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DELPH Reflections: A Journey Towards Creating a More Equitable and Just Democracy Fredrick Echols DELPH has helped public health professionals reflect on their purpose, cultivate compassionate leadership, understand system dynamics, and build a community of advocates to create a more equitable and just democracy. As an African-American male living in the United States, I have encountered numerous obstacles in life, particularly in my efforts to reform systems that fail to support marginalized and vulnerable populations. These systems have had devastating effects on myself and other individuals belonging to Black, Indigenous, and People of Color (BIPOC) communities as they restrict access to essential health and social services. As a Black physician and public health professional, I continue to encounter this stark reality that engenders a sense of hopelessness in communities across the United States. These systems obscure their true intentions and deceive individuals into believing that they operate in the best interest of marginalized populations while perpetuating inequitable and disparate health outcomes. In consideration of these personal and professional experiences, the Diverse Executives Leading in Public Health (DELPH) program has played a significant role in shaping my career and purpose: Fostering Critical Reflection: It provided me with a journey that encouraged me to think critically about my future and how I can leverage my platforms and relationships to help propel the public health ecosystem toward a system that embraces the humanity of all individuals and prioritizes uplifting and empowering the most vulnerable and marginalized populations. Important note: That said, the presence of silos, political posturing, and missed opportunities due to inefficient and ineffective operational practices resulting from insufficient fiscal investment continue to plague the public health ecosystem—limiting its ability to make strides toward a system that wholeheartedly supports the pursuit of health equity and social justice. Cultivating Compassionate Leadership: The program also provided access to experts and public health thought leaders who helped my colleagues and I understand the evolution of health and social service delivery in the United States (particularly for indigent populations), increase our capacity to embrace divergent thinking, and engage in constructive dialogue. The availability of such a space provided us with an opportunity to establish a secure and conducive environment, one that upheld the virtues of compassionate leadership and fostered effective relationship building. Our ability to engage with stakeholders, both like-minded and those with differing opinions, was characterized by a spirit of intentional listening that sought to comprehend their perspectives. Through this, we were able to create an atmosphere that supported open dialogue and nurtured mutual understanding. Understanding System Dynamics: The experience has enriched my comprehension of the intricacies that drive the amplification of inequality and the resulting health disparity gaps that are pervasive among communities and individuals across the nation. The knowledge thus obtained is of paramount importance to ensure my competency in identifying and avoiding perpetuating the issues that I aspire to address. This, in turn, will prevent any inadvertent harm to the communities I seek to uplift and empower. Building a Community of Advocates: Moreover, the program has enabled me to connect with individuals who are unwavering in their commitment to upholding justice. Despite our diverse backgrounds, we set aside cultural differences to work toward a common goal: the accessibility of quality healthcare and the delivery of justice for all humanity. The DELPH program's fundamental principles and culturally sensitive support structure have played an instrumental role in shaping my professional growth as a public health expert. As I chart the course for my future professional endeavors, I intend to leverage the lessons learned and the tools provided by DELPH to strengthen the public health ecosystem. My ultimate goal is to foster collaboration across various segments of society to create a more equitable, just democracy. The DELPH program has equipped me with invaluable knowledge and skills that will enable me to make meaningful contributions to society's betterment. For this, I express my profound gratitude to the Association of State and Territorial Health Officials, the Morehouse School of Medicine's Satcher Leadership Institute, and CDC for their unwavering commitment to advancing BIPOC leadership in public health. Their steadfast support for this program has enabled me and countless others to acquire the skills and knowledge necessary to effectively lead and drive the transformative change that public health requires. I sincerely appreciate their continued investment in this vital initiative, which has empowered many to become the change agents that public health needs. website yes

Prioritize the mental health and well-being of public health workers who face stress and burnout due to their work; read about practical strategies for improving workplace wellness and the impact of declining workforce well-being on public health initiatives.

It has never been more important for public health to better understand the disability community and quickly build skills and resources to better serve them, which makes it critical to include more people living with disabilities in the public health workforce.

Building More Equitable Communities Through Public Health Law Dawn Hunter Every week, my husband and I place a grocery order. We shop at an employee-owned supermarket chain known for its workplace culture. Sometimes we order online and pick it up, sometimes we have it delivered, and sometimes we do the shopping ourselves. In any case, we often purchase our groceries without much thinking—if we order online, we are prompted to “buy it again” and even in person we tend to buy the same staples. Prices are higher online than in store. In addition, we live in a community where plastic bags are still an option, but we used to live in a community where plastic bags are banned. Why am I sharing all of this? Nearly every aspect of our weekly grocery trip is shaped by the law. Laws impact: Food placement, packaging, expiration dates, and prices. Employee wages and benefits. Store location, hours, and accessibility. Availability of rideshare drivers for delivery orders. Whether to choose paper or plastic. Law impacts the way we experience our everyday lives by establishing the framework in which we operate. The grocery store is just one example of how law can shape our decisions and, more importantly, our choices. Because it shapes the resources and opportunities available to us, law is an important determinant of health. Exploring the Landscape of Public Health Law What we think of as “law” can take many forms. It includes statutes, regulations, case law, organizational policy, and budgets, and how they are interpreted and enforced. The law can be a set of requirements or prohibitions, establishing norms and expectations for our behavior as individuals, organizations, and systems. The law can also be the processes and procedures associated with creating laws, making decisions, and interpreting existing laws. Public health law, specifically, is important as a field because it includes the laws that are designed to protect and promote the public’s health and that define the power of the government to act on our behalf. In fact, law is behind every public health success of the 20th century. A 1999 issue of the Morbidity and Mortality Weekly Report listed vaccinations, motor vehicle safety, safer workplaces, healthier moms and babies, and recognition of tobacco as a health hazard among those successes. These achievements would not be possible without the law, including: School vaccination laws. Helmet and seatbelt laws. Speed limits. The Occupational Safety and Health Administration. Food fortification. School lunch programs. The Women, Infants, and Children (WIC) program. Newborn screening. The Tobacco Master Settlement Agreement. Clean indoor air laws. At the same time, these laws have not benefited everyone equally. In fact, they have often operated as a tool of racism and other forms of structural discrimination. The lesson here is that the law can create the conditions that lead to differences in health outcomes, but it can also create the conditions for equity. The Civil Rights Movement and Advances in Health Equity One must look only to the civil rights movement to see the potential. As just one example, today’s robust network of Community Health Centers was born from the activism of the Black Panther Party, which established free health clinics in response to continuing discrimination in the health care system, as well as the work of H. Jack Geiger and Count D. Gibson Jr., who established the first community health centers in 1965. The success of these efforts led to funding for additional community health centers through President Lyndon B. Johnson’s Office of Economic Opportunity as part of his War on Poverty. In fact, key legislation enacted during the civil rights movement led to significant, even if insufficient, improvements in health outcomes for Black Americans. For example, there is evidence that women’s suffrage, the Civil Rights Act of 1964, and the Voting Rights Act all led to improvements in premature mortality and infant mortality, among other benefits. The enactment of the Patient Protection and Affordable Care Act in 2010 and the resulting adoption of Medicaid expansion saw similar success. There is ample evidence of the Medicaid expansion impact on health outcomes and financial well-being, both at the individual and population level. Addressing the Training Gaps in Public Health Law for More Equitable Public Health Practice The fact that law shapes how we experience our lives on a day-to-day basis is perhaps the most important reason that public health professionals should understand the relationship between the law and health outcomes and how to use the law to achieve more equitable, thriving communities. However, knowledge of public health law continues to be one of the biggest training gaps in the public health workforce. The 2021 Public Health Workforce Interests and Needs Survey, conducted by the de Beaumont Foundation and ASTHO, found that strategic and systems thinking was one of the top training needs as well as an increased interest in policy engagement and topics related to justice, equity, diversity, and inclusion (visit the 2021 Dashboard). Another report in 2021, “Challenges and Opportunities for Strengthening the US Public Health Infrastructure: Findings From the Scan of the Literature” by the National Network of Public Health Institutes, found a need for increased awareness among the public health workforce of the legal basis for public health authority and identified both how to influence law and policy development and how to understand the effects of law and policy on health among the top training needs. These findings align with public health accreditation standards. Whether or not you work for an accredited health department, the Public Health Accreditation Board Standards and Measures serve as a guidepost for the practice of public health. There are two specific domains where this is relevant: domains 4 and 5, as detailed in Table 1. Padding Block - Medium(10) Table 1. Public Health Accreditation Board Guidance for Equity Domain Measure Examples Domain 4: Strengthen, support, and mobilize communities and partnerships to improve health. Measure 4.1.3 A: Engage with community members to address public health issues and promote health. Making the decision-making structure inclusive and transparent to empower community members or developing mechanisms for shared ownership in the process. Enhancing residents’ capacity to understand levers of power or influence in policy change. Domain 5: Create, champion, and implement policies, plans, and laws that impact health. Measure 5.1.2 A: Examine and contribute to improving policies and laws. Assessment of the impacts of the policy or law on equity. Input gathered from stakeholders or strategic partners. Padding Block - Large(2) Lessons Learned: Involving and Empowering Communities The inclusion of community members in assessment, decision-making, and capacity-building efforts to understand levers of power or influence reinforce key lessons learned in the past three years, spurred by COVID-19 and the racial justice movement of the summer of 2020: The first lesson is the need to recognize and rectify historical injustices. It is important that we understand the historical legal context behind current health inequities. We must know and name the problem to solve it. The second is the need to rectify current inequities by analyzing and assessing the ways in which our current system of laws is creating and reinforcing inequities. The third is the need to engage impacted people in identifying, designing, and implementing solutions. One of the lessons learned from the work of Geiger and Gibson was that there is a difference between what the health system thinks people need and what communities think they need. It seems we are still trying to learn this lesson today. Leveraging Law to Drive Equity and Make Public Health More Trustworthy Law is the only way to truly change the game for inequities. It can give a voice to historically marginalized people by creating pathways to ensure inclusion and representation in the political process. It can also change systems and institutions by changing the way they operate and the way that people within those systems operate. Additionally, it can serve as a tool to enforce conditions that will lead to more equitable outcomes and to hold people in positions of power accountable. We have often heard in the past few years about the need to rebuild trust in public health. I’d like to reframe that to think about how we make public health as a field more trustworthy. It starts by increasing our understanding of the authority of public health to promote the public’s health and to use that authority to create systems in which we all can thrive. article yes

Strengthening Leadership, Risk Communications, and Preparedness in the Islands Strengthening Public Health Preparedness in the Islands Sidnie Christian, Alyssa Boyea Key strategies in on leadership, risk communications, and preparedness, can help island jurisdictions prepare for and respond to emerging public health threats. ASTHO convened a two-day, in-person workshop in Honolulu from June 25 – 26, bringing together public health preparedness staff from American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Guam, Hawaiʻi, the Republic of the Marshall Islands (RMI), and Palau, as well as federal partners from CDC, the Department of Homeland Security, and the Administration for Strategic Preparedness and Response. The workshop focused on leadership and workforce development, risk communications, administrative preparedness, and more to support island areas as they prepare for and respond to natural disasters and other emerging public health threats, of which emerged key learnings that can benefit all island jurisdictions. Leadership and Workforce Development Leading through change requires transparency, trust, and collaboration. Planned change involves assessing readiness for change, identifying resources needed, securing buy-in, and determining a path forward. However, sometimes change can leave little to no time for preparation. Island jurisdictions have encountered challenges in the face of change, with many workshop participants sharing firsthand challenges around retaining institutional knowledge, infrastructure, and receiving assistance from the mainland United States in a timely fashion. As such, change readiness, succession planning, and effective change management practices are of utmost importance in the islands. Key recommendations and takeaways include: Utilizing a reputable framework, such as Kotter 8-Step Change Model, is pivotal for improving change readiness and change management. Change management frameworks and methods can assist with different types of change including structural change, strategic operational change, people-centric change, etc. Trust is hard to build, but easy to lose. Participants spoke about characteristics of high trust relationships including open communication, consistency, good judgement or expertise, and cultural sensitivity, while low trust relationships characteristics include lack of communication, inconsistency, and lack of teamwork. Succession planning is important to ensure institutional knowledge and capabilities remain in the wake of staff turnover or retirement. Identifying the necessary expertise, skills, and capabilities for each role is vital in the case of unplanned changes in staffing. Promising practices include annual review of critical positions, conducting talent calibration sessions, defining action plans, and obtaining buy-in from leadership and relevant partners. Risk Communications The island jurisdictions face emergencies that require creative response efforts. Both Hawaiʻi and RMI demonstrated innovative approaches in risk communications during COVID-19, finding success in forming critical partnerships, utilizing trusted voices within the community, and bridging communication gaps: Hawaiʻi utilized social media to showcase individuals such as doctors, pastors, social media influencers, and even local sports teams getting vaccinated, and utilized trusted voices to deliver messages. Additionally, they translated their materials into three languages (Marshallese, Samoan, and Hawaiʻian), modeling that no one gets forgotten, the true meaning of “ohana.” RMI created a working group with a mix of partners that curated press releases, educational materials, and sitreps, and served as a liaison between RMI Ministry of Health and Human Services and the community. It also partnered with several media outlets (e.g., radio stations, local papers, and other private sectors) and utilized mass text messaging to spread information quickly. The latter proved to resonate with most island jurisdictions who struggle with staying connected to hard-to-reach populations, namely those in more rural and disconnected communities. RMI was able to connect with these populations through WhatsApp to keep them updated throughout the COVID-19 response. Administrative Preparedness Improving administrative preparedness plans and processes ensure timely and efficient access to needed resources for a public health response. Most workshop participants are currently in the process of updating existing administrative preparedness plans, while some are working with other departments to create and implement new plans. Attendees discussed key partnerships for collaboration including other departments, Medical Reserve Corps, and other volunteer organizations. One common key challenge that emerged was around staffing (e.g., finding qualified people to fill vacancies, hiring process issues, making sure positions are competitive, etc.). To address this issue, island jurisdictions can work closely with other departments or jurisdictional agencies to streamline current processes, establish memorandums of understanding with different partners/facilities to assist with emergency procurement, and ensuring staffing vacancies are competitive and match public health classifications. Disease Forecasting A survey on state and territorial expertise and needs for infectious disease forecasts, models, and other outbreak analytic techniques—implemented by ASTHO with support from CDC’s Center for Forecasting and Outbreak Analytics—revealed that respondents from island jurisdictions experienced several barriers that led to limited use of infectious disease forecasts to inform communication and decision making. Challenges noted include limited software access, limited disease modeling capacity or skills, and lack of uniform reporting systems. Through a discussion-based exercise, workshop participants shared their challenges and considerations for ASTHO and CDC to assist with disease forecasting in the island jurisdictions moving forward. Challenges include but are not limited to: Delays with sending samples to labs and receiving results in a timely manner. Without timely results, it is challenging to take swift action. Lack of staff / staff wearing many hats with limited capacity. In most cases, there is no specific communication plan for disease forecasting within the departments. Communication can be challenging without clear processes and channels. Participants noted the desire for additional disease forecasting training and opportunities for collaboration. They suggested an integrated training session with island epidemiologists and other relevant staff to enhance disease forecasting knowledge and communication, as well as strengthen collaboration. Preparing for and Responding to Climate Events From hurricanes to typhoons to volcanic eruptions, the island jurisdictions are no strangers to the effects of changing climate. Willliam “Brandon” Aydlett, science and operations officer at the National Weather Service, and Shelbi Davis, Senior Analyst on the Environmental Health team at ASTHO, offer the following recommendations to island jurisdictions for preparing and responding to unprecedented climate events, as discussed with workshop participants: Create or update standard operating procedures for various climate related responses unique to the island. Always prepare for a category higher storm than is expected. Consider conducting regular vulnerability assessments to better understand areas where the island or its people may be most susceptible to adverse health impacts from climate events. Jurisdictions can learn from one another and find a sense of camaraderie in their preparedness efforts, much like the workshop participants. For example, one island jurisdiction noted that they currently do not have a warehouse to store equipment but are working on a plan to secure one; another jurisdiction, having recently revamped their warehouse, noted that they could assist their island neighbor in this endeavor and provide lessons learned as well as strategies to help secure a warehouse that will fit their needs. Looking Toward the Future Sharing lessons learned with one another and reflecting on how to apply those learnings in respective communities is crucial. Workshop participants shared their intent to share and utilize resources and information shared throughout the workshop with their leadership and team to begin implementing in their jurisdictions, as well as using strategies and skills learned to enhance partnerships. To all the participants and our Hawaiʻian hosts, we say mahalo. Related Resources Modernizing Infrastructure and Facilities for Readiness and Response | ASTHO PH-HERO Workforce Resource Center | ASTHO ASTHO STAR Center | ASTHO Evidence-Based Strategies to Enhance Public Health Emergency Preparedness and Response | JPHMP article yes

As the overdose epidemic continues, it is imperative for the medicolegal death investigative community to understand the importance of continuous training and the role that accurate death certification plays in protecting the nation’s health.

Sandra Powell, deputy director of Rhode Island Department of Health, how her department was able to increase the number of permanent positions to meet critical public health needs.

ASTHO CEO Michael Fraser, PhD, and Tracey Wareing Evans, President and CEO of APHSA, sit down to discuss building a foundational family well-being roadmap amidst the COVID-19 pandemic.

Over the years evidence has expanded on community health workers (CHWs) improving outcomes and even reducing disparities in heart disease and many other public health priority areas. However, their presence in state and local public health workforce is still modest. A number of efforts have sought to expand the role of CHWs in medical care settings by developing reimbursement through third party payers, along with including them in managed care contracts and incorporating them in state Medicaid plans. The experience and lessons of the COVID-19 pandemic could substantially change the way we practice public health in the future, and provides opportunities to expand the role and presence of CHWs in the state and local public health workforce.

If there is any word to describe 2020 it is “unprecedented,” with the work of health agencies front and center since COVID-19 emerged in the U.S. But as we approach Public Health Thank You Day and the Thanksgiving season, ASTHO wants to send a special appreciation to our entire state and territorial public health workforce. We have been so impressed by your tireless work to address COVID-19 in your jurisdictions and you have wowed us all with your dedication and commitment to the work of health protection and improvement. Thank you all for all you do to keep your communities healthy!

An ASTHO blog article about how to communicate with care to staff about telework policies with the shift of the pandemic.

After decades of underinvestment, health departments received increased funding for disease intervention services, strengthening the existing workforce, and providing opportunities to expand workforce capacity.

Five great reasons to attend ASTHO's 2023 Health Equity Summit.

Avia Mason discusses three pillars for public health leadership of the future: care for yourself, communicate effectively, and convert from transactions to transformation.

As in any sector, there is often talk in the public health field of “working upstream,” or addressing problems at their source. If public health is going to be a changemaker in the world, its leaders must be equal parts nimble and innovative.

Accompanying an infusion of federal funding, states are considering several policy changes to strengthen the public health workforce and address challenges within the health care workforce.

Colleen Arceneaux and Jantz Malbrue from the Louisiana Department of Health to discuss why forgoing community health worker certification was the right course of action for their state.

An ASTHO blog article about the importance of resiliency in the workplace, pertaining to leadership and organizational work environment.

As part of ASTHO’s Public Health - Hope, Equity, Resilience, and Opportunity initiative, we are using this post to highlight some acts of thanks for organization leaders and supervisors to consider.

Building a Culture of Care: Leadership in Public Health Agencies astho, association of state and territorial health officials, association of state and territorial health officials astho, state health official, public health official, territorial health official, island jurisdictions, state health, health department, public health, centers for disease control, creating a culture of care, public health workers, health equity, physical health, building a culture of care, health departments, public health professionals, training program, school of public health, mental health problems, public health leaders, public health workforce, mental well-being, culture of care, mental health, workforce development Chris Taylor ASHTO | A blog post highlighting three simple actions agencies can take to strengthen a culture of care. Throughout the COVID-19 pandemic response, many of us have witnessed or experienced increased feelings of exhaustion, mental distance from our work, negativism or cynicism related to our jobs, and reduced professional efficacy. The World Health Organization classifies these symptoms of burnout as an occupational phenomenon, rather than as a medical condition. For governmental public health agencies to successfully promote and protect the health of their communities, it is imperative that they support their staff to remain healthy and resilient. This blog provides information and considerations for state, territorial, tribal, and local health departments to identify and address work related causes of burnout, as well as build and maintain the health and mental wellbeing of their staff. Governmental public health continues to play a central role in the COVID-19 response, which for more than two years has created unprecedented and prolonged demands on staff. Beyond the COVID-19 response, there continue to be massive changes in how and where we do business, as well as how we interact with one another, contributing to additional organizational stress. In 2021, CDC surveyed state, territorial, tribal, and local public health staff to assess symptoms of anxiety, depression, post-traumatic stress disorder (PTSD), and suicidal ideation. Among 26,174 public health staff who participated: 53.0% reported symptoms of at least one mental health condition in the preceding two weeks, including anxiety (30.3%), depression (32.0%), PTSD (36.8%), or suicidal ideation (8.4%). The highest prevalence of symptoms was among respondents 29 years or younger, as well as transgender or nonbinary persons (i.e., those who identified as neither male nor female) of all ages. Public health staff who reported being unable to take time off work were more likely to report adverse mental health symptoms. Severity of symptoms increased with increasing weekly work hours and percentage of work time dedicated to COVID-19 response activities. In a 2022 follow up survey, 75.5% of respondents did not think their employer had increased mental health support. Additionally, other recent surveys have indicated a trend of rising stress and burnout in the public health workforce, leading many to resign and more to consider leaving their agencies. While some support to the workforce may be available in government agencies, staff may feel they don’t have time, or feel supported to utilize these programs. This blog series will explore strategies that health department leadership may consider to strengthen a culture of care in their organization. Three Simple Actions You Can Take Today to Strengthen a Culture of Care Health department leaders can have a major impact on the behaviors and health of their workforce. Consider taking these actions: Practice and offer a model of your own commitment to self-care Self-care, which includes a healthy diet, adequate sleep, and regular exercise, are critically important for leaders in maintaining productivity and effectiveness, particularly during stressful periods. Other ways to practice self-care can include meditation or mindfulness practices, journaling, expressing gratitude or acts of kindness, or connecting with friends and loved ones. Send a message to your entire department discussing the importance of self-care and sharing examples of how you practice self-care. This not only demonstrates that your organization values and supports self-care, but also gives practical examples for staff to consider implementing. This would also be an excellent opportunity to highlight the availability of an employee assistance program (EAP) or employee wellness programs and benefits. Acknowledge the mental health effects of the COVID-19 response Share an example of how you (or someone you care about) has been impacted emotionally or psychologically by the COVID-19 pandemic. Your example can normalize the burnout and moral injury that some of your staff may be experiencing, as well as build trust and connectedness. Talking about mental health at work is important to reduce the stigma and create an environment that is more open and understanding about anxiety, depression, and other mental health issues that might show up in the workplace. This is also an opportunity to discuss mental health coverage in your health insurance plan(s), as well as resources available in the community, some which may be funded by your department. Exercise at the office or on the office grounds One well-proven approach to addressing stress and improving mental health is exercise. As a leader, you can model the importance of exercise to your agency. This can be as simple as taking the stairs rather than the elevator, incorporating stretching throughout the day, or walking during phone calls. Invite staff of all abilities to join you in a stretch, movement, or walk break. Consider a standing desk, replacing your chair with a stability ball, or keeping exercise equipment in the office for use during breaks. By prioritizing and modeling physical activity, you are sending a message that self-care is important. What Does a Culture of Care Mean for You? Has your organization prioritized a culture of health and well-being? Are there lessons learned for your organization’s support of staff during the COVID-19 response? How is your organization ensuring a manageable workload, particularly during times of emergency response? Speak with your employee wellness, workforce development, human resources, and/or professional development teams to ensure the organization is best meeting the health and wellness needs of employees. Based on the alarming findings of the CDC surveys, special emphasis should be placed on ensuring employees have additional information about, and are aware of, services/referrals to treat anxiety, depression, PTSD, and suicidal ideation. What’s to Come? Many employers and leaders have been creative in strengthening a culture of care in their organization. Over the coming months, ASTHO will highlight specific strategies to increase a culture of care in your organization. We’ll also share examples employed by health officials and other senior leaders within health organizations. Finally, we plan to curate a list of resources for executives, supervisors, and employees for creating a culture of care, stress reduction, self-care, and burnout prevention. Conclusion For public health systems to serve their communities most effectively, it is imperative that their staff are healthy, both physically and mentally. State, territorial, tribal, and local health departments should consider policies and programs that support the health and mental well-being of their staff – particularly in high stress emergency responses. We look forward to additional opportunities to discuss these important issues, hear how health department leaders are strengthening a culture of care, and learning how ASTHO can support your efforts. website yes