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An increasing body of research finds racism can have a significant impact across one’s lifespan. Research shows that persistent exposure to racial discrimination may result in premature aging, poor health outcomes, and increased prevalence of certain chronic diseases. At every level of government, policymakers are seeking to acknowledge the systemic oppression of people of color that persists and to elevate racism as an urgent public health crisis comparable to other public health emergencies.

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.

I think we all welcomed 2021 with open arms as we look to put the worst of 2020 behind us. We have all been through a lot—we have lost family members and friends to COVID-19, we have seen public health officials harassed and maligned, we sheltered-in-place, stayed home, and radically altered our day-to-day schedules, we have witnessed protests over police brutality and racial discrimination, and we have lived through (and still are living through) a presidential transition unlike any other. Despite all the challenges, turmoil, and changes wrought by 2020, the work of state and territorial public health continues. What is on our ASTHO horizon as we greet this new year and the opportunities and challenges it presents? Here are a few things on my mind as I look toward the future.

On Dec. 3, the International Day of People with Disabilities commemorates disability rights and brings awareness to essential issues for those with disabilities by promoting the “well-being of persons with disabilities in all spheres of society.” While the ADA laid a critical foundation for disability rights, the work to ensure equitable access to services and needs continues, including access to state and local emergency preparedness and response activities like crisis communication, access to resources, allocation of vaccine and other medical countermeasures, and transportation.

As we celebrate National Rural Health Day this year, we are reminded of how important telehealth can be for public health and healthcare. Telehealth can minimize challenges faced by rural patients and communities—such as transportation, provider shortages, etc.—manage volume, increase the quality of healthcare, and lower overall costs by reducing readmissions and avoidable emergency department visits. However, the COVID-19 pandemic has shown that access to reliable broadband is still a challenge and is a key social determinant of health for rural Americans.

COVID-19 has elevated our nation’s stress level. When not managed properly (or without any buffers like social support) stress is associated with increased depression and anxiety. Because COVID-19 impacts risk factors for suicide, such as depression, anxiety, substance misuse, and unemployment, the implications for suicide prevention are many. And with September being Suicide Prevention month, it’s a good time to take stock of how public health leaders can reduce suicide risk during this pandemic.

Responsible for planting, growing, harvesting, processing, and preparing the food we eat, agricultural workers are essential workers during the COVID-19 response to keep the U.S. food supply chain operating efficiently. But farmworkers are particularly vulnerable to COVID-19 due to lack of physical distancing, lack of access to health insurance and sick leave, and poor access to clean water for handwashing throughout the work day.

The movement to address racism through policy change in the U.S. is receiving significant political support at every level of government. Government institutions are acknowledging the systemic oppression of people of color that persists in the United States and elevating racism as an urgent public health emergency comparable to other public health crises.

How to Support Youth Post COVID-19 With More Flexible Policies Caitlin Langhorne Griffith, Victoria Pless, Martha Yeide Over the past few months, COVID-19 has highlighted how current policies and funding do not support an equitable approach to health. However, states and territories have begun to leverage statutory and regulatory flexibilities to improve health outcomes for the disproportionately affected during this pandemic. One of the ways that states and territories can support these groups and maximize these flexibilities during and post-COVID-19 is by deploying a Shared Risk and Protective Factor (SRPF) Framework to address negative health outcomes. Research has demonstrated that addressing both the risk and protective factors across sectors can lead to multiple improved health outcomes, including heart disease, asthma, depression, and substance use. Because youth are at increased risk of exposure to Adverse Childhood Experiences (ACEs), and have fewer supportive resources, they are a particularly vulnerable group potentially affected by COVID-19 policies and funding. ACEs are a risk factor shared across numerous health outcomes, such as substance use disorder, chronic disease, and mental health. However, implementing the SRPF Framework can promote protective factors in upstream ways, like reducing and mitigating the impact of ACEs. During the COVID-19 response, some areas where state officials can take advantage of policy flexibilities to better support youth and reduce some ACEs include youth experiencing food insecurity, youth with incarcerated parents, and youth witnessing violence in the home. Ultimately, these examples illustrate the benefits of extending innovative policies to decrease negative outcomes and promote health across the lifespan beyond COVID-19. Youth and Food Insecurity Food insecurity is a public health issue that plagues the United States and has been associated with negative health outcomes including obesity and unhealthy brain development. More than 11 million children in the U.S. live in food insecure homes, with an estimated 11 percent of households reporting food insecurity at least some time during 2018. New data show that food insecurity has increased for youth during the COVID-19 pandemic, with almost one in five of mothers — 17.4 percent —with children ages 12 and younger reporting their children were undereating because they could not afford enough food. When state officials closed schools to prevent the spread of COVID-19, food access was upended for youth who participate in free-or-low-cost school meal programs. States can mitigate this disruption by safeguarding access and expanding these programs to ensure the continued physical and mental development of youth. Jurisdictions have implemented innovative practices allowed under expanded flexibilities to ensure that youth receive regular nutrition during COVID-19. Vermont is conducting telephone appointments for the Women, Infants and Children (WIC) nutrition program due to social distancing, and has also expanded the list of foods available through WIC during the COVID-19 pandemic. Forty-seven states and territories have implemented the Pandemic Electronic Benefit Transfer (EBT) benefit passed as part of the CARES Act. This allows households to offset the cost of meals that would have been consumed at school by youth. Wyoming has adapted its WIC program services, which includes providing curbside deliveries and conducting phone screenings. Youth with Incarcerated Parents It is estimated that between 1.7-2.7 million youth have incarcerated parents. This leaves them at a higher risk of adverse outcomes, including mental health problems, poor school-based outcomes, and increased antisocial behavior later in life. Parental closeness between incarcerated parents and youth can be an effective strategy to promote resiliency, and jurisdictions are implementing programs focused on connecting the incarcerated individuals with loved ones. The Pennsylvania Department of Corrections has created a virtual visitation program for all state-run facilities, and all inmates are eligible to participate. In Connecticut, organizations such as Children with Incarcerated Parents have created programs that provide free calls with incarcerated parents each month during the COVID-19 pandemic. Other innovative avenues to connect children with incarcerated parents include the Governor of Illinois issuing an executive order suspending the transfer of some inmates from county jails into the Illinois Department of Corrections during the public health emergency. This approach may increase the likelihood that inmates remain geographically closer to home. Washington executive order 20-47 suspended statutes that limit an individual’s ability to receive post-conviction relief, as well as prosecutors’ and courts’ ability to file and process criminal cases. Washington executive order 20-50 broadened the Governor’s authority to grant clemency to reduce the prison population. New Jersey Gov. Phil Murphy issued an executive order establishing an Emergency Medical Review Committee, which will review which inmates can be released to home confinement—identified by the Board of Parole—and outlined the process for ensuring those who are released are aware of reentry benefits. Youth Witnessing Violence in the Home Witnessing violence at home also is associated with a higher risk of negative health outcomes, as well as experiencing or perpetrating violence later in life. "Stay at home" or "shelter in place" orders during the COVID-19 response has corresponded with increased risk of family violence and increased calls to domestic violence hotlines, posing another public health crisis as many children have been exposed to violence in their homes. While trends also show a decrease in reports of child neglect and abuse, this decline may be due to restrictions on the child welfare surveillance systems that monitor and intervene in situations of abuse and neglect. State lawmakers have offered help to those experiencing domestic violence, despite restrictions on travel. Massachusetts and Maine ordered all state hotels to only provide rooms for vulnerable populations or essential workers, including those that may be experiencing domestic violence. New Hampshire established the COVID-19 Emergency Domestic and Sexual Violence Services Relief Fund for shelters across the state to aid those who may be experiencing domestic or sexual violence. Nevada developed a process for individuals to file online temporary domestic violence protective orders. The District of Columbia developed a process so individuals can file an extreme risk protection order through an online form and phone call, which can remove firearms from individuals who may be dangerous. Finally, California released a safety planning guide for those who may be experiencing domestic violence. The COVID-19 response has prompted states to provide flexibilities in funding and suspend or modify policies that would have made it more difficult to protect the public’s health — and in turn would have exacerbated negative health outcomes among youth. Through innovative practices these efforts have worked to mitigate the negative impacts of food insecurity, youth with incarcerated parents, and youth experiencing violence in the home. Health officials can be at the forefront of this innovation to ensure that protective factors are leveraged to reduce disparities and impact multiple outcomes with upstream approaches for youth. website

ASTHO interview with Norman Oliver, MD, MA (alumni-VA) about achieving health equity and optimal health across racial lines.

This report shares results and key takeaways from interviews on topics including the overall structure of Legionnaires’ disease programs, diagnosis and clinical testing protocols, and risk communication.

Community Action Plan Templates for Children’s Environmental Health Environmental Health Community Action Plan Templates Health agencies can use these community action plan templates to bolster their children’s environmental health programs. ASTHO, through support from EPA, developed a set of four Community Action Plan Templates for use by state and territorial health agencies. These templates are intended to be adapted and customized by jurisdictions according to their specific needs and goals for children’s environmental health. Jurisdictions can prioritize the most pressing actions based on the areas of highest importance, needs, strategic plans, and timelines. The templates focus on air quality, climate, environmental justice, and lead poisoning. They provide a roadmap for creating community change by specifying what will be done, who will do it, and how it will be done. Health agencies can utilize the templates when helping communities develop new (or refine existing) action plans. Learn more about the templates by exploring the primer, or dive right in with one of the four templates below. website yes

This resource provides strategies to incorporate health equity in overdose prevention programs.

The Keys to Driving Generational Health, Well-Being, and Justice 30:13 Tune in to this podcast episode to hear a discussion about the vital conditions for health and well-being framework to reach full potential. PH Conversations Series - The Keys to Driving Generational Health, Well-Being, and Justice Somava Saha and Andrew Martin from Well-Being and Equity in the World (WE in the World) discuss the vital conditions for health and well-being framework or what we all need to collectively thrive and reach our full health and wellness potential. Through their conversation, they offer reflections and stories around how public health and community collaborations across the country organize around the vital conditions, prioritizing belonging and building civic muscle, to drive health, well-being, and justice across generations. Show Notes Guests Somava Saha, MD, MS, President and CEO, WE in the World Andrew Martin, MS, MHCDS, Director of Networks and Partnerships, WE in the World Resources Organizing Around Vital Conditions Moves The Social Determinants Agenda Into Wider Action | Health Affairs Thriving Together Springboard Vital Conditions | WIN NETWORK Pathways to Population Health Equity PHC Podcast Transcript - The Keys to Driving Generational Health, Well-Being, and Justice website yes

Leveraging Medicaid to Support Community Health Workers and Address Health-Related Social Needs This conversation dives into the role community health workers play in improving public health and how Medicaid funding can support them. 20:13 PH Conversations Series - Leveraging Medicaid to Support Community Health workers and Address Health-Related Social Needs Across the nation, states are exploring opportunities to improve population health by integrating community health workers (CHWs) into the health care workforce. CHWs are public health workers who typically have lived experience and personal connections with the communities they serve. Through these connections, CHWs build trust with community members and serve as crucial links between health systems and marginalized communities. CHWs are vital to addressing health-related social needs (HRSN) and play critical roles in achieving more equitable care across the nation. CHWs may work in clinical and community-based settings under a range of titles, including promotores. CHWs provide many different services and assist clients in navigating resources to support their needs. For example, CHWs can conduct outreach and education, and link people to state and federal benefit programs. State Medicaid agencies and state/territorial health agencies can support the provision of CHW services through collaboration and cross agency-partnerships between public health and Medicaid agencies. These partnerships are particularly salient as state Medicaid agencies begin covering more HRSN services, related HRSN case management, and CHW-provided services through Section 1115 demonstrations and state plan amendments (SPAs). Section 1115 demonstrations, which allow states to test new policies to support Medicaid members and their needs, can fund state pilots for Medicaid-funded CHW programs. Approximately 20 of 64 approved 1115 demonstrations related to HRSN and five states have used 1115 demonstrations to support CHWs. The Centers for Medicare and Medicaid Services’ new 1115 demonstration opportunity on HRSN allows states to invest in CHW certification programs, among other workforce development infrastructure investments. SPAs are another pathway to create sustainable funding for CHW programs. To date, Centers for Medicare and Medicaid Services has approved SPAs to cover CHW services as formal Medicaid benefits in nine states, including Louisiana and California. To learn more about the financing mechanisms states can use to integrate CHW services into the health care system—and how state/territorial health agencies can support Medicaid in these efforts—ASTHO spoke with Diana Crumley, JD, MPAff, Former Associate Director of Delivery System Reform at the Center for Health Care Strategies. Listen to an abbreviated version of the discussion below. Show Notes Article Authors Jahira Sterling, Center for Health Care Strategies Madison Hluchan, ASTHO Interviewer Jennifer Jean-Pierre, Director, Content Development and Communications, ASTHO Guest Diana Crumley, JD, MPAff, Former Associate Director of Delivery System Reform, Center for Health Care Strategies Resource ASTHOBrief: Leveraging Medicaid to Support Community Health Workers PHC Podcast Transcript - Leveraging Medicaid to Support Community Health Workers and Address Health-Related Social Needs website yes

This toolkit is designed to support public health leaders in leveraging the policy development process to achieve health equity in their jurisdiction.

This podcast explores innovative practices for leveraging non-traditional partnerships to support and sustain health equity expansion efforts.

Hypertension disorders in pregnancy are the leading cause of maternal death, but state and territorial health agencies can address hypertension in pregnancy and reduce maternal morbidity and mortality.

In addition to PFAS exposure assessments, state and territorial health agencies may also consider the role of social stressors during the risk assessment process.

Social determinants of healthcare are the conditions in which people are born, live, work, play, worship, and age. Read how these issues affect population health.