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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

The Boundary Spanning Leadership Framework’s Impact on Public Health Boundary Spanning Leadership's Impact on Public Health Alice Schenall, Tyrone Bethune, Alyssa Merski Explore three examples of Boundary Spanning Leadership's public health impact, from overdose to Alzheimer's to youth behavioral health. Since 2018, ASTHO has customized the Boundary Spanning Leadership (BSL) framework for the public health workforce. BSL develops leaders’ ability to create direction, alignment, and commitment (DAC) across both vertical and horizontal relationships within health departments and with community partners. The framework aims to work across differences in geography, demographics, leadership level, department, or unit. It’s designed for settings where the goal is not only to lead people but to lead across these differences, bridging agencies, sectors, levels of authority, and communities. In short, while many leadership models help individuals become more effective leaders, BSL equips public health professionals to mobilize collective leadership across systems, which is essential for addressing complex issues such as behavioral health and emergency response. Here are three examples of BSL’s impact and utility in public health, two of which are multi-state projects. Preventing and Responding to Overdose Overdose Data to Action (OD2A) leaders are faced with boundaries that can inhibit overdose surveillance and prevention activities without proper navigation. For example, partnership with community organizations to reduce overdose may not be effective without first exploring differences between the state health agency and community organization goals and working to build trust. Throughout BSL trainings, OD2A leaders have demonstrated many ways they bridge these boundaries and apply DAC in their overdose surveillance and prevention work. OD2A leaders may need to span boundaries… Between departments within the agencies in which they work. Between hierarchical levels within the organization. With external partners like community-based organizations. With diverse cultures, demographics, and populations with which they work like people who use drugs. Across rural/urban regions, states, or localities. Collaborating across these boundaries ensures stronger team relationships, exchange of perspectives, expertise, and experience, and alignment of vision and strategy to improve program impact. For example, BSL can help OD2A leaders secure critical health agency buy-in while meaningfully engaging people with lived experience in the planning, implementation, and evaluation of prevention programs. “This program allowed me to focus on specific skills and teach me things I had never learned before. My work will be significantly better because of this. I cannot tell you how important it has been to be able to network with the others as well.” — Participant of OD2A Reducing Risk for Alzheimer’s Disease and Related Dementias In 2025 and 2026, ASTHO and the Alzheimer’s Association hosted two BSL trainings for health departments and their partners throughout the Healthy Brain Initiative. These helped equip them with a dynamic approach to addressing Alzheimer’s disease and related dementias (ADRD) by aligning partners across public health, aging, and other sectors. Through DAC, participants engaged in dialogue that bridged boundaries to integrate brain health into chronic disease, injury prevention, and other public health initiatives. Applying BSL practices to brain health created synergies that addressed shared risk factors such as hypertension, obesity, and lack of physical activity. BSL enabled state and jurisdictional teams to adapt quickly to the latest science, engage nontraditional partners, and build the skills needed to navigate potential boundaries. These practices strengthened cross-sector collaboration and built sustainable systems of shared investment and learning, positioning brain health as a priority across the public health landscape. ASTHO selected the BSL training because leaders who effectively collaborate across boundaries are better positioned to address complex public health challenges such as ADRD, which requires interagency and multisector action. Public health leaders need solutions, and there is evidence to support and measure the usefulness of BSL concepts. Participants successfully met the expectations and objectives of the workshop: Breakthrough Innovations: Drove creative solutions that integrated culturally responsive care and brain health promotion across settings. Cross-Functional Learning: Built shared understanding between public health, aging services, and community stakeholders to address complex problems (e.g., ageism, risk reduction, caregiver burnout, access to care). Partnership Development: Leveraged cross-sector collaborations to expand age-friendly environments and relationships. The BSL training left a lasting impact on those who completed the workshop, with participants reporting increased knowledge of major boundary types and mechanisms needed to boost ADRD strategies. Participants shared their excitement to immediately implement BSL elements into their public health practice. As BSL gains momentum and attention across the field, we urge organizations to leverage the framework as a conduit to build the capacity needed to accelerate brain health strategies and beyond. “My participation in this BSL training will have a lasting impact by strengthening both my individual capacity and our team's ability to approach strategic planning, stakeholder engagement, and the development of sustainable. For my team, this will translate into stronger collaboration, clearer direction, and more cohesive implementation of our ADRD strategies.” — Participant of the Healthy Brain Initiative Building Bridges for Youth Behavioral Health in New Mexico In April 2026, leaders from New Mexico’s Departments of Health and Education came together — not just to coordinate but to truly collaborate. Partnering with ASTHO, they convened an in-person BSL training designed to move beyond siloed work and toward a shared vision for adolescent behavioral health in schools across the state. A total of 18 participants joined the training, representing a cross-sector mix of state agencies and community-based organizations. While the group brought diverse perspectives, they shared a common purpose: improving outcomes for young people across the state. The BSL framework offered them a structured way to navigate differences, build trust, and define collective direction. Throughout the workshop, participants deepened their understanding of the boundaries that often limit collaboration, whether structural, relational, or based on differences in processes and priorities. More importantly, they built the skills to identify and bridge those divides. For many, the experience shifted how they think about partnership — not as coordination across systems, but as intentional, interdependent, and relationship-driven leadership. The impact was immediate. Participants reported increased confidence in their ability to break down barriers and apply BSL strategies to advance adolescent behavioral health. Just as critical, they described forming authentic connections with colleagues across sectors, which laid the groundwork for more cohesive, aligned work ahead. Perhaps most telling: Every participant committed to using BSL strategies in the next 30 days to six months. This wasn’t a one-time training, it was the start of a new way of working. The group plans to continue meeting monthly to apply these tools, strengthening direction, alignment, and commitment in their shared efforts. “Addressing boundaries is a great practical step in all of the projects we will have going forward.” — Participant of New Mexico School-Based Health Program For public health professionals, the takeaway is clear. Complex challenges like youth behavioral health don’t sit neatly within one sector and they can’t be solved there either. Boundary spanning leadership offers a practical, human-centered approach to building the partnerships needed to create lasting change. Explore more of ASTHO's work in Boundary Spanning Leadership. article yes