Just after Claude Jacob started his new job as director of the San Antonio Metropolitan Health District, the city hosted a meet-and-greet with local media outlets.
Given the delta variant-induced spike of COVID-19 cases, the discussion ended up focusing largely on the pandemic. There’s much more to know about the health department’s leader, his background, and how he views health equity.
Jacob, 53, is a jovial, curious man who laughs easily and can recite the many awards and accreditations Metro Health has received without glancing at his notes. While the interview was conducted with masks on inside a room in the department’s new City Tower office, he revealed a warm smile when we walked outside to take photographs.
Jacob previously served as the chief public health officer for the City of Cambridge, Massachusetts. He and his wife, Nicole, have three teenage children: Alex, Ania, and Max.
This interview has been edited for clarity and length:
Where did you grow up?
I’m a first-generation American. My folks came to the U.S. from Haiti in the ’60s as clinicians. Little did I know that they had made a pact to always go back to the home country. So while I was born in the States, myself, my sister, and two brothers, and my folks then returned to the islands. I spent all of five years down there … and came back to the U.S. at the age of 12. Some people assume that I was born in Haiti because I still speak the languages [Haitian Creole and French] — it throws people off. I consider Chicago home only because it’s just the easiest place to describe where I spent most of my life.
Do you have family in Haiti?
I have roots from both sides of the family and networks down there because of previous projects, but most of my immediate family are stateside or in Canada.
When the earthquake hit 11 years ago, I ended up chairing the Cambridge-Les Cayes, Haiti sister city project. Each year, I would bring a team of paramedics to Haiti. Ground zero of the recent earthquake is in that part of the peninsula where the sister city project is.
Plus, we have a family clinic down in that part of the region. It’s just a commitment we made over 20 years ago. Family members go and volunteer. So we still have connections to the home neighborhood.
Pre-HIPAA, I used to go with my dad on rounds. I didn’t know what he did, I just knew he saw people and helped them. But probably what made the biggest impression was they would volunteer at community clinics outside of Chicago. I watched them without realizing how it impacted my lens. And I ended up writing my master’s thesis based on how the elderly from Haiti access the health care system.
What was it that that led you down a public health path instead?
There is often that sentinel moment when you realize that there’s a fork in the road. For me, it involved an injury. My freshman year in college, I broke my back in a freak accident. While I did recover from the injury, it did take its toll. It also gave me insights about the underbelly of the U.S. healthcare system.
I temporarily lost motor function and lost a semester of college.
How did that happen?
I got crushed by a hayride.
This was a tractor-drawn hayride. Usually, they have one flatbed. This one had two. A friend of mine fell in between the two flatbeds as it was moving. When I reached down and pulled her up, I lost my balance and I fell. The good news is that she was not injured. The bad news was that I got sawed in half. My lumbar vertebrae were pinched, but not severed. I had to have surgery. To this day, I have a plate in my back. Every once in a while when I go to the airport and they get that wand close enough, they’re like: “Hey, what’s going on here?”
Dude, trust me, there’s just a metal plate in there.
I realized I wanted to be able to look at systems and the alignment of systems. I went to three hospitals in about an 18-hour window. I went from a rural hospital, to the university hospital, to a regional spinal cord unit. I paid note to how I was cared for at each place. The good news is that I was cared for in each place. But I needed to understand, how do these systems align, so that the paramedics can move me from point A to B, and from point B to C? How are they trained? What do they understand about me? How does this fit into the bigger system?
How these systems work, or don’t work, ties directly into health equity. What is health equity to you and how can we improve it?
The two big questions: the what and the how. The latter is a lot more complicated than the former.
Let me use COVID-19 in Cambridge as an example. The COVID storm landed in March of last year. And within about 30 or 45 days, we were starting to see these patterns in terms of where the cases were coming from. Part of public health most people don’t realize is that epidemiology is the study of disease and the study of patterns.
We saw a pattern based on race, ethnicity, and socioeconomic status. We saw an acceleration of cases based on not just skin color, but their occupation type and their housing type.
We have to do a better job making decisions based on the data so that we understand the patterns. That’s important because then we can figure out: Where do we send added resources to address those patterns?
We tried to address the inequities in Cambridge by making sure that we had testing sites in the hardest-hit neighborhoods, that we had outreach in the hardest-hit neighborhoods, that we reported regularly what we’re seeing, broken down by race and ethnicity, recognizing that there is bias in reporting.
I’ve seen the same lens and tools used in San Antonio.
The patterns that we saw tied to COVID were the same patterns we would see tied to chronic disease, the same patterns that we would see tied to the impact of climate change. So it’s the conditions that need to be addressed. And not just, “Well, how many cases of COVID can we count?”
Further challenging the cause of equity was the economic downturn between 2008 and 2016. Over eight years a quarter of the workforce literally evaporated across health departments nationwide.
Having the infrastructure to assure the conditions where all can be healthy is about aligning systems so that everyone can be healthy: it’s the work of community development, it’s the work of the police department, it’s the work of the fire department, it’s the work of human services, it’s the work of the businesses, it’s the work of the schools, it’s the work of the hospitals. We have to engineer an ecosystem where people can be healthy — not just a health department. Every entity, private or public sector, has a role tied to public health.
My and the department’s role is figuring out how to deputize other entities to be a part of assuring the conditions where people can be healthy.
Because of the conundrum of resources, the average health department is just trying to get through the day — they don’t have the luxury to think about the bigger picture. If you go back 20 years, in some communities, the fire chief and the health director, or the police chief and the health director lock horns because they’re competing for resources. Here, it’s complementary. So that, to me, is the exciting part.
I’m spoiled in that I have a chief of informatics, I have epidemiologists, I have trained, seasoned clinical staff, who helped me triangulate. I feel like literally I’ve won the Powerball.
Do you feel San Antonio’s health department has the resources it needs to look beyond the pandemic?
We’re humbled by the pandemic.
We’re still building the plane while flying it when it comes to dealing with COVID, but I do feel that there is a space and an opportunity for the city to pivot to having deeper conversations. That was the appeal for me coming in the door.
The city’s leadership is thinking ahead to the post-COVID era, so that Metro Health, in concert with our partners, can do a better job with ensuring an ecosystem where all can be healthy.
We already have a blueprint. Over the course of the coming years, we have to implement the Strategic Growth Plan, which speaks to the investment, not just in Metro Health, but other city entities like police, fire, or human services. I feel that we are well-positioned.
The 2022 proposed budget more closely aligns Metro Health and the police department. Has that pivot to a more holistic, system-wide thinking already begun?
Yes, there is an appetite to stretch our thinking.
About 15 months ago, the tragedy that happened in Minnesota with the death of George Floyd was a flashpoint in the midst of COVID. In the midst of a global pandemic, that episode became an accelerant. It forced conversations in communities across the U.S. and internationally about, well, what role does public safety play?
Right now, there’s a lot of talk about how do we support not just public health, but how do we support the community, recognizing the role occupied by public safety. What you do see in the design of the role of the police department and coordination with our department, it’s not an either/or — these are literally pieces of the same puzzle. The whole point is to have a better system to address the conditions where all can be healthy.
We’re still figuring out the role of other ambassadors in the neighborhoods to help us figure out, how do we respond, not react? How do we help communities heal? Because the scar tissue has been there for a long time.
Just because we have a new-fangled multidisciplinary team responding to mental health calls, … that doesn’t solve the historic ills that people may have experienced. So we do want to be sensitive to the plight of folks and that initiative has to be tied into a broader structure.
Metro Health is in charge of a new data initiative to measure the impact that programs such as prekindergarten and affordable housing have on crime. What can we expect to see out of that?
It’ll be very difficult early on to show causality.
We have to be very careful that we don’t inadvertently profile neighborhoods, or assume that by virtue of one policy, we’ve now addressed all the historic ills that have been here for generations. While there’s the urgency of dealing with COVID, there’s also the urgency of dealing with the quality of life of folks on the ground. But I want us to take the time that we need to capture the right information.
I don’t think the intent is for us to try to figure out all of the things that are impacting neighborhoods and try to address them. Rather, it is to find a way for us to do a better job responding to these criminal events as they happen. Right now, we’re in the design mode. We’re hoping that over time we have a better balance of data and the stories behind the data.
Then, in theory, we should have a better way to respond. We minimize the tragedies, and we become better connectors to support the community. People have different opinions about this, but if it had been working well, we would not be coming up with different ways to do this.
We’re acknowledging the long legacy in the history of the -isms — the institutional racism and impacted communities. What should come out on the other end is a better way for us to address communities.
… Some treat this as binary — it’s either you support police or not. It’s not binary.
I applaud the leadership in the midst of COVID, making this commitment to stretch our thinking, to stay ahead to address what has been historical inequities. It requires conversations where we revisit some of these policies. Some forget the sad legacy of redlining and underinvestment in infrastructure. Fast forward and we wonder why is it that certain communities are really feeling the burden of climate change, or diabetes, or COVID? Well, duh.
The endpoint is to revisit some of these policies and acknowledge their impacts. It’s not just counting crime stats, it’s recognizing the constellation of conditions that impact communities.