Charity Dean may have a background in tropical disease, but she’s had to branch out. Delivering babies. Amputating limbs. Anything that was needed during her stint as a surgeon in Zimbabwe under Robert Mugabe’s leadership.

“It doesn’t really matter what kind of doctor you are when you’re in Africa,” said Dr. Dean. “You are the surgeon, you are the obstetrician.”

These days, she’s branching out in new ways, turning her attention to Medi-Cal, wildfires, and skilled nursing facilities. After returning to the U.S. to practice in Santa Barbara – where Direct Relief’s warehouse and offices are located – Dr. Dean became a county public health officer, then joined the California Department of Public Health.

Her career has included some wide-ranging responsibilities. Dr. Dean planned prevention efforts when, in 2014, a West Africa Ebola outbreak spurred concerns about the virus spreading to the U.S. Worked in a clinic for people experiencing homelessness. Responded to natural disasters.

She’s currently CDPH’s assistant director.

On November 12, Dr. Dean stopped by Direct Relief headquarters to talk flu shots, emergency management, and predictive analytics.

She also sat down with Direct Relief to discuss California’s unique public health landscape, what’s in store for the state, and what keeps her up at night.

This interview has been edited and condensed.

Direct Relief: Last year, you made the move from serving as public health officer of Santa Barbara County, and now you’re the assistant director at the California Department of Public Health. What are some of the biggest differences when it comes to implementing health at the county versus state level? And what stays the same?

Dr. Dean: The main difference is, at the state level, it’s just bigger. The problems are bigger, the solutions are bigger, collaborating with stakeholders is bigger. It’s really similar to what I did at the county, it’s just on a larger scale, and problem-solving is on a larger scale too.

I think a key difference is that Santa Barbara County is a medium-sized county. When I was a health officer there…let’s use Ebola as an example. When I was designing a novel response to a new pathogen, at least I could look at other comparable counties across the state and ask “What are they doing?”

The difference is that, with California, there is no comparable state. We have 40 million people to protect and take care of, and so we do look at other states, we do look at New York, and we do look at Florida, but as far as population and some of the unique challenges, and the fact that we border Mexico, California is so unique that oftentimes, trying to solve a problem, it’s clear that California will be the one to lead.

Direct Relief: What makes health – and health care – in California unique?

Dr. Dean: In many other states, they have a centralized model of public health, where all public health is just under the state health department.

In California, we have 61 local health jurisdictions, and it’s decentralized, meaning that each local health jurisdiction in California can set their own priorities or make their own decisions. For example, how they’re going to mitigate flu season.

Because of that, in California, the way we accomplish things in public health and health is by voluntary collaboration. It’s not by a mandate or a dictate that comes down from the state [Department of] Public Health, or from the Department of Health Care services.

California has different regions that have different challenges. The southern region that borders Mexico has unique challenges. The central region with rural areas and many populations that need more doctors and need more health care facilities – that has challenges. The Bay Area, Northern California. And so it is very much like a nation state, where we have to look at and manage the specific health care and public health needs of different regions and populations.

Direct Relief: California’s climate is changing quickly – we’ll have hotter temperatures, more and worse wildfires, etc. How do you anticipate that health care needs in the state will change as a result, and how will you work to meet those needs?

Dr. Dean: In the California Department of Public Health, there are a number of things that we have been doing and will continue to do and even enhance.

The Office of Health Equity [within CDPH] was looking at the impacts of climate change disproportionately affecting the health of those who are already vulnerable or already marginalized. People that already lived on the edge of poverty and can’t afford to leave the area when the Air Quality Index is 300 during wildfire smoke, or don’t have a choice but to continue to work out in the fields during poor air quality because they have to earn money to feed their families.

We’re seeing those impacts across the state, and so we at public health said, “What can we do, what resources can we develop, for the local health coalitions or department, to look at the impacts of climate change?”

So [CDPH] developed the California Building Resilience Against Climate Effects project, otherwise known as CALBRACE. They developed a number of resources for local health departments presenting, essentially, indicators looking at which people, which geographic regions, are at a higher risk of adverse health effects from climate change.

But the real work, as with any issue, is at the local level. Local health departments, and the collaborations with local agricultural commissioners, and water boards, and air resource boards, those collaborations are happening at the local level. And we at the state, our hope is that we can provide data, expertise, indicators, outlines of action plans, for different regions and different health departments in California.

Really, our obligation in public health is to say, “How can we mitigate the disproportionate impacts of climate change and the ensuing natural disasters on those populations that are already vulnerable?” Children, pregnant women, the elderly, those with underlying health conditions, they’re significantly more impacted by those disasters.

Direct Relief: What about demographic shifts? What changes are in store for California, and what does that mean for the health care landscape?

Dr. Dean: One of the big shifts that we’re seeing and anticipating is an aging population, and the need for the health care system and public health in California to be prepared.

For example, we can just look at the number of skilled nursing facilities and the number of beds they have, and you can do math on the back of a napkin and say “In California, we have a shortage of nursing facility beds.”

I’ll give you the story of what happened when Paradise burned down in Butte County last year. They lost a skilled nursing facility, and that had a significant impact on the community. Not just on the residents that lived there, but their loved ones and family who visited them. In California, if we lose even one skilled nursing facility, it has a ripple effect, because there’s already a shortage of those beds.

Direct Relief: What do you feel most optimistic about when it comes to health in California?

Dr. Dean: I am most excited about the governor leaning forward into integrating public health and health care. Historically, they were divided into two different camps and operated within their own silos, but this governor and his new administration and the new secretary of Health and Human Services are very interested in working across those silos.

As an example of that, [we’re] looking at, “How do we incorporate public health concepts, or population health concepts, into the way that we manage Medi-Cal?”

Medi-Cal is not a sexy topic for a lot of doctors. But it’s exciting to me because the lens of public health and population health, when applied to Medi-Cal, could really elevate the care that’s delivered in the state of California.

You’ve probably heard the quote that states are the “laboratories of democracy.” If that’s true, California is doing some pretty innovative things in health and public health and health care in our little laboratory here. I believe that California will get to lead the model on health for the country and say “Let us show you how you can cover an entire state.”

Direct Relief: And what’s got you up at night?

Dr. Dean: It’s always disasters. It’s always disaster response and communicable disease. My background, I’m a microbiologist at heart. I did laboratory bench research a number of times, lived in Africa twice, and have a degree in tropical medicine.

So I know how quickly some of these viruses mutate, and I know the real threat of microbial resistance that many of the bugs are developing, and also I know the need for bioterrorism preparedness.

What scares me most, and what I think about most, is our ability to quickly respond to a potential new pathogen, maybe one we’ve never seen before, or an old pathogen, like influenza that’s just mutated.

The H1N1 pandemic of 1918 was over 100 years ago now. The world is overdue for a pandemic like that, whether it’s influenza or something else. And in public health, we know that we have to be prepared for that. That’s what keeps me up at night.