Interview by Julio Bracero-Rodriguez
Global Pulse is extremely honored to present this interview with Admiral Joxel Garcia, USPHS, MD, MBA, the 13th Assistant Secretary for Health within the Department of Health and Human Services, Medical Director in the Regular Corps of the Public Health Service, and the representative of the U.S. on the Executive Board of the World Health Organization (WHO). He was Deputy Director of the Pan American Health Organization (PAHO) from 2003-2006 and served as Commissioner of the Connecticut Department of Public Health from 1999-2003.
Born and raised in Puerto Rico, he graduated from Ponce School of Medicine, in Ponce, Puerto Rico, and did his residency in obstetrics and gynecology at Mount Sinai Hospital in Hartford, Connecticut. Nominated by President George W. Bush for the above positions on January 22, 2008, the interview, partly conceived as a “student-alumni” dialogue, took place on March 9, 2008. True to form, he was confirmed by the U.S. Senate on March 14, 2008, becoming the first Puerto Rican to serve as Assistant Secretary for Health.
Admiral Joxel Garcia, USPHS, MD, MBA
GP: What experiences made you get involved in public health?
Dr. Joxel Garcia: I really became involved in public health while working in the clinics at Mount Sinai. I realized the needs of the people and all their difficulties, especially with people from other countries, not just the Latin population. For example, there were ladies from Eastern Europe coming to Connecticut and they had the same issues that we discuss now in terms of communication and access to healthcare. Coming from other countries, many had poor medical histories, so by itself this was a harbinger that I was getting involved in some aspects of public health.
Another thing happened when I was in private practice that actually led me to understand more about public health. We had a practice in the suburbs of Connecticut, and despite that I was a Spanish-speaking doctor, we did not have many Spanish-speaking patients, regardless of how much we tried to market the practice to those patients. Later on, I realized the problem was not that they did not know I existed, but that the closest bus stop from my office was located miles away. Meanwhile, every emergency room in Connecticut has a bus stop, so for people that did not have access to primary care providers, it was easier to go to the ER vis-ŕ-vis to a private practitioner, regardless if they had insurance or not.
Then, I also realized there was a lack of communication between the practitioners, the front liners of any kind of health relationship to patients, and the system per se. In my view, one of the problems was the hospital system itself. While this does not cause a total disconnect, it may lead to a lack of real communication, all the while ignoring the patient’s needs. I thought that to understand this “culture” of organized medicine better, I needed to comprehend this system at the social and economic level. So, during the weekends, I did my Master’s in Business Administration (MBA) at the Barney School of Business in Hartford.
Keep in mind that I was still a practicing Ob/Gyn. It was funny because as soon as I finished my MBA, I was nominated by the governor of the state to be the Public Health Commissioner of Connecticut! That was another incredible learning experience for me, because I went there from the knowledge I had gained from my MBA, my experience working at the hospital level, but also with the frame of mind of a healthcare provider who sees and treats the patients in front of me, and not with a population-based type of thinking.
Being the commissioner allowed me to learn that there was something else to the patient beyond the doctor-patient interaction – the reflection of what is happening in his or her community. I realized very soon in my tenure as commissioner that if I wanted to help the different communities in Connecticut, I had to help the entire state. In order to help the state, I had to get involved in shaping health policy at the national level in terms of regulations, the private sector and all the different aspects of the healthcare industry. So I had to work with prevention and education programs, policy, planning, plus interacting with the different state and federal agencies to protect the health of every person in Connecticut. During that time, September 11 happened.
GP: Can you tell us some of your proudest accomplishments as Health Commissioner of Connecticut?
Dr. Joxel Garcia: Two things I will tell you right away. One, probably we got national exposure because of our response to anthrax – in less than 3 days after the events of September 11, 2001, we were able to identify a person with anthrax. At the time, we were the fastest state to do so, and even though our patient died, as sad as it was, our response was essentially a national record, and a benchmark that was reported internationally. On September 12, we had to literally build up a network not only with all the government agencies, but also with every hospital and public health department in Connecticut.
Though the media got to know us because of that, what I consider my proudest accomplishment was the work that we did at the state level from the prevention perspective. We created a concept called “de puerta en puerta”, or “door-to-door” in English, were we literally went “door-to-door” in the local communities. We partnered with all the players involved in public health: volunteers, the private sector, allied health providers, nurses, insurers, teachers, community leaders, faith-based organizations. Through “door-to-door”, we were able to educate the local players and network them into Connecticut’s health care system.
We worked on issues related to obesity, diabetes, from cardiovascular disease to mental health, and access to health. We found many patients that, for example, had the opportunity to be insured but did not know how to get insured, so we connected them to insurers. We have a large population of Latinos here in Connecticut whose children were affected with asthma, so we got very involved in asthma initiatives. As a reference point, there were several studies that showed kids that miss at least 7 days of school per calendar year were going to have lower grades, and lower grades essentially mean the chances of them being accepted at higher education opportunities throughout their life would be lower, so we were able to work with our counterparts on the state and federal level to come up with some solutions and protocols for this group of patients. We were very proud that we were connected to and supported by the community.
We were doing “door-to-door” on a weekly basis, sometimes twice a week, for a very limited amount of money. In one instance, for less than $5000, with the help of volunteers and faith-based organizations, we were able to talk to over 20,000 individuals in little more than half a day! Another success was the fact that many public health departments in Connecticut started doing their own “door-to-door”, with no intervention from the state at all!
When I came to Washington, people immediately asked me the same type of question: what kind of budget did you have for these initiatives? (laughs) And to be honest, the budget was just a reflection of how much people were willing to put into the initiative, and for me it was one of the most inexpensive ways to help our state.
GP: Can you tell us a bit about your work with the Pan American Health Organization (PAHO)? What do you feel were some of your accomplishments during your tenure?
Dr. Joxel Garcia: PAHO is the regional office for the Americas of the World Health Organization (WHO) and the specialized health organization for the Organization of American states. My job as deputy director was to set the general direction and strategy of the organization alongside the director, and to establish and maintain effective relationships between the organization and the governments of the U.S., Canada and Puerto Rico.
PAHO has many hats at the international level. One of my biggest functions was to help in the diplomatic process of aiding countries in their public health efforts. I got involved in matters of public health preparedness, bioterrorism, disease prevention, and planning and budgetary functions. Being a Latino working in an American/Latin America outreach, I feel PAHO had a better interaction with the countries I was helping.
I think one of the highlights for me was my involvement in US-Mexico border issues. We were very actively involved with both countries and actively worked with the Secretary of Health and Human Services, Tommy Thompson, his successor, Secretary Michael Leavitt, and with Dr. Julio Frenk, the Secretary of Health of Mexico. Dr. Frenk was instrumental in helping me serve as a liaison between our office in El Paso, Texas, and both governments, and in providing technical support and logistics to the 4 U.S. states (Arizona, California, New Mexico, and Texas) and 6 Mexican states (Baja California, Chihuahua, Coahuila, Nuevo León, Sonora, and Tamaulipas) that make up the U.S. – Mexico border. This was an incredibly rewarding process. We did the “door-to-door” campaign as well, and another one of PAHO’s projects, Vaccination Week.
This project aims to vaccinate millions of people, from Canada to the tip of South America. To give you an idea, last year, over 47 million people were vaccinated, and we were able to bring this amazing endeavor to the U.S.-Mexico border as well. By the way, if you ever have the opportunity to visit the border, it is like having 2 countries and 3 nations, because the border area itself is home to close to 14 million people. The characteristics of that region are very different from the north and the south. If you are from the border, you are not from Mexico, you are from the border, and that is how people feel about it. As such, the health issues, in context, are very particular to them.
GP: You have had the opportunity to work in both the domestic public health and international public health sphere. Can you tell us the about the differences, and similarities, of the experiences?
Dr. Joxel Garcia: I really appreciate the question because of the following: during the early years of my being Commissioner of Public Health in Connecticut, I did not grasp the importance of the globalization of our world, and how international events could impact my state. The events of September 11, 2001, gave government officials a wake-up call and a hint of things to come. For example, around December 2003, there was an avian flu outbreak of the H5 subtype, reported in various countries, which affected trade and commerce for a limited time between the U.S. and Japan. I did not know, as a public health officer, that something like that was going to happen! I did not understand how the events of a small island in the Pacific could adversely affect my state, nor did I fully comprehend how immigration was, and is, actively changing the health profile of Connecticut.
When I became an international public health officer, I realized that in order to succeed at the macro level, it was important for me to be knowledgeable about what was happening at the micro level. Of course, I needed to work with other countries and treaties and such, but again, in order to be effective at the international level, we had to be effective at the local level. The time spent at PAHO allowed me to understand that as an international public health officer you are essentially an extension of a local health public officer, but at the macro level.
As complex as it sounds, we need to comprehend that as public health officers we are essentially agents of global health. In fact, every healthcare worker is a part of global health, and I think it is important for people in leadership positions in our field to understand that we do not work in isolation. Sometimes I feel there are significant players of the public health leadership in the U.S. who are not aware of how we are all interconnected. Sooner or later, it is going to affect all of us.
Coming from a farm in Puerto Rico – my mother was a housewife and a teacher, and my father a dairy farmer – where you have to prepare yourself for rainy seasons, drought seasons and diseases, as well as check the quality of the milk production, and one day you have a sunny day and the next they are announcing there is a hurricane (laughs), prepares you not to be complacent, or in a reactionary mode. You always have to be in a pro-active mode.
What I just said may sound ridiculous to some, but it is not. We should not take lightly how or where we were trained or brought up. I think some of the things I saw while training in the clinics in Ponce prepared me as a policy maker. Being in academia helped, as did being a hospital officer and a private practitioner. I would rather not say one experience prepares you for the other, but I think my personal experiences facilitated being Commissioner of Public Health at the local level and then an international public health officer.
GP: Did you ever see yourself getting involved in international health, or did you consider it an extension of your previous work?
Dr. Joxel Garcia: No, never! (laughs) I never planned to be involved in global health, to be a commissioner of health, or in public health as a career. I always told everyone I wanted to be a doctor. When I was a kid, I first wanted to be an astronaut-doctor, then a soldier-doctor, and then just a doctor. (laughs) During my residency years, I saw myself as an academic and as a leader, but I never saw myself as a global player, or even a state-level player. At the most, I saw myself in the private sector.
Back then I was just thinking one patient at a time. However, in my thirst for understanding my patient’s conditions, I sought to understand what was happening in their communities. There had to be something beyond the clinical encounter that I missed, and the condition might be a reflection of their daily environment.
To get involved, I wanted more training, but I did not seek a master of public health degree like most health professionals do. Instead, I ended up with an MBA because I was convinced that the private sector is a major component in healthcare delivery. So I am not coming from one track. My training as a manager, as a business-type decision maker, has helped significantly in “managing” public health. I am not sure if you grasp my way of thinking, but I wanted to explore a field that was foreign to me. Now I am convinced I did the right thing because in public health we cannot assume that the only people, or only field, that is going to help us tackle clinical problems are just those in public health. There are issues related to transportation, cultural issues, issues related to ecosystems and the environment, and so on.
I wanted to be the best in whatever I was doing, and the process of searching for the answers to my clinical questions led me to where I am now. My getting involved in global health did not happen because of a coincidence, it happened because of my thirst for understanding. I think it is important to not look for just one solution, but to search for all possible answers, even if those come from different disciplines.
GP: In the context of popular American discourse in the past few years, global issues have become very regionalized. We tend to associate the term “global health” with Africa, and immigration is the only thing associated with Latin America. Do you think that the health concerns of Latin America should become more a part of the lexicon of “global health?” and if so, how? And which Latin America health issues would you like to see higher on the global agenda?
Dr. Joxel Garcia: As global health advocates, we should repeat this question on a daily basis. Of course, I am very supportive of every effort available to help Africa on not just HIV/AIDS but on other issues, such as malaria, disease prevention, human rights and so on. But I agree with you that some areas of the world have been neglected, and Latin America is one of them.
It is easy for me to not ignore Latin America, as I have a Hispanic background, but people in the United States have to realize that we are neighbors of Mexico, a Latin American country, and nothing will change that, so we need to start paying attention to what is happening there. And we cannot do so with the perspective of “oh, there is a new disease happening in Latin America” or by concerning ourselves with migrant workers. We should be thinking in terms of the socioeconomic issues affecting the healthcare in those countries.
Such problems are especially evident from an economic perspective. Any process that affects the health of any one country immediately affects economic indicators such as trade and commerce. If the working conditions in one country stagnate, you will have migrant workers, and the local conditions at each country’s borders are disrupted. Then it becomes a vicious cycle that affects everybody. We have to help strengthen the health of every country in Latin America. This hemisphere is only going to be as strong as its weakest link.
Of course, Latin America is not a homogenous region, and people in the United States – especially policy makers – need to understand this reality. There are different cultures within Latin America, different needs, and different levels of development. It is a bit naďve to expect that a policymaker in the U.S., much less a layperson, will immediately understand all of the complex variables happening in more than one country, but it is our duty to continue to educate others.
I think it is also important for people who live in developed countries, such as the United States, to make a stronger effort to get involved in issues related to health, starting at the local level. Get involved! It is important that we pay attention and become active in our communities, and thankfully more people are getting involved as volunteers, working with NGOs and various initiatives, such as the ones done by PAHO, or by other organizations, such as Project HOPE. However, getting involved in such initiatives, large or small, should not be just the obligation or the work of the government per se: it is of the people, and always will be. I pay attention to health issues that are happening all over Latin America, even though I am not working with PAHO anymore.
GP: Could you share your thoughts on the moral/ethical obligations, and conflicts, of health professionals from the “global north”, i.e. the developed regions, such as the United States and Europe, seeking to work with the “global south”, i.e. the developing regions such as Central and South America, Africa and Asia?
Dr. Joxel Garcia: It is beyond the stage of how we define ethics or what we are supposed to do. Disease and epidemics do not stop at any country’s borders or shorelines. Anything that happens in one part of the world, regardless if it is in Asia or Africa or Latin America, is going to affect Europe or the United States sooner or later.
Take PEPFAR (President’s Emergency Plan for AIDS Relief). Though not perfect, it is an example of an initiative in which billions of dollars are being channeled to help people in 15 countries around the world, most of them in Africa, with almost half of the money designated for treatment. However, one important aspect we need to consider in this and future initiatives is that we also need to help recipient countries absorb those kinds of resources. So it is imperative to train and educate health workers in those countries how to provide the services their patients need.
We have to move away from the usual way in which we clinically tackle disease and epidemics and realize we have to support an entire system within a particular country, or within a region. We also have to help them improve the standards related to their own professions at all levels. All of this should be done based on the economic, political, and social realities of each country, because then the solutions become applicable. It is sad when we assume that what works in the United States should work in another country, or to believe the solution resides in just giving a country a large amount of money.
In terms of whether it is ethically or morally correct to help, we all know the right thing to do. But it is extremely important that we understand that it is not only money that countries need. We have to help them strengthen their infrastructure so they can absorb the support that is being provided, provide the required services and then sustain that effort well into the future. My personal opinion is that people in other countries do not really like help just for help’s sake. What they want is to be helped so they can help themselves.
However, the global burden of disease goes beyond the clinical disease that is affecting the community, as a sick community simply cannot be productive. Everyone is affected, so we need to emphasize prevention in order to increase productivity. When talking about these topics, I have heard friends and colleagues say, “I cannot believe people in this place are living in such conditions! Why do they not realize “X” issue is affecting them?” Well, many times people do not have the opportunity to move away from where they are. They have little to no education, and no training, so it is no surprise that they do not know what is right or wrong in terms of disease prevention.
I firmly believe the reason global health has taken such a permanent part of the current health movement worldwide is the internet. In many countries people now have easy access to the internet and it allows them to compare their situation with the economic, social, and health standards of other countries. It allows them to recognize where they stand and assess how to improve, while allowing us in the developed world to see the other part of the world that you were alluding to.
GP: We understand you have been nominated by President Bush to the positions of Assistant Secretary of Health and Human Services and Medical Director of the Regular Corps, as well as Representative of the U.S. on the Executive Board of World Health Organization. How has your experience in both domestic and international arenas been influential in obtaining these positions?
Dr. Joxel Garcia: I have been blessed to be a Commissioner of Health and then be a Deputy Director of PAHO. Also, I have worked as senior executive in a firm that deals with health education and public health. So I am in this unique position that I have been able to help locally and internationally, with a clinical, academic, and management background. It is this uniqueness, I believe, that has helped the President to think that I can deal with three full-time jobs while being paid only for one, but anyway! (laughs)
Seriously, I have been blessed to be in this position and I am looking forward to the challenge. There are very few people that have been able to work and thrive in all of these different areas. Personally, I feel very blessed for all I have received… I believe in God, I have a very supportive family, and the teams of professionals I have worked with throughout the years have all played a role in this.
Who you are is important, but how and with whom you work is important as well. Here is a piece of advice: never surround yourself in a team that you have had the privilege to create, such as close friends or people from the same backgrounds, because eventually the group will start seeing everything through the same glass and you will always end up approaching a problem from the same perspective. In every team that I have been involved, I have requested that they be as honest as transparent with me as possible, and if they disagree, I want them to tell me right away.
The difference is whether one learns from their mistakes or continues to make the same mistakes. In my experience, the leaders that keep repeating the same mistakes are usually surrounded by people who convince them they are not making a mistake. The best people I have had in the operating room have been the nurses that had no problem whatsoever saying: “Dr. Garcia, I do not think you should be using this!” Then I realize that I might be wrong and she might be right, and at the end it does not matter who is correct because we all have the same objective, in this case helping the patient.
Likewise, working with a diverse team has allowed me to solve problems and help many people in different settings, and I believe it is the combination of all of this that has allowed me to be considered for this position.
GP: If you can speak about it, what are you goals working with the World Health Organization and as Assistant Secretary of Health? These positions seem quite disparate from each other.
Dr. Joxel Garcia: They are not that different because one of the main functions of the Assistant Secretary of Health is to serve as the primary advisor to the Secretary of the U.S. Department of Health and Human Services. Many offices are overseen by the Assistant Secretary of Health, such as the Office of the Surgeon General, the Office of HIV/AIDS policy, Office of Minority Health, of Women’s Health, the Presidential Advisory Council on HIV/AIDS, and many others, so in a sense I would be advising on issues I already have worked with at the international level through PAHO. Having these two positions work together is a homogenous way of dealing with health issues in the United States and in the global arena.
My main goal on working in these two positions is not to focus on X or Y issue, but rather to bring together the different perspectives, and the resources, that these positions entail in order to be more successful on issues such as health disparities, HIV/AIDS, disease prevention, minority health, etc.
I think it is a great opportunity to bring that farm boy who had been exposed to public health at the local, state and international level to help our country with a variety of different issues.
GP: What is the biggest challenge for you as a health professional working in the field of global health?
Dr. Joxel Garcia: I think the biggest challenge for me is to keep abreast of all the ever-changing conditions that are happening in all countries. Not just health issues, but social, economic, policy, and political changes, and not just within a country per se, but in different regions. Remember that everything is interconnected.
We cannot get comfortable with just knowing something about a certain issue – we have to seek the answers to all of the questions that we will face as health leaders. At the personal level, it is a challenge to keep myself applicable and up-to-date. In fact, we have to be beyond up-to-date, we have to see beyond the horizon. As a health professional working in global health, you have to be ahead of the curve.
At the global level, it is a challenge navigating and working thorough all the systems, and making others understand that in order to succeed and survive we have to work together.
GP: Finally, what advice will you give to health profession students looking to get involved in global health issues?
Dr. Joxel Garcia: This is a hard question to answer. I feel every student or young doctor has to realize who they are as a human being and honestly evaluate what they are capable of. Once you deal with those aspects, you have to seek the areas in which you are most interested in working. All of us are going to have a strategic area in which we will feel much more comfortable and want to expand upon. However, I think that when you or your peers are interested in global health, they have to realize one must be a very complete professional.
It is like studying a star in a galaxy. You have to study the entire galaxy in order to understand its relationship to the star you are looking at. Well, the same thing happens with global health. You have to realize the global situation, and starting at the local level, how that affects the big picture. Take malaria for example. It is not only about the mosquitoes and the people getting sick and if they are using a net or not. It is about water stagnation, it is about ecosystems, education, prevention – it is about many things.
Again, I will repeat it a million times, it is about economics, about social issues, about people. When you see the Black Death, malaria, HIV/AIDS, and how these diseases have affected countries, entire economies, wars and even the history of the world itself – those are not accidents. It is a reflection of the changes a disease at both local and global levels can create.
Lastly, try to seek new questions and work towards the solutions. In global health and public health we have to be verbs, we have to be action. To be successful and become an agent of change, you have to comprehend the situation in the context of each country and act upon that, not simply theorize about what may or may not happen – there are plenty of international treaties with lots of big sentences, but to the people living without basic human rights, without access to healthcare, these sentences are meaningless. What we need to do is go from there, from a noun to a reaction so the sentence actually has some meaning for the people that we serve.
GP: Thank you for this opportunity to interview you.