Poverty, depression and domestic violence aren't just 'social determinants of health' to Northwell CEO Michael Dowling — they're part of his remarkable past

Michael Dowling's childhood home in Knockaderry, Ireland, was a thatched-roof cottage made of mud and stone. It lacked electricity, indoor plumbing and running water. To obtain peat to heat it, he traveled an hour with his father in a borrowed donkey cart to a bog. 

This might sound like the colorful storytelling the Irish are known for. But, the details of his upbringing in 1950s and 1960s Ireland at times resemble those of life in the 1800s. 

"Sometimes when I talk about the way I grew up, people have a hard time believing it was only in the '60s," said Mr. Dowling, president and CEO of New Hyde Park, N.Y.-based Northwell Health.

Mr. Dowling's new memoir After the Roof Caved In hardly romanticizes the challenges he confronted as the oldest of four children in Ireland, as well as his immigration story to the United States in the 1970s. In it, the reader comes to see how the longtime leader of New York's largest integrated health system has a unique relationship to many of the circumstances and factors that are referred to as "social determinants of health" in the industry: inadequate housing, substance abuse, domestic violence, depression, poverty and classism, to name a few. When Mr. Dowling finds himself in a board room discussing any of the aforementioned with corporate executives and leaders, his perspective is often unmatched. 

Here, Mr. Dowling reflects on what got him to put pen to paper, how he squares privilege with his past, his assessment of care for mental health in the United States and more.  

Question: After the Roof Caved In is a very honest account of your childhood, family and upbringing in Ireland. In it, you share some painful experiences and memories. How open have you been throughout your career about the less-than-perfect parts of your past? Does this book mark a departure from norm? 

Michael Dowling: I've always been pretty open. I've never been shy talking about my past, or embarrassed by having grown up in poverty. In fact, sometimes I think it's a good thing. This is the first time I've ever written about it, however. 

I resisted writing a book for many years, but many people told me I should after the debates about immigration in the United States. As an immigrant, I finally decided at the encouragement of others that it could be an interesting story and important to write it. There's a part of everybody's history in this book. We all have an immigrant story, whether it's our own or our predecessors'. 

Q: The book touches on housing, substance abuse, domestic violence, depression, poverty, classism and other themes that many accomplished CEOs may speak about as corporate citizens, but have not experienced firsthand. How has this influenced your leadership and communication style, especially toward stigmatized issues?

MD: Having lived through them, you have much better appreciation of their impact. You can empathize more. 

People have often asked me, "Why did you decide to work in health and human services?" Well, it directly emanates from my past. My mother was deaf and my father was very ill. I've always had a direct personal interest in those issues, and I've always tried to figure out how I can have some kind of a role in making things better for people who suffer from those concerns. 

On the other hand, I'm a very strong advocate that you should never reduce the incentive for people to work and do things for themselves. It's that fine balance. In the book, I discuss when I worked in child welfare for the state of New York. I helped initiate a lot of innovative programs to help create less disincentive to work because I think people have an obligation to help themselves. But for those people who legitimately cannot, we have a social and moral responsibility to help them the best we possibly can. 

Growing up the way I did has made me pretty passionate about what I do. If someone talks to me about not knowing where the money for their next whatever-it-might-be will come from, I know that. And I get upset with people who take advantage, but I also get upset with people who do not fully appreciate the inconvenience of being in a very difficult circumstance. 

Q: One thing that stood out when you talk about growing up in Ireland is the tension around class, money and opportunity. You describe a "cacophony of no" that constantly reminded you of your plot in life, as did many people in your village. A priest would read off families' donations to the church, and embarrass your father when the Dowlings were able to afford a smaller contribution than other families. Nonprofit healthcare isn't exactly the most lavish of sectors, but corporate leaders do have privilege. How do you square that and not feel like you're turning your back on your roots?

MD: I remind myself that I today have a very fortunate life. I live in a beautiful community, have a nice home and have everything I need. A model of the house I grew up in is in my home now, because I like to look at it and remember how fortunate I am. It's important to stay grounded, be a decent person, do the right thing, treat people well, keep your feet on the ground and remind yourself that everybody, whether rich or poor, puts their pants on the same way every morning. 

All of us who have done relatively well and have kids, I think my kids are fortunate and don't fully understand. I want to make life easier for them, but not easy enough where they don't understand what it's like to have it hard. 

Know where you come from, but try to understand where other people are coming from. In any discussion or policy debate, you can only get to a point of compromise if you understand the other side and their circumstances. If I'm dealing with people who have had a privileged life, I try to understand that background because quite frankly I'm in that situation today. It's about a balanced perspective and appreciating where you are today is not where you were, and where some people are today is not where everybody is. For almost everybody who finds themselves in a good situation today, at some point or another, their predecessors were not in that position. We stand on the shoulders of those who came before. 

Q: You describe your father, Jack Dowling, as having an unpredictable temper. As a result, you and your siblings walked on eggshells around him. He also kept his emotions, besides anger, to himself. Years later, you and your siblings have come to see he was likely experiencing depression, and you went through a difficult time yourself in the 1970s. We have learned a lot about depression and attitudes toward it have shifted a great deal, but only recently. Do you think U.S. healthcare has fully embraced mental and behavioral health, or does work remain?

MD: I think healthcare does a relatively poor job overall of embracing mental health. 

First of all, we silo it in its own separate, distinct category, and it has been stigmatized. There is some positive improvement, however. I dream of being able to come up with a name other than mental health. Some people now are calling it "brain health," because "mental health" has this negative connotation.

We don't educate people about it as much as we should, we don't have the proper facilities in most cases to treat mental illness. We don't integrate it with physical health services as much as we should. When I was having problems in the 1970s, I never got treatment or help. I was never diagnosed with a mental illness, but I know enough about it to know through that period I was in all likelihood suffering from depression. It needs to be accepted a lot more and we need more education about it. 

Q: You mention in your book that some of the most important and formative social gatherings growing up in Ireland were wakes and funerals. The Irish wake is such an interesting tradition and celebration of life. We have now gone a year as a society when wakes and funerals were very difficult if not impossible to organize. Do you think social gatherings will have renewed importance to us when we are able to be together again?

MD: I think they will have enhanced, renewed importance. People desire person-to-person socialization. We can do a lot with Zoom, but when families come back together, I think there will be increased appreciation of how important it is. If you're human at all, COVID has changed you and given you a different perspective on the importance of relationships. Things that you might have dismissed prior to COVID or were a little bit of an annoyance, now I think we will appreciate getting together more. 

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