Alumni Profile: Abdul El-Sayed’14

Tuning Up the Engine of Public Health in the Motor City
By

Peter Wortsman

Photo: Peter Wortsman

Detroit occupies a unique space in the social conscience of America; it stands for so much of who we are as a nation,” says Abdul El-Sayed’14, a native of Metro Detroit and executive director of the Detroit Health Department since August 2015. While Detroit’s troubles remain formidable, Dr. El-Sayed, a self-described “optimistic realist,” who also holds a DPhil degree in public health from Oxford University, sees a chance to make a difference where it matters and, in the process, rethink health delivery for the 21st century.

“It’s a fundamental truth,” he says, “that obstacles and opportunities are almost always two sides of the same coin. The workable solutions come from the community.”

At its peak population of 1,849,568, according to the 1950 census, Detroit in the heyday of the American automobile industry was America’s fifth largest city, one of the nation’s most dynamic industrial hubs and a magnet for people from around the country and the world, including African-Americans from the rural South seeking a better life. But changes in the global marketplace, the import of smaller, more fuel-efficient vehicles, conflicts in the Middle East and the concomitant spike in the price of gas, and the decentralization and outsourcing of car manufacturing, among other factors, led to steady economic decline, a shrinking middle class, and urban decay.

It all came to a head in 2013, when the bottom fell out and the city, now with a diminished population of some 700,000, was compelled to file for bankruptcy.

Such dire straits took their toll on health. Among other municipal agencies affected by the bankruptcy, the Detroit Department of Health and Wellness Promotion was forced to suspend its activities and cede responsibility for vital health services to a private nonprofit entity. Problems multiplied. The city’s infant mortality rate rose to above that of Mexico. Obesity became another pressing issue, aggravated by endemic poverty, inadequate public transportation in a sprawling urban environment, and an inequitable distribution network of fresh and healthy food. Violence soared. And, worst of all, the public lost trust in city government.

Control of most public health services returned to the retooled department in 2014, shortly before Dr. El-Sayed took the wheel. The most pressing task at hand, in his view, is to lead the department’s restructuring as “a paragon of effectiveness and transparency so that it’s about the people who own it,” and in the process to “re-instill public confidence in the city’s ability to care for its people.” For the new director, it’s a first step toward a long-term, more ambitious goal: “to focus on those places where health plays a role in intergenerational transmission of poverty,” and, thereby “promote the healthy trajectories of future generations.”

Dr. El-Sayed made time to outline the steps he is taking to realize his vision for a healthy and thriving Detroit in an on-the-go interview in April 2016, part of which was conducted, in true Motor City style, in his car en route to and back from a meeting at City Hall.

 

Combining Medicine and Public Policy

At age 31, Dr. El-Sayed is among the youngest, and most dynamic, individuals ever to run a department of health of a major American city. “There is,” he acknowledges, “a naïve optimism you bring to your work when you’re young.”

The son of Egyptian immigrants, raised in Bloomfield Hills, a suburb just north of the city, he had what he described as “a deeply privileged life” but added that “dignifying those opportunities to me means being able to right inequities for all.” A Michigander to the bone, he thrived socially and academically, playing high school football—that most American of sports—and spending summers with family in Egypt. He first experienced the sting of outright hostility as an Arab-American in the immediate wake of 9/11. After one taunt too many from a member of an opposing football team, he threw a punch. His coach took him aside and said: “You are going to be Abdul El-Sayed for the rest of your life, and you can decide to either use that as an excuse or a motivation.” He took the message to heart.

Earning a BS degree with highest distinction from the University of Michigan at Ann Arbor, where he double-majored in biology and political science, he planned to become a surgeon. But public policy was never far from his mind. His father, an automotive engineer who came from modest circumstances in Alexandria, Egypt, and mother, who studied medicine there, later opting for a career as a psychiatric pediatric nurse practitioner in the United States, were both outspoken opponents of the authoritarian regime in their native country and passed on a sense of social responsibility and a commitment to social change.

At the University of Michigan he came under the influence of epidemiologist Sandro Galea, who inspired him to focus on “the social factors that lead hazards to flare up into disasters.” One of Professor Galea’s postdocs conducted a study of the birth outcomes of Arab-American women and their infants in California following 9/11, documenting an alarming 50 percent surge in low birth weight. Troubled and intrigued, Dr. El-Sayed extended the study to Michigan, postulating that birth results would be better given the insulating presence of a large Arab-American community. (Wayne County, Mich., has the highest concentration of Arab-Americans in the country.) His premise proved correct. The public health bug bit.

Pursuing the first two years toward a combined MD/PhD in medicine and public health at Michigan, he applied for and was awarded a prestigious Rhodes Fellowship to study public health at Oriel College/Nuffield Department of Population Health at Oxford University, where he earned a doctor of philosophy degree. His thesis, “Inequalities in Obesity in England: An Agent-Based Systems Approach,” was a computer simulation modeling of the problem that would later come in handy back home in Detroit.

Upon his return to Michigan, he learned that his mentor, Professor Galea, had been appointed chair of the Department of Epidemiology at the Mailman School of Public Health at Columbia University, so Dr. El-Sayed applied and was admitted to the MD/PhD program at P&S. Parallel to his medical studies, he pursued postdoctoral research in epidemiology under Dr. Galea at Mailman, still intending to pursue residency training and become a surgeon. In 2012 he was awarded a Paul & Daisy Soros Fellowship to New Americans in support of his graduate studies.

 

The Patient that Tipped the Scales to Public Health

An experience on a sub-internship in internal medicine at the Allen Hospital with one patient in particular—an older woman who had fallen and hit her head in a state of inebriation—proved pivotal. The house staff in the ER intended to discharge her after dressing the wound, but the young medical student suspected underlying issues. “Nope, you didn’t do a fair assessment!” he protested and used various ploys to keep the patient in the hospital, including holding up the completion of her patient history and physical pending her alcohol withdrawal. Ultimately he succeeded in persuading his immediate superiors to admit the patient, who, as it turned out, suffered from adrenal insufficiency brought on by HIV/AIDS. After providing basic medical treatment, Dr. El-Sayed arranged for her transfer to a rehabilitation facility that admitted individuals with AIDS. On the day before her discharge she announced that she was going home with her daughter. He urged her to try rehab, but she insisted she would be all right. Two weeks later he found her sleeping on a bench on the subway. Disgusted by an outcome he perceived as a direct function of “systems of failure,” he decided to pull his application for residency and embrace public health.

“There are very few jobs where you actually see the fruit of your labor so quickly."

“The safety net failed her,” he concluded. “She made bad decisions adversely affecting her health, but there are a lot of things that we could have done to put this person into a better decision-making mode. The best you can do at a hospital is to stabilize one patient at a time, but you’re not dealing with big picture problems that are creating the health disparities. I realized that I was a lot more interested in what happens before a patient gets to the door than what happens in the hospital.” While still a doctor at heart, with a surgeon’s hands-on desire to intercede and make things right, he was determined to have a hand in altering the big picture.

In 2014 Dr. El-Sayed was appointed assistant professor in the Department of Epidemiology at the Mailman School of Public Health. There he pursued studies in prevention science, the social cost of psychopathology and drug use, and the health of Arab-American New Yorkers, among other areas. He taught courses in systems science and population health, systems thinking, and principles of epidemiology. “I wanted to be a researcher,” he says, “because I thought research could move policy.” But he grew disillusioned and frustrated with academia, writing papers, and raising grants with limited tangible results. “What I’m really interested in,” he says, “is building institutions, building ideas, making things happen.”

Michigan-born friends who had returned to take jobs with the newly elected Detroit mayor, Mike Duggan, a former director of the Detroit Medical Center, spoke of the can-do attitude and accomplishments of the new administration, including the installation of 62,000 street lights, success in fighting urban blight, and reducing EMS response time from nearly an hour to eight minutes. Hearing that Detroit was looking for a new health director, Dr. El-Sayed decided to apply, and despite his youth and limited experience, he landed the job. Following “a couple of hard conversations” with his wife, Sarah Jukaku’15, then a resident in psychiatry at Cornell, who remained in New York pending her transfer to a psych residency program at UM Ann Arbor, he took the leap, relishing “the opportunity to come back home to help rebuild the collapsed health infrastructure and make it work.”

 

A “Societal Surgeon” Intent on Redressing Health Disparities

“Sometimes I do wish that the entire field of scope of my job was entirely under my hands,” says Dr. El-Sayed. “And in some ways, my role is to perform societal surgery. We know what we want to accomplish, but the task is far more complex. Rather than digging around in fascia and tissue, you’re digging through the bowels of bureaucracy and social entities, coordinating various perspectives to come up with a workable solution to seek an outcome that sometimes will take a long time to accomplish and sometimes will happen immediately.”

The swift solutions are, of course, the sweetest.

Case in point: When the Marathon Refinery, located in southwest Detroit, sought permission to increase emission of sulfur dioxide, Dr. El-Sayed stepped into action. Southwest Detroit, a heavily industrial part of town and one of the city’s poorest neighborhoods, was already burdened with the public health consequences of pollution. “Mayor Duggan and I recognized that this was an opportunity to advocate for a community that has been largely left in the dust.” With the mayor’s blessing, Dr. El-Sayed drafted an op-ed piece published on the day of the company’s planned public hearing; 500 people turned out for this and a subsequent hearing, at which the mayor and his health director were also present, and testimony was presented about the public health consequences of higher levels of pollution. As a result, Marathon rethought its plan and voluntarily invested $10 million in an effort to reduce S02 emissions. “That came on the back of our efforts, those of the community, the mayor, and myself, and that’s pretty incredible,” Dr. El-Sayed says.

As a vote of confidence in the importance of public health and the effectiveness of Dr. El-Sayed’s efforts, Mayor Duggan’s administration added $4 million in city funding to the health department’s budget.

“There are very few jobs where you actually see the fruit of your labor so quickly,” he says, but conceded much more remains to be done. “When public health works best, it develops nonstories, nonevents.” The introduction and maintenance of clean drinking water, for instance, one of public health’s most notable accomplishments in the course of the past century, has had a prodigious effect on promoting wellness. “It’s an accomplishment society tends to take for granted.”

The Detroit Health Department, under his direction, secured a $135,000 grant to test for lead in the water in public schools and found high levels. But clean drinking water is only one among many pressing challenges to general wellness in Detroit. Infant mortality, endemic obesity, a staggering incidence of murder and violent crime, and high rates of teen pregnancy, a significant factor in the perpetuation of poverty, continue to plague the inner city.

To address the high rates of teen pregnancy, the Detroit Health Department has now partnered with Wayne State University to support a mentoring program between senior or seasoned mothers and younger pregnant women. In addition, a group prenatal care program also run out of Wayne State, called “Make Your Date,” stretches sparse financial resources by having six women meet for consultation and counseling with a single doctor for an hour, instead of having each rush through a 10-minute medical consult. The department is also committed to promoting “whoops proof” methods of contraception. “Preventing teen pregnancy is a way to save two children’s lives, that of the unwanted baby and that of the teen who, if she becomes pregnant, is far less likely to finish high school. If we can’t diminish teen pregnancy,” Dr. El-Sayed says, “then what we’re doing is condemning a whole next generation to the poverty that the earlier generation suffered.”

Another key priority is the social reintegration of seniors. “We have a large trove of wisdom that doesn’t get put to good use, because we in many ways have cut off our seniors, rather than value and tap them for their store of knowledge and experience.”

 

Toward the Ideal of the “20 Minute Neighborhood”

While obesity plagues many parts of the country, the sprawling size of Detroit—a city built around car culture but with little car access for many in its low density, low income, inner city population—aggravates the issue. The problem, says Dr. El-Sayed, is “how to foster walkable and safe access to healthy food. We’re really thinking about how you can move green leafy vegetables, the kinds of foods that are part of a healthy diet, into and around the city.” The department is working closely with sustainable urban farms in Metro Detroit, but the challenge remains: “How do you transport healthy food to where the people are, how do you engage local food providers to be more thoughtful about the range of foods they offer, and how do you make it affordable?” Rather than blame people for “bad food choices,” Dr. El-Sayed prefers to help foster opportunities for good choices.

“We might disagree about how we go about promoting wellness, but nobody is fine with the fact that some people are really sick.”

“Our city is starting to coalesce around a vision of what we call a ‘20 minute neighborhood,’ that is, a neighborhood in which your daily and even weekly needs are found within 20 minutes of where you live,” he explains. “That’s a walkable neighborhood with immediate access to healthy food, social cohesion, and community activities.”

At the peak of the 1960s, Detroit’s health department was run out of one central location. But Dr. El-Sayed believes in “moving public health into the neighborhoods where Detroiters live, work, and play. The solutions must come from the community. We’re going to have to use the challenges we face, to build them into the way Detroit rebuilds itself.” Among the government vehicles set in place by Mayor Duggan to facilitate a productive dialogue is a district manager program, in which locally based district managers appointed by the mayor—individuals with roots in the community—act as a direct liaison to the people.

Dr. El-Sayed also sees great promise in a departmental initiative, a health fair, at which health-related problems are aired and discussed and solutions sought at the community level.

 

Reshaping the Way the People of Detroit Think About their Health Department

He is proudest of his behind-the-scenes role in building a team of committed experts and programs to address such pressing issues as asthma, lead exposure, infant mortality, teen pregnancy, and chronic disease, particularly among the elderly, and of his efforts to “rebrand and reshape the way the people of Detroit think about their health department.” Though the task remains daunting and the department is still underfinanced, his job, as he sees it, “is to make sure that health is thought through as a value when government makes decisions in a way that allows for the best possible equitable and sustainable health outcomes.”

An attentive reader, inveterate coffee drinker, and avid sports fan, Dr. El-Sayed works out regularly: “Can’t be preaching something you don’t practice. Health is uniquely something that everybody can appreciate. We all know the pain of either suffering bad health ourselves or having somebody we love suffer. We might disagree about how we go about promoting wellness, but nobody is fine with the fact that some people are really sick. And so public health creates a great spear to foster reflection about how we ought to live as a society.”