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In-depth analysis on state health policy surrounding the public health workforce. This is part of ASTHO's annual legislative prospectus series.

ASTHO engaged Oklahoma public health officials, members of the Oklahoma Harm Reduction Alliance, Health Minds Policy Initiative, and representatives of the Southern Plains Tribal Health Board, and others in a Boundary Spanning Leadership workshop.

DELPH scholars discuss the important role of Community Health Workers (CHWs) in the public health workforce, the need for support, recognition, and investment in their development, and the importance of sustainable funding for CHW programs across the United States.

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

With many of the state and territorial legislatures reconvening over the next few weeks, we can look forward to new (and not-so-new) legislation start to crop up that will impact public health. To help navigate the new legislative sessions, ASTHO’s "2021 Legislative Prospectus" series highlights eight priority policy areas jurisdictions will address during this year. Each prospectus in the series provides a brief overview of the issue, the issue’s impact on health, and recent legislative trends aimed at addressing the issue. This year, ASTHO developed prospectuses on COVID-19, e-cigarettes, HIV, influenza, maternal mortality and morbidity, neonatal abstinence syndrome (NAS), polyfluoroalkyl substances (PFAS), and rural health.

Economic security and well-being, job stability, access to safe and affordable housing, access to healthy and nutritious foods, and access to resources to manage mental and physical health—all of these things impact individual, family, and community health. The COVID-19 pandemic has fundamentally impacted each of these social determinants of health for many Americans. Furthermore, some communities and industries have faced harder economic impacts than others, including households with low incomes, non-white households, and households with children. Human services and public health leaders can collaborate to make sure we are rebuilding systems and programs in a way that creates healthier, more resilient families and communities.

In February 2023, ASTHO staff traveled to Koror, Palau for a four-day health equity summit and held workshops to identify, select, and prioritize measures for Palau’s health equity work.

As the country prepares for the inauguration of President-Elect Joseph R. Biden, Jr. on Wednesday, the incoming administration has highlighted several priorities over the next four years. This post is a summary of priorities that are closely aligned with the work and interests of state and territorial public health, including continued COVID-19 recovery and response, and climate change.

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.

States and territories have broad powers to protect public health and safety, including powers to prevent and control the spread of communicable disease typically exercised by state and territorial health departments. This authority is an essential tool in the fight to keep the public safe and healthy.

Continuing ASTHO’s Legislative Prospectus series—which highlights the top 10 public health policy issues for 2022—we are focusing this week on mental and behavioral health as well as supporting the public health workforce.

Vaccines are one of the greatest public health achievements of the last century, as well as some of the most powerful and cost-effective tools to prevent disease, disparities, disability, and death among children and adults. The COVID-19 pandemic and the unprecedented development and distribution of the vaccines against the novel coronavirus have generated much focus on state laws related to vaccinations. As state and territorial legislatures prepare to convene in the coming weeks, we can already identify several topics within vaccine law that policymakers across the country will consider.

In addition to the countless hours worked during the COVID-19 pandemic, many public health workers are also grappling with how to repay outstanding federal loans. In response, the U.S. Department of Education (DOE) recently announced temporary relief to current and future Public Service Loan Forgiveness (PSLF) program participants as a result of the COVID-19 pandemic.

Pharmacies have long been instrumental partners in providing lifesaving vaccines nationwide. As state and territorial health officials evaluate their COVID-19 response, planners must include input from the pharmacy community when identifying areas for improvement, as well as best vaccination practices in advance of future public health emergencies.

ASTHO Files Amicus Brief in Michigan Case, Argues Against Criminally Charging Health Officials During Major Public Health Crises ARLINGTON, VA—Last week, the Association of State and Territorial Health Officials (ASTHO) filed an amicus brief with the Genesee District Court in Michigan asserting that criminal prosecutions of health officials based on their professional judgment and decisions will weaken governmental public health’s ability to respond during health emergencies and present additional risks to the public. The court case is the first of its kind where a standing health official has been criminally charged for an alleged failure to notify the public regarding an outbreak of Legionnaire’s disease in Genesee County in 2014 and 2015. The outcome of this case is of great interest to ASTHO and its members who are concerned that the threat of criminal sanctions based on a health official’s professional, discretionary decisions will endanger public health. “We are very alarmed by this case, and the fact that a health official can be criminally charged to this extent for doing his job, especially during a public health crisis, is not right,” says John Wiesman, president of ASTHO and secretary of health at the Washington State Department of Health. “ASTHO’s board has carefully considered the allegations in the case. As public health officials, our decisionmaking does not fit within a one-size-fits-all model, but rather includes a thoughtful approach to limiting widespread panic, translating meaningful communication about public health risks and proper efforts to address the crisis at hand, especially when information is subject to change or incomplete.” “The outcome of this case could have an immediate chilling impact on the entire public health profession and a cascading effect on critical life and death decisions public health officials face every day,” says Michael Fraser, CEO of ASTHO. “The public must trust our public health officials to make the right decision at the right time and the fear of criminal prosecution will stymie their efforts.” The amicus brief also notes that “the basis for responsible public health communication is scientific knowledge and consensus,” and “[p]ractitioners have a responsibility to examine the quality of the available scientific information prior to performing any communication activity.” ASTHO Press Release Boilerplate website yes

The Eliminating Structural Racism to Achieve Health Equity Policy Academy fosters the development of governmental workforce policy development skills and boundary spanning leadership to advance policy, systems, and workforce changes to achieve health equity.

Through the lens of the Public Health Accreditation Board's standards and measures, this report explores innovative programs and policies implemented by health departments in an effort to adopt system-wide approaches to achieving health equity.

Legislative Prospectus: Public Health Workforce 2022 ASTHO Legislative Prospectus: Public Health Workforce astho, association of state and territorial health officials, association of state and territorial health officials astho, public health officials, state health officials, territorial health officials, island jurisdictions, state health, public health, leading cause of death, mental illness, 10th leading, center for disease control, united states, national suicide prevention lifeline, save lives, suicide prevention resource center, disease outbreak, disease control and prevention, national institute of mental health, preparedness plans, centers for disease control and prevention, mental health conditions, preparedness and response, attempting suicide, mental health problems, health care, evidence base, covid-19, mental health, suicide prevention, pandemics preparedness, behavioral health Years of underinvestment in public health left a fragile public health system to respond to COVID-19 in early 2020. The public health workforce overcame extraordinary conditions responding to the pandemic—working long hours, risking exposure to the disease, and withstanding threats and abuse from the public—which negatively effected the mental health of many public health workers. A Spring 2021 survey of over 26,000 public health workers found that 52.8% experienced symptoms of anxiety, post-traumatic stress disorder, or suicidal ideation. States and territories are considering several policies to support the public health workforce, including efforts to increase the number of public health workers, strengthening protections for workers privacy and safety, and ways to sustain public health funding. Download the Prospectus website

Roots of Equity: Addressing Health Disparities and Advancing Inclusive Solutions in Michigan Ninah Sasy Addressing historical inequities and health disparities to promote health equity and well-being in Michigan. Social determinants of health (SDOH)—e.g., socioeconomic status, education, employment, housing, access to health care, and environmental factors—profoundly shape individual and population health. SDOH includes social and cultural factors such as racism, discrimination, and bias (based on race, ethnicity, gender, sexual orientation, disability, or other marginalized identities) that contribute to health inequities by creating barriers to resources, opportunities, and fair treatment. Understanding and addressing these factors is essential for promoting health equity and improving overall well-being. The Historical Landscape of Systemic Discrimination My grandparents were born in the late 1930s and early 1940s, during which a significant number of discriminatory practices and policies directly impacted their career trajectory and the stability of their family. Jim Crow laws enforced racial segregation, leading to inequities in education, housing, and employment opportunities. Like many African Americans, my grandparents relocated from the South to northern states for better opportunities (specifically Flint, MI, to join the automobile industry). When they arrived, they encountered additional discrimination, including redlining. The practice of redlining involved discriminatory lending practices by financial institutions, explicitly denying or limiting financial services, such as loans or insurance, to certain neighborhoods or communities, often based on the perceived risk of racial or ethnic minorities. Despite that, my grandparents were fortunate to live the American Dream of owning a home; I remember their beautiful green lawns and my grandmother’s flower gardens from when I was a child. Importantly, African Americans weren’t the only ones impacted by discriminatory laws and practices. My maternal grandmother, who was Native American, faced discrimination as well through forced assimilation, a direct contrast to the Indian Reorganization Act of 1934, which was intended to promote cultural preservation. Many minority populations and impoverished farmers faced unimaginable discrimination—and the repercussions are still evident today. Health Inequities and Racial Weathering Health inequities persist when comparing African Americans to their White counterparts. Most recently, during the COVID-19 pandemic, significant disparities in mortality rates became apparent. Understanding the origins of these disparities connects back to the historical landscape of our country and the antiquated policies that perpetuate these inequities. In addition to the Jim Crow laws creating an unfair advantage for some Americans to achieve generational wealth, there are day-to-day infractions that persist today. Racial weathering describes the cumulative physical and psychological toll of experiencing systemic racism and discrimination over time. This phenomenon manifests through chronic stressors such as microaggressions, unequal access to resources, and institutionalized racism, which can have profound effects on individuals' health outcomes. Research suggests that racial weathering contributes to disparities in chronic illnesses, mental health conditions, and overall well-being among marginalized communities. The cumulative physical and psychological toll of experiencing systemic racism and discrimination over time. This phenomenon manifests through chronic stressors such as microaggressions, unequal access to resources, and institutionalized racism, which can have profound effects on individuals' health outcomes. Research suggests that racial weathering contributes to disparities in chronic illnesses, mental health conditions, and overall well-being among marginalized communities. My grandparents and their neighbors took pride in their homes. However, several factors, including the closure of numerous factories, have contributed to disinvestment in the Flint, MI community. When the primary employer, the automobile industry, departed, so did a portion of the population to seek employment in other communities. Consequently, there was a lack of investment in the school systems, as they relied heavily on property taxes. This domino effect resulted in food insecurity and housing instability. Once vibrant homes with lush lawns and blooming flowers were replaced with abandoned properties and businesses. As a result, individuals must travel 20 to 30 minutes by car to reach a grocery store instead of taking a 10-minute walk for fresh produce. Transforming Public Health in Michigan Culturally Appropriate Solutions According to the Michigan State Plan on Aging, approximately 2.5 million people in Michigan (or 25.3% of the state’s population) are 60 or older. Considering the comprehensive policy and programmatic needs to support this growing population, we must better understand and create culturally appropriate solutions. It is also critical that we acknowledge and address the longstanding historical inequities intertwined in laws, policies, and social structure that have created health inequities in our aging minority populations. Addressing these inequities is crucial to support health equity and improve the overall well-being of all older adults in Michigan. We are fortunate to have the Michigan State Plan on Aging at the state level. The Plan was developed and implemented with the support of diverse voices by integrating fundamental principles such as health equity, elder justice, person-centered practices, and evidence-informed approaches across all goal areas through Michigan Department of Health and Human Services (MDHHS) leadership. Michigan Department of Health and Human Services (MDHHS) leadership. Building a Statewide SDOH Strategy As the Policy and Planning Director, I have the privilege of leading the development and implementation of our statewide SDOH strategy. This strategy aims to create a healthier and more equitable society by tackling the social and environmental factors influencing health outcomes. It is imperative to address health disparities to guarantee that everyone, regardless of their background, has an equitable chance to enjoy a healthy and satisfying life. The strategy strives for a future where innovative concepts and community-led solutions are central to dismantling health disparities and fostering the comprehensive well-being of communities. Representation Is Key Representation matters because it ensures that diverse voices and perspectives are heard and considered in decision-making. MDHHS recognizes the importance of representation and continually gathers information from community partners and residents to inform its work. Within the MDHHS SDOH policy team, I have taken proactive steps to assemble diverse leaders to provide insights and guidance for collaborative efforts. My leadership goal is to cultivate a culture where every team member feels appreciated and empowered to share their viewpoints, nurturing an atmosphere of transparency and mutual regard. Convening diverse partners is essential for fostering inclusive and practical solutions to complex societal challenges, particularly in public health. By garnering a wide range of perspectives, experiences, and expertise, these partnerships can better identify and address the root causes of health disparities and inequities. Through intentional engagement with our SDOH task forces, advisory councils, and SDOH Community Influencer Program, we strive to build trust and longstanding collaborative relationships. By prioritizing diversity and inclusion in our engagement efforts, MDHHS seeks to create policies and initiatives that genuinely reflect the needs and experiences of the communities we serve. However, there is always room for improvement. As public health leaders, we should continually assess how we engage with the community to ensure we build longstanding relationships. Healing Historical Wounds Reflecting on the Michigan initiatives makes me proud to be a public health leader. However, having lost two of my grandparents before they reached the age of 70 and remembering the challenges that they endured throughout their lives, I continue to feel disheartened. Many factors impact health care outcomes for the aging population, especially for BIPOC communities. Navigating the social and health care system is challenging. The digital divide, the deeply ingrained distrust in health care, and the rekindling of past traumas are just a few additional barriers for the aging population, which are further compounded in minority and low-income populations. As leaders in public health, it is crucial to continuously enhance our community engagement practices, ensuring that our programs and policies accurately reflect the community's needs. This involves: Cultivating solid relationships with community partners to reach our most vulnerable populations, particularly the elderly, effectively. Actively pursuing opportunities for professional growth, such as anti-bias and cultural competency training. Taking proactive steps to eliminate barriers to partnerships by reforming grant-making procedures, promoting flexibility in program design, and refining our community engagement strategies to capture the invaluable perspectives the community offers entirely. Embracing collaborative decision-making processes is essential. Advocating for policies like the Caregivers Act, which removes barriers for family members to care for their aging loved ones, aligning with culturally competent care. Prioritizing equitable solutions that address not only socioeconomic disparities but also the underlying inequalities among minority groups should be an essential aspect of policy reform discussions. Our commitment to investing in the elderly will benefit future