all people in America, not just the people that can make it into my office.” That caused me to shift a few things but definitely, as I did trips in the field, to do listening sessions and to break my team from setting up a listening session with people who would say, “We love your policy. We think your HIT approach is great right. We love electronic health records.” That’s not what I need to hear. I need to hear, “This is broken. You’re an idiot. These are the things you should do differently.” You have to be real about it. You have to get real input and feedback. I had to work to make sure I stayed in touch with a counterweight, counter opinions, counterpoints of view, and just frankly reality to find new ways to do it. We’ll get to Google, but I started to do listening sessions when I joined Google. Then the pandemic happened, so it’s been harder for me to feel like I can stay grounded in who I’m here to serve, which is really what drives me.
Lynne Chou O’Keefe 19:38
It’s beautiful because—I don’t want to put words in your mouth—but the one thing that’s given you an edge in your career is this perspective that started from childhood, the listening and understanding. Through your relationship as a physician, to the community, on a national level, and now you’re doing that at Google, too. That’s one thread if you will. Are there other edges or things in your career you feel have taken you to that next level of understanding or leadership?
Karen DeSalvo 20:14
I’m a little unsure how to answer the question because I feel so grateful for the opportunities that I’ve had. I know we’re not supposed to say that. I know we’re supposed to say, “I’ve worked hard. I prepared myself. All these opportunities are here because I made them and created them,” but I clearly didn’t create a hurricane. What I did do was say, “This is a mess, and I have skills, and I can make a difference.” I tend to run into the fire, is what I say sometimes. When there is a problem, a disaster, a broken health department, a broken community— I’m not saying Google’s broken at all, that’s a different issue. Google’s got an opportunity, but I don’t shy away from those kinds of challenges. I’m actually inspired by them. I love things that are a mess, finding order to them, and then seeing that they are a new, better iteration. I don’t know if that’s an edge, but it definitely drives me. Things have come to me and, while some people might run away because they look too messy and scary, those are exactly the kinds of thorny things I like to tackle with really smart people and think about what could be. How do you make something better out of something that’s not so good right now?
Lynne Chou O’Keefe 21:23
It energizes you. You can hear it in how you’re thinking. It probably dovetails to what your social studies teacher said to you: you’re intellectually curious. You put those things together and you listen.
Karen DeSalvo 21:36
One of my other skills is I’m a good bridger. I see ways that pieces fit together that sometimes other people don’t see. I don’t know why I can see those things. I love bridging medicine and public health and technology. I love social determinants of health and public health because it’s all about bridging these worlds. There are different languages and cultures and approaches to problem-solving. I love applying that in the different worlds where I’ve been. It’s like bringing the best of the best together. It’s part of that finding common ground thing, too.
Lynne Chou O’Keefe 22:11
Let’s talk about how you’ve bridged into the technology world. I’ll never forget when you and I were on a phone call and I was talking about what was happening in the Valley and you were talking about healthcare. You stopped at some point in the conversation and said, “Lynn, I just like the way you talk.” I know what you meant. We use these terms in Silicon Valley. I could hear the wheels turning on the intellectual curiosity and then the bridging that you’re talking about. Sure enough, a couple months after that conversation you joined Google. Talk about that decision. I can see it with the intellectual curiosity, the bridging. What has it been like to be part of this tech leader, which is so different from all the other experiences you’ve had?
Karen DeSalvo 23:02
It’s definitely different than any other experience. There are parts of it that are similar. I find, “Oh, that looks familiar. I understand that process.” To go back to the origin stories and thinking about other little girls and little boys growing up in poverty and the things they need to have the opportunities I’ve had: Part of my journey throughout my career has been, “Okay, well, I’m good at health. I’m good at medicine. I’m going to do that, but I also want to scale and I need a bigger platform.” There are more and more ways I can continue to make a difference. As I learned about the power of data to tell stories and to drive continuity of care, continuity of relationship to impact public health decision making, that got me more and more involved in understanding the application of data, the sourcing of it, the respect for it, and how we work with consumers and communities to do the right thing with their data. This is part of my office. The actual coordinator role is the National Coordinator. How do we think about consumer access to data, drive policy that gives them that access in a way that is meaningful to them? Then what are the use cases? How do we put it to good use? There’s more to the story than just the data and the people. It’s also about policy, revenue, spending, rules, and all these other accouterments. I’ve had experience in a number of those areas, but the one thing I never have had the chance to really understand is how do we give agency or ignite the agency in consumers? When you’re doing public health, you’re trying to get people to feel empowered or want to take care of their health or engage in your Let’s Move program and it’s a struggle because it’s hard to know what’s on their minds and how to meet them where they are when you’re not as knowledgeable about it. Fast forward to a company like Google where every second of every day, people all around the world meet us where we are. They’re like, “Hey, I have this question.” “Hey, I’m interested in this.” The shift of focus then for me is, if I understand the healthcare and public health side, another important part of the equation is how can we empower consumers? How can we give them the power? They have power, we just don’t know how to harness it and they don’t know how to harness it, so that was a huge driver for me and being excited to join the company knowing that this is an opportunity to work with the community and see if we can figure out how to create a healthier planet.
Lynne Chou O’Keefe 25:41
It completely makes sense. You are one of these rare people who have now seen all these experiences. You started at Google in late Q4 and then we flash forward into the first quarter of 2020, COVID hits. I have to believe there are not many people at Google who have the right type of experience for this type of crisis. What has it been like to address COVID in this world on a Google Platform?
Karen DeSalvo 26:17
I’ll caveat it by saying I would be delighted if we’d never had the pandemic. On the other hand, I wouldn’t want it to be anywhere else. You said it. I have this experience with crisis management. I know public health, I know science, I know medicine, I understand policy. I didn’t know Google that well at the time, but I was able to marry up with people who did. I got pulled into the company central response early on in the crisis so I was able to apply my talents not only from what I learned during Katrina but, as health commissioner, you deal with crises all the time. When I was in Washington, we had Ebola and Zika and plantain crises there as well, so I was able to provide the clinical leadership for the company response as well as product stewardship around how we message to the world about what COVID is and how they can protect themselves and their communities. We have search and maps and YouTube and ads and Play and all kinds of other platforms where we can amplify the messages from public health authorities. That’s essentially most of what we’ve done, however, quite a bit is also providing data for evidence-based decision making for public health and for medicine and partnering with public health through the exposure notifications work we’ve done. For example, some public health messaging around COVID to direct people to public health authorities on YouTube. Within the first six months, we had more than 400 billion impressions of people looking at health information that we put forward. You can never get that kind of reach, no matter which government you work for. The fact that we’re giving people good information, I’m glad we can be here and partner with public health at this time. It’s been a whirlwind year, though. We can talk more about what else I’ve learned, but I was glad I was here at this moment in history because I think we’re doing a lot of good.
Lynne Chou O’Keefe 28:10
I’m glad you’re there, too. In a way, you’ve scaled from the one-to-one relationship. I should check how big the city of New Orleans is, then we had 330 million people in the U.S. when you were in HHS, and now you’ve gone to 45 billion in the world and being able to touch that.
Karen DeSalvo 28:30
It’s a dream for public health nerds like me.
Lynne Chou O’Keefe 28:37
Quite frankly, now is what you’re tackling, Karen. Truly, it’s what you’re tackling. I want to wrap up with reflection. You talked about little girls and little boys. If you were to give one piece of advice to your younger self, what would that be?
Karen DeSalvo 28:55
I have two pieces of advice. One is about pacing. This is a common question I get from people earlier in their careers. They want to do all these things and do them so quickly. It’s not that you shouldn’t be helpful when you can be but, in retrospect, there are some things I could have paced a little bit better so you have some of that balance. However, I probably wouldn’t have changed a thing about what I did. We have a family motto, which is “don’t let people get you down.” My husband and I think about that a lot. It came up, especially after Katrina. Things were very difficult. I was sometimes at odds with people in power, but we were always trying to do the right thing for the community first. I had some terrific support from our university president, for example, Scott Callen, but sometimes people weren’t so nice. Jay would often tell me that. He’d say, “Don’t worry about that. Just do the right thing. Just keep doing the right thing.” I would have told myself that before 2005 when that started to be our family motto.
Lynne Chou O’Keefe 30:00
That’s amazing. Maybe that’s the title of your book. If you were to have a book, maybe we have that title there. Karen, thank you so much. Honestly, you are the right person, at the right time, at the right place to make this world a better place. Your story is so powerful. Thank you so much for taking this time with us and sharing from the earlier years to everything in between to influencing world health now, which is the platform you have. We really appreciate it.
Karen DeSalvo 30:37
Lynne, thank you so much for the time. It’s always a delight to get to talk to you and I’m happy I got to share a little bit of my story. Thank you so much.
Sanjula Jain 30:47
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