Rachel Levine has been sworn in as one of the top health officials in the United States, following her confirmation by the Senate earlier this week. Although she has made headlines for becoming the highest-ranking openly transgender official in the country, researchers familiar with her work as a public-health leader laud her drive to improve the health of marginalized people. She’s done this through conventional public-health measures, they say, but also by trying to remedy inequities arising from discrimination and from social and political factors.

Levine led Pennsylvania’s COVID-19 response as the state’s health secretary, and takes her position as assistant secretary for health at the Department of Health and Human Services (HHS) as the United States continues to battle the pandemic. One issue she will have to grapple with is that the coronavirus is infecting and killing Black and Hispanic or Latino people and Native Americans at higher rates than white people.

“COVID-19 has shown us the tip of the iceberg of the lack of health equity,” Levine told Nature last September, while still head of Pennsylvania’s health department. “Socio-economic status, food security, affordable housing, access to childcare and health care, systemic racism and discrimination” all contribute to disparities in the effects of COVID-19 and other diseases, she said.

Fighting the root causes

Health officials and community groups who worked with Levine during her six years at the Pennsylvania Department of Health say she sought to correct disparities in how COVID-19 and other health issues affect various groups, by considering their root causes.

“She thought about rural Pennsylvanians, LGBTQ, disabled people, incarcerated citizens,” says David Saunders, director of the department’s Office of Health Equity. “She understands the problems that people are dealing with because she listens.”

Levine is a doctor and professor of paediatrics and psychiatry at Penn State College of Medicine in Hershey, Pennsylvania, and served as the state’s physician-general before becoming its secretary of health. In these government positions, she focused much of her effort on tackling the opioid epidemic.

In April last year, as data on COVID-19 cases and deaths began to indicate the disproportionate toll on Black and Hispanic communities in the United States, Levine launched a COVID-19 Health Equity Response Team, which guided Pennsylvania’s approach to testing and, later, vaccination distribution, says Saunders. “Without the Health Equity Response Team, we wouldn’t be as far along as we are.” Other states launched similar task forces.

Fred Brown, one of the founders of the Black Equity Coalition in Pittsburgh, Pennsylvania, says Levine listened closely to his group’s suggestions. With her support and empowerment, the coalition pushed to give grass-roots organizations more control in determining what COVID-19 interventions would be put in place, because such groups often have a better sense of what communities will accept than do doctors or government officials. And the coalition advocated addressing health and socio-economic issues beyond those directly related to COVID-19.

“She embraced it 200%,” says Brown. “She positioned us to speak with decision makers, and pointed us to resources and strategic partners.”

In another effort under Levine that took in under-represented perspectives, Saunders’s health-equity office commissioned a survey of immigrant communities last June, to identify the challenges people were experiencing during the pandemic. Respondents indicated that they were struggling with unemployment, a lack of access to testing and the difficulty of social distancing in dense households and workplaces. One key lesson was that communities wanted COVID-19 information in multiple languages, not just English, says Katherine Yun, a paediatrician at Children’s Hospital of Philadelphia in Pennsylvania who helped to design the survey.

Levine has also urged the state’s health department to tackle problems outside its usual remit, which is more typically limited to issues such as childhood immunization and nutrition.

“I’ve talked about declaring racism as a health crisis. Gun violence is a health issue. Housing is a health issue,” Levine said in September. Although health officials can’t regulate guns or build affordable housing, by tying these topics to health, members of her department could discuss their perspectives with policymakers, she explained.

A new role

Whether she can now push for more equitable health nationally remains to be seen. In her new role, Levine will be the top health adviser to the HHS secretary, lawyer Xavier Becerra, who was also confirmed this month.

Some divisions of HHS already support social services, such as the Administration for Children and Families, which backs educational programmes for low-income families. Levine could strengthen partnerships between these divisions and the strictly health-focused ones at the agency, says Anand Parekh, chief medical adviser to the Bipartisan Policy Center in Washington DC, who served as deputy assistant health secretary in 2008–15.

Parekh adds that, with the ongoing pandemic, “I could foresee the assistant secretary of health playing a significant role in the vaccination campaign, and trying to ensure vaccine promotion to minority populations”. Levine will also oversee the HHS Office of Minority Health, which houses the national COVID-19 Health Equity Task Force, established in January by President Joe Biden.

A message to transgender youth

Parekh says that the responsibilities of the assistant secretary have varied with the needs of administrations, adding, “we’ll just have to wait and see” what Levine’s role will entail.

Saunders notes that policies in support of health equity can be controversial, such as raising the minimum wage. And Levine has already sparked opposition from some Republican lawmakers who disagree with her advocacy of transgender rights, particularly those of minors.

Levine pledged support for transgender young people in a statement e-mailed to Nature after her confirmation. “Some of the challenges you face are from people who would seek to use your identity and circumstance as a weapon. It hurts. I know. I cannot promise you that these attacks will immediately cease, but I will do everything I can to support you and advocate for you.”

This article is reproduced with permission and was first published on March 26 2021.