In January 2015, Governor Bruce Rauner appointed Nirav Shah, JD’07, MD’08, Director of the Illinois Department of Public Health. He took office on Jan. 20. Soon after, ScienceLife met with Shah, 37, to discuss his hopes and plans for an organization created to “protect the health and wellness of the people of Illinois” and the training—much of it at the University of Chicago—that prepared him for the role.
About getting “the call”
Science Life: You have now been on the job for nine days. How does it feel so far?
Nirav Shah: Those nine days have brought a level of busyness that I didn’t think was out there in the world, and this is coming from someone who spent years at one of the world’s biggest and busiest law firms. It has been outrageously busy, with many moving parts.
Sometimes it can be stimulating to hit the ground running. What made your first days here so challenging?
It’s a huge new job that requires a lot of rapid acculturation. Then, on Day Four, we had a case of measles. That dominated my first weekend.
Measles is a public health issue, a highly contagious, vaccine-preventable disease that we have not really seen much of for a few years. We acted exceedingly quickly. We got the report on Friday afternoon, sent it immediately to our laboratories, as well as outside labs for confirmation. That evening, we got the final result and promptly initiated protocols to prevent spread.
That process starts with trying to figure out where the case came from, how the patient acquired it, and who might have been exposed. Working with Cook County, we educated individuals who could be at risk in various locations. One of those spots was a Hispanic grocery store, so we worked with the Spanish media get the word out. We distributed flyers, got it on the news.
How does this mesh with your current skill set?
I have a background in disease-control work. I spent a couple years in Cambodia, managing outbreaks of dengue fever, multi-drug resistant malaria, Japanese encephalitis. I also have the benefit of an outstanding staff, with epidemiologists as well as regulatory, legal and policy experts.
Each outbreak raises its own questions. When can you quarantine someone? How do you balance the need to protect the public health against patient confidentiality? This job calls for about a dozen such core skills sets, and counting. I’m proud to say that my education at the University of Chicago and my work at a law firm, Sidley Austin, prepared me for at least two or three of those, maybe four.
How enthusiastic are you about this responsibility?
This is my dream job. I have already rolled up my sleeves. Mahatma Ghandi and now Governor Rauner— a curious pair—have both said that we will be judged as a society by how we treat our most marginalized members. I’ve told my colleagues here that this describes the work we do. This agency speaks up for the health and the rights of the most disadvantaged. What we do matters.
How did the Governor choose you? Does one apply for this position?
This is a political appointment, but it is not, for me, a political job. I’m a public health person and this is the job that I would feel lucky to have at the pinnacle of my career. So, imagine how it feels to get the call 30 years sooner.
To be clear: I met the Governor for the first time in Springfield in mid-January. I was not a donor to his campaign. I never worked for his campaign. I think I got on their radar screen because of some writing and speaking I did on the recent Ebola outbreak—how municipalities, states, the country could be better prepared. My background is in public health, regulation, law. He was seeking individuals who are passionate about the subject matter. Once they noticed me, his team made quiet inquiries at the law firm. They must have said that I fit the description. I think you’ll find that many of his appointments follow that pattern.
What did you think when you got the call?
It wasn’t out of the blue. I had multiple interviews with his vetting team, handpicked to find Cabinet-level appointments. When I did eventually get “the call,” I was over the moon. Did I mention this is my dream job? I told them I was honored and humbled and happy to serve. When could I start? They said Tuesday (because) Monday was a holiday.
Hopes and concerns
What are your goals for this job? If you were extraordinarily successful, what would change?
Although Illinois scores well on a variety of health care markers and metrics, we have significant room for improvement. I’m hoping to be more active, more aggressive in disease-prevention areas like smoking cessation, vaccination rates, obesity. That begins with education, but there are also legal levers that we can use to encourage vaccination. Those are some of the classical areas of public health where Illinois has lagged. I hope and intend to make improvements.
I also am concerned that modern public health has come unmoored from its classical underpinnings, gone a little astray in two areas. There are two cultural shifts that I want to instill:
- First, the field has taken on a decidedly paternalistic tone. “We know what’s best for you and, therefore, we are going to tax your soda.” This is where my U of C stripes show. Rather than hectoring people about losing weight, smoking, things of that nature, we should help individuals who want to make positive changes in their lives. In a period of austerity, we want to become a resource for individuals who are willing to make the effort. That’s a better investment than spending to convince them.
- Second is the notion that public health is all about programs. I think modern public health is more about being a convener, ensuring that voices are heard, that all parties are included and have a stake in the outcome. That doesn’t cost much. It’s resoundingly effective to pull key individuals, community leaders and others, you name it, into a room and say, “OK, we’ve too long thought about health as simply a medical model.”
Health is not just diabetes or heart disease. We need to focus on basic issues like food—quality food, food deserts, food security, take your pick—and housing. For many years these issues have been siloed off in other departments. The Governor’s focus on efficiency is an opportunity for us to work with colleagues at other agencies to reframe how we think about fundamentals.
Any quick wins, any easy pickings?
One win—if I may—is the absence, so far, of a widespread outbreak of measles. Maybe by the time people read this I’ll have to retract that, but I think that our rapid response to the measles case was a solid success. With measles you have to act fast. [By March 4, 2015, there were 15 cases in Illinois, 12 of them connected with a daycare facility in a Chicago suburb.]
What are the things that you dread, the insurmountable hurdles?
Excuse the Rumsfeldian terminology, but the thing that keeps me up at night is the “unknown unknowns.” There could be things going on that we need to know about but are not aware of. I spent my first weekend, when I wasn’t chasing down measles, reading documents, plowing through binders, asking hard questions, looking for such smoldering but under-the-radar issues.
The second thing I worry about is outbreaks. I’m more comfortable with this part of the job. That’s where I cut my teeth. MERS, Ebola and its cousins, Hanta virus, Rift Valley fever, Marburg. Some of those are only a plane-flight away. So I keep very close tabs on the Centers for Disease Control and Prevention and World Health Organization emergency response briefings.
What does the public health program in Illinois need that you worry you might never get to?
One of the biggest challenges in public health is taking a holistic view of health care. I would like to make that a signature of my tenure here, but it is outrageously difficult. I worry that we will continue to proceed in a piecemeal fashion. We’ll have a diabetes program on the South Side, an asthma program on the West Side and a vaccine program downstate. We’ll never get to a unified health care approach.
I’m not even talking about a unified system. That’s way too ambitious. I’m just talking about an approach where you think ahead about all the components needed to make a program really work, nutritional implications, housing implications, exercise, things of that nature. A lot of programs focus on one variable, say, “Let’s reduce hemoglobin A1C levels in this group of people with diabetes.” With that kind of a singular focus we’re going to miss a lot, never get to that big-picture view of health care.
The impact of past events
What drew you to this sort of work, especially your focus on epidemiology?
I caught the bug, to use a bad metaphor, when I was in Cambodia, during time off from medical school. I was a second-year student, and not a particularly happy or outstanding one. I found medical school involved a tremendous amount of memorization and, to my mind, not a lot of big thinking. Every week we would each get our copy of the New England Journal of Medicine. My classmates would turn to the case report or the newest study about this or that. I would turn to the policy articles. That’s what I read first.
So, I applied for, and was lucky enough to win, a Henry Luce scholarship to work abroad. After you are chosen, there’s a back and forth over where they place you. I wanted to work in a small country that had problems I could get my head around and perhaps, with luck, make a difference. In 2001, that was Cambodia. I took an intensive language course and off I went.
I was uniquely unqualified for the work I was sent there to do. I was a medical student who knew some economics. So I did a lot of basic work—first-semester business school stuff: budgeting, accounting, cost effectiveness. I also did a lot of epidemiology work: disease-outbreak monitoring, investigating counterfeit drugs. And then I fell into what became the focus of my work there, dealing with corruption and fraud.
How did corruption become a key topic for you?
I was on was the hospital management team. We helped hospital directors create a budget, take inventory, and allocate resources. We were sent to a hospital in a remote province of Cambodia, Preah Vihear, way up north, on the border with Thailand and near Laos. We arrived, and the hospital was vacant. It was a shell—almost no staff, three or four patients. It was miserable.
We go to the first person we can find and ask, “Where’s the hospital director?”
“He is at home.”
We say, “Bring him here.”
When he arrives, we ask, “What kind of an operation are you running here? Why is this place so dilapidated?”
He says, “I have no money.”
We whip out our spreadsheets, really ledger books, and we say, “You’re not broke. In the last three months you asked for something like 280,000 riel,” (the currency of Cambodia.) “We gave you something like 220,000.”
“Look,” he says, “I don’t know what your fancy books show. I asked for 280,000 but I only got 30,000. That lasts about a week. What can I do?”
Long story short: We did an extensive investigation. It took months. It was true that 220,000 riels was authorized, but by the time it went from the Ministry of Economics and Finance all the way to the hospital, 85 percent of it had been plucked off. At each step—and there were maybe 13, 14 administrative steps—someone takes a cut. The allocation shrank and shrank and shrank. Cambodians call this “an ice cube moving on a hot day.”
Thanks to an obscure Western journal, we came up with a solution to the problem. In Cambodia, there isn’t a lot to read. So when someone gave me an issue of the Journal of Supply Chain Management, I read it cover to cover, even though I had only a vague notion what a supply chain was. But I latched onto an article about how brutal Walmart can be with its suppliers. If they can find a way to cut people out, they do. We used that approach to eliminate nine or 10 of the 14 steps. It made a substantial difference.
That was the genesis of my interest in fraud and corruption, something I’ll continue to focus on here.
Is there a need for that in Illinois?
In any organization that works with many partners, there is a need. We are a large grant-making organization. That process requires constant monitoring and vigilant oversight.
Priorities and issues
You mention various issues in diverse communities, the South Side, the West Side, downtown and downstate, each with a different socio-political overlay. How do you make plans and determine priorities with so many competing, needy and remarkably diverse target populations?
I keep asking myself and others: Who is our constituency? In a broad sense, we answer to all the people of Illinois, but we can’t prioritize everyone. I suspect that Wilmette, for example, will be fine. But even wealthy areas that do well on classical markers of progress can improve. In some states the wealthiest areas—Vashon Island, off the coast of Seattle, or Santa Monica and Sausalito, California—all have 11 to 15 percent vaccination opt-out rates. They will probably be fine, in a way that folks on the South Side of Chicago may envy, but a pocket of measles that starts in an unvaccinated area could spread in a devastating way to the elderly in Englewood—just like that.
One of the things I have learned in public health stems from an old saying: The plan doesn’t matter; the planning matters a lot. My staff and I recently sat down and devised provisional plans. We may chuck them all, but that process of planning—talking about issues and contingencies, stakeholders, blinds spots, what we do and do not know—that’s what matters.
What are the public health issues that affect not Chicago but the rest of the state?
This is a highly diversified state, but social isolation, obesity, smoking are all problems. Smoking rates in Illinois south of Springfield and in the Northwest are very high, significantly higher than in Chicago. Family planning is a big issue downstate.
What about care for highly complex illness? Chicago has multiple academic medical centers and there are excellent hospitals around the state, but what if you need something that is not widely available, say, an organ transplant or complex neurosurgery. There must be pockets where it’s a long way to even a community hospital, much less an academic center.
You framed it as academic medical centers. I would take a step back and just say medical centers. A lung or liver transplant is an extreme issue. What about something more common, a hip or knee replacement? Many specialties—orthopedic or neurosurgery come to mind—are scarce in much of the state.
As you well know, there is a shortage of immediate access to trauma care on the South Side. But in much of the state, there is limited access not just to specialty care but to primary care. That’s an issue for many regions.
You also have an interest in global health.
Global issues 10,000 miles away, such as an outbreak, can quickly become local issues. Right now I’m excited to refocus my efforts on Illinois. It’s the same substantive set of issues: bringing people to the table, being a neutral listener, achieving consensus, reducing fraud. Those are the basics of public health, nothing exotic, just a focus on your own backyard.
How important is the South Side to this focus on your backyard?
The South Side is critical. It is my actual back yard; I have a condo near 55th and Woodlawn. It’s also a place with a lot of exciting things going on, not classical public health things. The community health centers on the South Side, for example, do innovative things to manage diabetes and end-stage renal disease. We are looking at those models. The South Side also has community gardens everywhere. You don’t see those up north.
Influencers and mentors
Biology in college, economics at Oxford, corruption in Cambodia, medical and law school at Chicago: You have a lot of diverse skills and interests. How did you get to be this way?
My parents. They generally let me do what I wanted. They rarely watched TV, so as a child I read like a demon. My mother would drop me off at the library and, I later learned, she would ask the librarians to look after me. I would wander around the stacks; spend four, five, six hours there every weekend, reading.
My father believed in debate and argument. He sharpened my rhetorical skills, debating everything with me when I was a child and even to this day. Last night we argued about raw milk. It doesn’t affect a lot of people, but those whom it affects care strongly about it.
So reading, education, constant exposure to new things—that was our family. And I was interested in everything. Once I stumbled across what I wanted to do, though, I was more focused, like a dog on the pant leg of learning and career.
And that career was medicine?
Well, no. My father was a physician. I did well in school, was good at science. What else do you do but go to medical school? My primary interest at the time was ethics, but you can’t really make a career out of that. OK, Dr. Mark Siegler did. But during my first year in medical school, my focus on ethics morphed into an interest in policy.
Who helped you get started in those areas? Who were your mentors at the University?
This is a long list. It includes Dr. Siegler, Larry Wood, Norma Wagoner, Sylvia Robertson. Richard Epstein, from the law school convinced me to study law, with a boost from Judge Posner. David Meltzer, a physician-economist, was very encouraging. Since getting this job, I’ve been emailing him.
The thing I admire about that whole crowd is how they wouldn’t let me settle. They knew all the students well, and they knew when to push people.
This seems like the moment for my well-deserved shout-out to Pritzker for letting me find my own way. I was different. In my second year, I won the scholarship to go to Cambodia. I wanted this. I was prepared to withdraw from medical school, whatever it took. But Dr. Larry Wood, the Dean of Students at the time, listened carefully and said simply: “OK. Go. Just send us an email explaining why, send us some pictures while you’re there, and send us an email a month before you come back. Bon voyage.”
That allowed me to tackle the work I did in Cambodia, which was tremendously rewarding.
A few years later, same story with a different dean, Dr. Holly Humphrey. This time I left to go to law school, two more years away. No objection, just encouragement. Finally, in my fourth year, I don’t recall that I even had to tell them my plan. I think Dr. Humphrey knew even before I did that I would never do a residency, that I would work at Sidley and teach health policy-global health care. I went to her ready to explain the 400 reasons why. But Dr Humphrey said, “Sure. Given your background, fine. That makes sense.”
The legal world
How was the transition from medical school to law school, and back again? Was that a difficult shift?
It was a breath of fresh air. I loved law school. For me, it was easier than medical school. Maybe it was just a better fit for my mind, but a number of Pritzker students have gone on to the law school, and they have all done quite well.
You mentioned that the University of Chicago and Sidley Austin prepared you for IDPH. How do those two fit together?
The University of Chicago educated me about medicine and law, but it fundamentally taught me to think rigorously, empirically, how to analyze data and use it to inform policy decisions. Sidley Austin taught me how to be a professional: how to be an effective communicator, manager, advocate; how to write a good business letter, interact with opposing counsel or soothe angry clients. Much of the work I did there involved public health, such as disaster preparedness. They gave me a firm grounding in the legal and regulatory aspects that are indispensable for my new job.
Whose work do you currently follow at U of C?
I keep an eye out for work by Marshall Chin and David Meltzer. I follow Mai Pho, a hospitalist who does tremendous work on the efficacy and cost effectiveness of hepatitis C screening as well as Greg Dwyer, in ecology and evolution, who works on epidemiology and mathematical modeling of disease dynamics.
I also pay attention to many of the law school faculty: Judge Posner, Richard Epstein, Geoffrey Stone, David Strauss, Anup Malani. I also read Todd Henderson’s work. When it comes to weird thinking in corporate law, there’s no one better. The economists also get my attention.
Searching for ideas
Does Illinois’ financial status place a drag on your hopes to move quickly?
Without a doubt, we have to do more with less. Illinois’ bond rating is the lowest of any state. It has the most underfunded retirement system, the country’s largest pension burden relative to state revenue, plus more than 100 billion dollars in unfunded liabilities and debt. A recent article in the Economist noted that Illinois is on a par, fiscally, with Botswana. Some people felt this was unfair to Botswana. So, yes, we have to be imaginative, efficient, frugal and wise.
That sounds like the kind of challenge a dual UChicago degree person might choose. What can we do to help?
We need ideas, preferably radical ones. I have several of my own, but I want any faculty, staff, student, reader to email me if they’ve got an innovative idea. I will read them and try to respond. I have a few of my own, but I need a lot more.
Tell me three of yours.
Perhaps my craziest notion is to move away from educational models and toward frank incentives. Idea one: I want to reward people for doing the right things, for example not getting HIV. Two, we should look for ways to rationalize allocation and motivate donation to our organ-procurement system. Three, on the local health side, there are way to incentivize healthy behaviors at minimal expense. For example, offer cell phone minutes to people who can verify they are taking their hepatitis C or tuberculosis medications.
Here’s one more wild idea. I would be delighted if, by the end of my tenure here, our department was the Google for public health, the place where our brightest young minds with an interest in public health want to work. I want to attract top University of Chicago graduates, undergraduates, bright people clamoring to get jobs in health policy or epidemiology or finance. That would be a coup.
I don’t think we’ll get there any time soon. But what I think we can offer, somehow or other, is a really competitive internship program, where we take four or five people from across the University, give them essentially free reign to explore the department, find problems and fix them. They would report directly to me—no 50 layers of bureaucracy. If I like their ideas, we meet with the Governor. We can’t pay much, but if you are smart, ambitious and care about public health, I can provide autonomy and opportunity.
You teach in the global health program here. Are you going to keep teaching?
I truly enjoy teaching. I thoroughly believe the adage that you don’t really quite understand a subject until you’ve taught it. That’s particularly true in the epidemiology and policy. Until you stand up in front of 20 bright people, all of them eager to catch your mistake, and write out the equations, you can’t claim to know a subject. At the University of Chicago, there are 400 people who could teach what I teach, so I am very fungible in that regard, but I do enjoy it and hope to continue.