Protecting Public Health Authority: Law, Equity & the Public Health Workforce

Good morning or afternoon. I'm thrilled to welcome you to today's session, public health authority and public health workforce development. My name is Shauneequa Owusu, and I'm the chief strategy officer at ChangeLab Solutions.

Before we dive into today's topic, I wanted to take a moment to welcome you all and briefly introduce you to ChangeLab. For those who are not familiar with us, ChangeLab Solutions is a nonpartisan, non-profit organization that uses the tools of laws and policy to advance health equity. We partner with communities across the nation to improve health and opportunity by changing harmful laws, policies, and systems. Our interdisciplinary team works with community organizations, governments, and local institutions to design and implement equitable and practical policy solutions to complex health challenges.

Our work is rooted in the belief that laws and policies that have perpetuated racism, discrimination, and segregation throughout our nation's history, have, had, and continue to have a profound effect on health and well-being. So at ChangeLab, we work on addressing what we call the five fundamental drivers of health and equity. Those drivers are structural discrimination and racism, income inequality, disparities in opportunity, disparities in political power, and governance that limits meaningful participation. We go into much more detail about this framework and our blueprint for changemakers, which you can find on our website.

Today's webinar is the third in our four-part equity and action series. Each session in this series explores strategies to address these drivers by focusing on a specific issue area and by hearing from folks who are doing great work to shift harmful policies and systems. Some of you may have joined our previous sessions. We kicked off the season with a conversation about housing justice, discussed equity considerations when it comes to housing code enforcement, and explored fair labor practices. And our final session, which will take place tomorrow, we will focus on equitable policy making in rural communities. But we're here today to explore the important role that public health authority and public health workforce play in supporting equitable health outcomes. We have a great panel with us today. So with that, thank you again for being here, and I'll pass it over to my colleagues, Sabrina Adler, vice president of law at ChangeLab, to get the conversation started. Sabrina.

Thank you, Shauneequa. So thanks to everyone for being here today. Before we dive into the substance, I just want to take a minute to go over some logistical notes for today. So we are recording this event. It will be posted to the ChangeLab Solutions website, and everyone that registered should receive an email with a link to the recording once it's ready. If you have questions for our panelists throughout today's discussion, as Becca has helpfully said in the chat, you can post those or submit them through the Q&A box. Specifically, Becca and some of our other colleagues will be monitoring incoming questions, and we hope to save some time at the end to address them.

As you can see, the chat function for this webinar is open. So please feel free to share comments or reactions along the way and to engage with your fellow attendees. And in previous sessions, we've had some really engaging discussion in the chat as well. And we will also be live tweeting during the session. So if you are so inclined, you can join us on social media using the #Policymaking4Equity with the number 4 as opposed to the word.

I want to also let everyone know that closed captioning is available for today's session. So in your Zoom window, you should see a button that says show captions as pictured on this slide here. If you click that button, you'll have the option to show or hide captions. You can also adjust the font size to fit your preferences under the captions settings. And our colleague Bernard Lim is here today helping us ensure that all the tech runs smoothly. So if you run into any tech issues, please feel free to drop him a direct note in the chat.

So that brings us to today's conversation as Shauneequa said. And hopefully you all know because you signed up for this event, we are talking about public health authority and public health workforce development today. We'll be focusing on some of the recent changes to public health authority and the implication of those changes, particularly on public health departments and the public health workforce. We have a lot to cover today. We could talk about this for days probably, but we were going to preview that the session is going to focus on both of those topics with questions like those that you see on the slide. So in what ways have recent challenges to public health authority impacted public health departments and public health outcomes? And how can the workforce be empowered amidst this climate of challenges to public health authority? We're going to spend some time talking about actionable ideas, promising policy interventions and strategies that we can pursue. And also, hopefully, we'll talk about some collaborative partnerships and ways that folks can join together, knowing that there's no one organization or sector that can tackle these issues on their own.

So before we are joined by our wonderful guests, I want to just provide a little bit of context for each of the topics that we'll be discussing today. So if you're on this webinar, it's probably not a surprise to you that in 2020, as the pandemic started to unfold, the public health systems and structures that, for the most part, have been in place for many decades and often just operate behind the scenes with no one paying attention to keep the public safe and healthy, very quickly took center stage. And while most people supported the measures that were put into place, there was a large and often very vocal contingency of both the general public and of policymakers who took issue with even the most basic of public health activities, so things like masking, social distancing, vaccination. And this contingency often caught the attention of the media and controlled a lot of the messaging, quickly began to translate into a variety of actions. So we saw protests and attacks on public health officials, in legislatures, in governors' offices. We saw policy changes that often sought to undermine the ability of those who are most equipped through their expertise and training to protect the public's health. So public health became very politicized. Decades-old structures were dismantled in some places, the really rushed and uninformed votes that were often just reactions to what some folks saw as infringements on personal liberty, even if they were in service of the common good. We also saw a mixed bag--mixed bag in the courts. So some many actually judges upheld the authority of public health officials to take various measures to combat COVID-19, but others veered from longstanding precedent to find what they saw as overreach and to strike down actions based on rationales that could have implications for future actions as well. And many of these had detrimental effects on the public health and particularly for the most marginalized communities.

So as we saw all of that unfolding, public health lawyers, including those of us at ChangeLab Solutions, started to get to work. And I think we've gone backwards in the slides. Actually, there we go. Next slide, please. So we categorized various types of legislative actions that we were seeing. So, for example, in some places, we saw preemption of local public health authority, states taking authority away from local governments. We saw a lot of shifts from the executive branch, so governors' offices, or in particular health departments, to the legislative branch, both at the state and the local level. Some things were specific to COVID that happened. Others--other changes or proposed changes would have broader and will have broader impact beyond the scope of the pandemic. So there was a lot of categorizing and trying to understand what was happening. And seeing the need for more coordinated action, there was a group of us--you can see the organizations on this slide, public health law organizations that came together more formally to form what we call Act for Public Health. So with funding from the Robert Wood Johnson Foundation and in partnership with some other organizations, including two that are joining us today, ASTHO, and the Local Solutions Support Center, but also APHA, and [INAUDIBLE], and others, we have been tracking legislation and litigation, providing TA and directly consulting with folks, producing resources and hosting webinars and events, and really trying to keep folks informed about what has been going on.

Now we're at this point where we're still doing this work, but the acute phase of the pandemic is over. Some of the very COVID-related attacks have slowed down, and we're seeing some different types of legislative action now. And we're really moving from a more reactive firefighting mode to taking a more proactive view. And part of that is recognizing that everything that we saw happening during the pandemic and trying to prevent these kneejerk reaction changes to the public health system doesn't necessarily mean that the system that was there before was working for everyone. And in fact, it probably wasn't working or definitely wasn't working for many folks. So when we're looking at what communities really want and need from the public health system and particularly those most marginalized communities, asking ourselves, how can law really be used to help achieve those outcomes moving forward?

So shifting to the workforce, which is obviously intimately connected to this, in order to respond to the current rollbacks of public health authority, address future public health issues that will inevitably arise, and address all the various conditions that made the pandemic worse like the unequal distribution of structural, political, and social determinants of health and the inequities that result from them, it has really never been more important for public health officials and professionals to understand and use the tools of law and policy. Since the 1988 IOM report, the future of public health, there have been repeated calls to strengthen public health capabilities around law and policy. And in spite of that, that consensus, but research consistently shows there is a strong need for additional public health law training for public health professionals.

So in some of the work that ChangeLab has been doing, for example, we've found that out of 190 accredited schools and programs of public health that offer a Master of Public Health degree--so recognizing that's just one pathway into public health, there are many others as well--but only 17% of those schools offer a course dedicated to public health law, not require but just even offer that course. In addition, a study in Health Affairs found that no schools required an advocacy course to graduate. And those skills are really needed if we want to start to address some of the issues that we're seeing in the fundamental drivers of health inequities in our country.

So to address that gap for nearly 30 years now, ChangeLab Solutions has been working to demystify the law and support public health professionals and building the skills that they need to use the tools of law and policy to address health inequities. So we partner and have partnered, continue to partner with federal, state, and local entities to provide research and analysis. So we do policy analysis and legal research to answer questions about feasibility, financing, enforcement, impact. We have worked on policy and strategy development. So we do a lot of development of model policies, and laws, and guidance on how to form policy. We've done a lot of training and capacity building, in person, online, webinar series, et cetera, both on the policy process, generally, and on specific policy areas. We do some individualized coaching on the policy process. We also have formed communities of practice, so bringing folks together to work across disciplines or sometimes in the same area but from different locations, bringing community stakeholders together to work towards a common goal. And then we do a lot of product development. So if you haven't checked out our website, and I'll provide some more resources at the end, but we have a number of guides, sheets, infographics, et cetera, that translate complex legal and policy concepts into actionable solutions.

More recently and very specific to the workforce, we've also partnered with the CDC's public health law program to identify some ways to more systematically support public health professionals across their careers. So as part of that work, we have developed the Public Health Law Academy, which is free online, on-demand trainings on public health law concepts that are helpful for all public health practitioners to understand. We're also looking at how to increase law training for future public health professionals while they're still in school, so addressing the gap that I was just mentioning in terms of the lack of that training available in the educational setting. We also have a Public Health Law Fellowship program together with CDC that connects graduate students and recent graduates with public health law job opportunities. And we'll put some of these links in the chat as we go and also at the end if you're interested. And then we also have programs in trainings related to legal epidemiology, which is the scientific study of how laws affect health. And if you're interested in that, I would also direct you to our website and that other partners who do a lot of work in that space.

So we recognize that these are just some of the many ways that we can and should support the public health workforce. There is also a need for more consistent funding, for equitable pay, especially for roles like community health workers who are more likely to represent the community itself and have some of the lowest salaries in public health, for policies that support the health and well-being of the workforce itself and protect against things like harassment which we saw a lot of during the pandemic, for DEIA policies, processes, and trainings, and for a whole number of other policies that empower the workforce. Which is why I'm excited to have our panelists here today to be a part of this critical conversation. So with that, I would like to get the conversation started and stop being the one--the only one talking here. So I'm going to welcome our panelists today.

First, we have Maggie Davis, who's the director of State Health Policy at the Association of State and Territorial Health Officials or ASTHO, where she works to advance health equity by providing policy and legal technical assistance to state and territorial public health agencies. She convenes a state and territorial legislative liaison peer network to best--share best practices and information, and identify emerging public health policy issues, and develop policy toolkits to provide current and former health officials an overview of current law, of pending litigation, resources to prepare public officials for legislative testimony or overseeing administrative rulemaking processes. So welcome to Maggie.

Next, we have Adam Snipes who is the Oklahoma lead consultant for the Local Solutions Support Center, where he works to protect public health authority. Adam has over a decade of experience in government affairs and advocacy organizing and is known for crafting persuasive strategies to shift public narratives around controversial issues. His experience includes acting as national advocacy director, regional campaign manager, deputy chief of staff, and advisor to national organizations, members of Congress, and local politicians.

Next, we have Lonias Gilmore who's the director of Health Equity and Social Justice at the Big Cities Health Coalition. BCHC is a forum for the leaders of America's largest metropolitan health departments to exchange strategies and jointly address issues to promote and protect the health and safety of the more than 61 million people that they serve. Previously, Lonias was a senior public health consultant with the Michigan Department of Health and Human Services. She is a mission-driven public health practitioner who believes that we can eliminate the power in race, culture, and language, zip code, and socioeconomic status to predict health and well-being.

And finally, we have Samantha Bent Weber who's the acting health equity officer for CDC's National Center for State, Tribal, Local, and Territorial Public Health infrastructure and workforce. In this capacity, she's the principal advisor to the director and deputy director providing guidance, consultation, and evaluation of activities to assure our work across the center is planned, executed, and evaluated with consideration for the social determinants of health and health equity. Sam was previously a public health analyst and team lead with the CDC's public health law program, where she specialized in work to improve public health through the development of legal tools for the provision of legal assistance--legal technical assistance. So welcome to all of our speakers--or I should say not speakers. We're not just going to have people speak one after another. We are going to talk to each other. So let's shift to conversation. Hello. Now I can actually see you so I'm going to kick us off by asking you to talk about the ways that recent challenges to public health authority have impacted the ways that health departments approach their role and can do their jobs. So let me start with you, Maggie. I know you and your colleagues at ASTHO have been tracking some of these changes to laws and bills that have been introduced. Can you talk a little bit about what you have seen?

Yeah. So since the 2020 legislative sessions, our team has been looking at legislative proposals among the states and territories that alter both the emergency public health authorities. So these were the--power is usually exercised during the pandemic. And a lot of those legislative proposals say limited the scope of a public health order, so saying that you can no longer use a public health authority to maybe close a store that sells firearms. That was a common trend we saw, or limiting the effect of public health orders in houses of worship or facilities of worship under that First and Second Amendment categories. Then we also have seen some efforts to address some of those more fundamental public health authorities such as isolation and quarantine powers, which are separate from an emergency order or what we saw in the pandemic. So that really gets more to that every day, responding to a tuberculosis case or food safety issue. We saw legislation introduced in almost every legislature. However, not every state enacted these bills. So there were a number of states where there is dozens of bills introduced, but the bills ultimately didn't go anywhere. We are tracking and continuing to see the impact of the legislation that did pass. And last week with one of the partners with Act for Public Health, we actually published an updated interactive map on some of the legislation that has been enacted and some of these implications. So I encourage folks to go check that out at the lawatlas.org website. But the other next phase of this is for us to see how these laws that have passed have been actually implemented on the ground. So one of the first bills we saw was in Ohio. And it was a shift from the executive branch to having a legislative oversight committee to invalidate public health orders within seven days of them being issued, which makes it very difficult to plan around and can cause a little bit of chaos. And what's been interesting on the implementation side is that that legislature had planned to have this committee that has primarily staffed with legislators, and they have never staffed the committee. So now it leads to the health department trying to navigate what would this look like in practice if the law has not been fully implemented. So that is the next phase as we continue tracking this legislation.

Thanks, Maggie. It's interesting--as lawyers, I feel like what's on paper and what's actually happening is it's important to pay attention to both, not just as lawyers. It's interesting as a theoretical issue--theoretically as lawyers and very practically for the folks that are working on the ground, so. Lonias, can you share some thoughts here?

Sure. At risk of sounding like we're picking on Ohio, we don't mean to. But there is a pretty rich and poignant example here. When I got this invitation, this is the example that came to my mind and maybe many others, which is the recent outbreak of measles in the Columbus, Ohio area. Recent laws that were changed before and around the time that this outbreak began last fall, fall of 2022. The changes produced some really significant changes to public health authorities. So I'll highlight two major ones that really were impactful in Columbus. Local boards of health authorities with the duties of a local board of health may only issue quarantine or isolation orders to individuals who have been medically diagnosed or to individuals have been in direct contact with someone who's been medically diagnosed with the disease, that is the subject of the order. And then furthermore, Ohio law removed the authority of local health departments to prohibit public gatherings or to close schools or even preschools, as I'll talk about a little bit, except in limited circumstances. So you have an outbreak of measles which we have extensive history with, which maybe was recently declared eradicated. But we're finding that resistance to childhood and other vaccination has really reversed that. So in the context of an outbreak from a disease that we have history with, that we understand pretty thoroughly, especially in terms of how easily it can spread and therefore how many people it can potentially infect and harm, in this context, health officials in Columbus area were trying to figure out how they might fight the outbreak. And I am happy to say that they were able to use other tools to do so. But it was still pretty impactful the ways that Ohio law really hindered them. But nevertheless, health officials in Columbus and surrounding areas were able to fight this outbreak by being transparent about the state of the outbreak, including sharing exposure sites, informing the public about how easily measles spreads or can spread, and promoting the importance of getting young children fully vaccinated. So in other words, they had to lift and use their other tools. We also

Found that several child care facilities voluntarily notified parents and closed temporarily. And I feel comfortable saying that our experience, our collective experience, and shared experience with COVID is probably what made those particular decision-makers really understand the need for that, even though that request could not—end it—not come from the health department.

As of February, when the outbreak was officially contained, there were 85 pediatric cases and 36 hospitalizations. And it’s just the fact that there are preventable. One thing I just wanted to point to in this example is that it’s a high bar that these legal challenges are presenting. State laws, not just in Ohio but in other places, are prohibiting science-based and proven public health responses. And these public health responses used to be routine. And I think—and I still actually believe that a majority of Americans understand that we can suspect infection based on known symptoms. I think that most Americans understand that we can think about the risk of infection based on the contagiousness of a disease or an infectious agent. I think that we understand that. But I think the public health authorities are trampling on what we know and really making it challenging for us to take action, but also for us to communicate about public health threats and our ability to address them.

Yeah. Thank you. There are so many threads we could pick up on there. I feel like that is just a prime example of how something that happened during COVID is already having more like a broader effect in other contexts. And this one is specific to infectious disease. But I think we could also play this out beyond just infectious disease. I know, Maggie, you mentioned like core functions like infections or things like that. So thank you for raising that. I think there’s also—someone noted in the chat this issue of trust. And I see that bubbling up in some of what you’re saying, Lonias, because I think the motivation behind the law was probably a lack of trust among many other things. But also you noted that some folks voluntarily—like child care centers that voluntarily closed—in understanding and maybe on some level trust that was also built during the pandemic. So cutting in different directions there, I think.

I know we’ve talked a lot about Ohio. Adam, I know you’re in a different state and would love to hear some of the context that you bring from Oklahoma or just looking even across state lines and how you’ve experienced some of these changes. Yeah, it’s the O state’s, right, this afternoon. I think that the comments that were said previously have definitely been our experience in Oklahoma. So we’ve got a supermajority state in our state legislature, as you all would imagine. But we’re really seeing demonstrated in this conversation is the urban and rural divide. So we see a lot of our local school boards, for example, trying to take action to protect public health. So our governor decided to reopen a lot of things preemptively and prematurely. And as we saw our school boards or local health departments taking action to protect public health, we saw a lot of retaliation and retribution happen in our state legislature and backlash, so trying to head off schools from being closed and things like that from the state legislature, even though the folks who are elected on these school boards, for example, are trying to do what with the best interests of the constituents and the kids and what they’re being advised to do from the Oklahoma City County Health Department. So it’s just creating some really interesting additional dynamics in that urban and rural divide that we see happen at the Capitol, but then also the local control arguments of, well, there’s actually—there’s school board members and board of health members here who do have concerns—having their authority cut off—potentially cut off by the state. It’s really alarming for the public health in Oklahoma.

Thanks. Yeah, and you’re really raising the importance of local governments to be able to respond to their conditions locally. And when that ability gets taken away through preemption, both in this context and others, that becomes very challenging. Sam, do you want to weigh in here?

Yeah. I’m just reflecting on both the examples that Lonias and Adam provided. There’s something that still feels a little bit—like it’s being tested, right, in terms of the impact on the public health system when stripping away public health authority results in the decentralization of public health measures and public health practice and really puts the onus on health departments, on school boards, community organizations, child care facilities, individual schools, health care providers at a number of levels. And then you get to a point where it becomes even harder to protect public health, and more burdensome, and more challenging for the various providers who are just trying to meet the needs of the kids and communities they’re serving. And I think the maybe pat answer to that, but maybe something the answer that I think is also the necessary one, is it really highlights the importance of real engagement and relationship building and partnership between public health entities, and agencies, and the various sectors within communities they serve, like really planning and working together around various public health threats and challenges. And I think that’s going to become—it’s always been an important part of this work. And it’s going to become even more acute as we go forward.

Yeah, I think that’s a hugely important point, Sam. Actually, I’m going to use that to transition us to the next question, because I think it’s directly on point and then have folks weigh in on that and other aspects of this, which is that I really want to hone in specifically on the effects of these challenges and changes to public health authority and the effects on the workforce on health equity specifically. So as we’ve been doing this work, we’ve seen two things really, one, that many of the challenges to public health authority over the past few years have really made it difficult for the public health workforce to do their job in ways that advance health equity and center community, but secondly, that the solution isn’t always just protecting the status quo. I think, Sam, you’re pointing to a major gap that is not new to COVID, right, that relationship building that I see a lot about trust popping up in the chat. This is not—that existed—those problems are more deeply seated than just COVID. The reaction that we saw was in some ways related to some of that. So coming back to the solution is not always just to protect the status quo, we’ve been trying to put out some fires. And I think rightly and necessarily so by pushing back against some of these attacks on public health authority, but as I alluded to and mentioned at the beginning, the laws that are currently in place haven’t, in many cases, led to equitable outcomes during COVID, before COVID, and sometimes even have actively caused harm. Even the word authority is very loaded. And it can represent a lot of different things. So just opening up the floor I think around the specific equity effects of some of these changes and what we saw leading up to COVID, during COVID, where does that leave us? Where are we? It’s a very open-ended question. I actually didn’t see if someone had hopped off and wanted to respond to Sam’s most immediate thoughts about the relationship building piece. But let me pause and see if someone did. Otherwise, I’ll hand it to Lonias to kick us off.

Yeah, I’m just going to build on Sam’s comment about the relationship building going back to the Ohio example. And I’m, full disclosure, was born and raised in Ohio. So we’re not intentionally picking on my home state. Some of the impetus behind that legislation in 2021, I think, was a breakdown in trust among policymakers. And so I know from the health department side, there was really an effort to have communications on the back end to limit how bad that bill would be for the health department and scoping out like, well, what is the authority the health department plans to use, because it always comes down to you might have that authority on paper, but the agency might never intend to use that in any given situation. And so it’s trying to chart out for health department response moving forward of not just what are your authorities on paper, but what are the authorities you actually feel comfortable in this environment and with all of your other policymakers and partners of actually exercising, because we, in the vaccine space, vaccine requirements only are effective if there’s already a high level of trust in that vaccine. So there is that interplay between that law on paper and that community trust and relationship building which is critical to all of public health’s work.

Yeah, thanks, Maggie. Lonias, do you want to jump in?

Sure. What strikes me around this issue of the impact on health equity is this issue of vulnerability and how it often gets conflated with the roots of inequities and how it’s important for us to address both. So a public health response needs to be attentive to the immediate issue, especially if we’re talking about an outbreak. They need to be really, really in tune to the immediate issue where communities are being impacted. But also, it has to think across the population and think about who might be most at risk for that particular—I’ll just use public health threat at the time that, that particular response is aiming toward. And so in the example, again, coming back to Columbus, the people who were most at risk of infection were people who were not vaccinated and people who are not fully vaccinated. And so that outlined who was at risk and who was at greatest risk. Sometimes when you broaden out to thinking about, OK, and public health is responsible for protecting population health broadly, we are supposed to be protecting—and sometimes our purview is a specific geographic area. Oftentimes it is. And we are responsible for zooming out and having fundamental capabilities in order to respond across the 10 essential public health services and responsibilities, I prefer to say. And so that is the way that public health has to respond. What ends up happening is then it becomes, well, how do we get the average person—even our own neighbors—to understand that our response, which might seem big, and looming, and has this huge shadow behind it, how do we get them to understand that we’re responding this way because a population-level response, population-level public health protection requires that we respond in a way that might feel constraining and all-encompassing. Like how do we get to the point where we’re communicating about that and making people understand that? Now the way that we—the avenue that we’ve taken is to give people all the technical information. And we try to get people to understand like in COVID, trying to get people to understand how infectious a certain strain is and trying to get people to understand why it’s important to maybe exercise some physical distancing in public spaces, all that good stuff. And all that was important and was really necessary. And we need to start working into our communications, which I think will lead to more trust in government maybe generally and in public health—governmental public health in particular—is that we need to get a lot of this stuff out of the theoretical or out of the diffuse realm in order to make it more relevant for people. There’s actually several studies that were going on. In fact, the Big Cities Health Coalition is exploring messaging around community safety. And one of the themes that I keep coming up—not just in the work we’re doing but other reports that I’ve read and webinars I participated in—is that people need—maybe it’s tools. Maybe it’s just messages to understand that a health threat and its—and maybe governments in particular response to that health threat—is important to you and it’s relevant to you—to you and yours. Trying to get people to buy into something that is good for humanity generally is just simply harder for people. So I was intended to be really—I had some really nerdy stuff laid out here. But essentially the idea is that people or things that are more psychologically distanced from us makes it hard for us to have concern for. And then you have the overwhelming way in which we’ve been socialized in the United States, to distance ourselves from each other psychologically. And many of these ways are rooted in racism and other forms of oppression. These ways in which we’ve been socialized resist our efforts to create equality, to repair the impact from injustice and inequity. And so I’m certainly not suggesting that it’s super simple. But there has to be a way for us to make our public health messages, which in some cases are going to impinge upon what people might describe as freedom, and to get them to understand that this is relevant for themselves and people that they care about. There was a paper that I read around—communicating around climate change—that I think is a good example. If we frame climate change as a diffuse threat—rather, so saying we need to think about climate change and try to hold it in our heads as the entire world and humanity is under threat versus making a possible threat, because it is in one’s local community. If you go with the diffuse route, we reduce support. There’s less support for climate change mitigation. And I think that that’s true for mitigation of public health threats, whether that be infectious diseases, or food-borne illness, or whatever it is. We have to start to—we have to take into consideration that our brains have been formed to create psychological distance from somebody, right? Your somebody might be different from my somebody. But that’s the way we’ve been socialized here. And so we have to take that into account when we’re trying to rebuild/rebuild trust and we’re trying to communicate about how we all protect each other. We’re really all part of this system of protecting the public health.

Yeah. Thank you. There’s a lot there to respond to. And Sam, I’m wondering if you can respond to some of that in terms of the workforce and needs the workforce might have. And there’s a lot of threats here. There was a communication threat. There’s a society-wide tensions and challenges that we have. But you take whatever direction makes sense to you.

Yeah. I feel like I just—reflecting on everything Lonias has just said is—I feel like that could be the subject of this whole webinar. But I think from the workforce side, I think we’ve tried to—in working with the public health law program, and working with the infrastructure center, and CDC, we’ve really tried to be more attuned to how the public health workforce is responding to all of these challenges in order to be able to meet the needs of the communities they serve and the work they do. And there are a lot of pieces that I think just in engaging with folks who are in state, tribal, and local, territorial health departments around the country, they’re really recognizing that the work—there are a couple of pieces here, right? There’s all of this historical stuff that needs to be unpacked that is shaping not just how our society is functioning but also just the nature of their day-to-day work, both within the health departments that they’re working in and in terms of just ensuring that they can get resources and be responsive to the needs they’re confronting. There’s a communication, and translation, and relationship-building challenge. And a lot of that has to do with like, how do we talk about what public health is, how do we make this accessible for people, and how do we understand that health equity is really about improving the health—to Lonias’ point—of not just one group of people but of large swaths of our population and ultimately, our population as a whole. And there’s a third piece around which you’ve talked about, [?Sabrina, ?] which is around just what kind of tools do we as practitioners need to strengthen the work that we do and to be able to help tell the story of how we’ve got a system that’s inequitable, how the inequities within that system are rooted, and laws and policies, and other big-picture things, but how they can be translated into what happens at the community level. And so we’ve been really trying to prioritize thinking about how we can do more to support practitioners who want to take on that first piece of how do we talk about our work and translate it and help people to understand what public health does, what it is, and what it does. It’s not people in lab coats. It’s not people who are just a bunch of experts trying to encroach on people’s space or lives but really people who are trying to support efforts that can improve health on a collective level. And then also to really—to show the thread in what public health does, and what it is, and what it does, and then how that translates at the policy level, like how can we do this work better to meet people’s needs and meet them where they are, regardless of where they live in the country, regardless of their socioeconomic status, regardless of their race. But that’s—I think that’s—I have gotten a really strong sense that, that is—there’s a tremendous amount of understanding around like what we need for in order to move health equity work forward in terms of language and concepts. But that translation piece and figuring out is it about how we translate public health data, is it about stepping back and talking about really this idea of social solidarity. The public health is a tool for solidarity. You don’t have good health across the population if you don’t have solidarity. And accepting that there’s always going to be pushback and I feel like this is—I think everybody on this call is doing a lot of work to try to be responsive to all of those moving pieces. But I think it’s, the decentralization that we’re seeing and critiques in legislation that’s seeking to undermine public health authority goes against that, right? And so some of our task is to figure out how we decentralize the narrative and the tools that are necessary to be responsive to that narrative.

Yeah. Thanks, Sam. Again, with all these comments, there’s so much to unpack there, I think. And situating this as some folks are doing in the chat and as you all have also raised, too, in a broader moment in time, where trust in government is not really at an all-time high, where there’s a broad move to deregulate and decentralize across a whole number of different issues and areas, and COVID opened up that front in the public health world, which is happening across a number of other policy areas as well. I do want to move to solutions. And Sam, you brought us there naturally, at least at a high level. I’m going to also ask folks to dive in a little more specifically on actionable steps. But before I do that, Adam, do you want to weigh in at all on any of the—or you can move us to solutions if you would like, but weigh in on any of your fellow panelists’ comments.

Just to say the overall rhetoric as a result in a chilling effect for [INAUDIBLE] public health, at least from speaking from our experience in Oklahoma of just being quite restrained in order to avoid backlash, particularly from our state’s executive team, just in the way that we were talking to the public as a local health department being concerned that the state health department would have political concerns and would punish us, right, I’m like, those are very real things. And lives are on the balance. And we have to weigh those things very, very thoughtfully. As far as solutions go, we do have purple or bluish-tinted [INAUDIBLE] in Oklahoma. And having the backing of organizations like Big Cities and being able to convene and find peers in other states, that’s really important for our thought leaders, municipal and local elected officials, because we have to work with the federal government. And if there’s a question about like, how do I square what CMS wants and what the state of Florida wants for me, as somebody who is in public health, right, how do I deal with that? And our state elected officials in Oklahoma will do things like not apply for federal grants and education across our state—hundreds and millions of dollars in education. Like, how do we live in that world with public health officials? What we started to do is build different coalitions to change the political calculus for the state government. So in Oklahoma specifically, that means they’re forming a state show. But ours will be different because we’ll have more tribal representation that’s unprecedented in the country. So that’s what we’re looking at is how do we change the political map? And then how do we work with folks nationally and do the work where we can? Because that’s where we have to stay focused is on the communities that we’re serving and where folks are. So that’s where we’re at. I wish the answer is better, and then messaging research.

Yeah, thank you. Maggie, I know—or I think you can speak to this. My understanding is that ASTHO, you also have been tracking or looking at some examples of policies addressing some workforce support needs. Can you talk to us about that, what you’ve seen there, anything good?

Yeah. So it is a little bit of a mixed bag. And I appreciate that Adam mentioned some of the funding challenges. And something we talked earlier about, there wasn’t enough trust in

Public health prior to the pandemic, and part of that is public health was drastically underfunded prior to the pandemic. And that is something that we've known for a long time. And just not having sufficient resources to do the work of some of the community outreach, of having enough staff to focus on these critical issues, has been a chronic challenge.

And one of the somewhat silver linings coming out of COVID-19 was the federal insight of needing more dedicated funding in public health and particularly public health workforce and infrastructure. So there was a once in a lifetime federal infusion of funding and grant funding to states and local health departments for public health workforce and infrastructure investment, which is something here at ASTHO we are helping with our partners implement, as well as the Public Health Accreditation Board and several other partners.

And there are some states that are taking this opportunity to expand their public health workforce to really build out that core infrastructure. And then we're also seeing, independently, state legislatures really doing an intentional assessment of what is the current state of their public health workforce to meet their overall health goals. So, for example, Maryland this past legislative session created a public Health Commission to really assess how is their current public health workforce aligning with the top 10 essential public health services, and where are the gaps they have, and what do they need to do to reach it.

Right now, we're seeing the Oregon legislature is considering a bill that would have a huge investment in their local health department workforce, in particularly, a way to build a pathway for people that represent those communities and are more closely aligned to actually enter a public health workforce through student loan forgiveness programs, apprenticeships, some efforts to try and create a more clear pipeline through, say, community college programs. So we are seeing some of those examples. And I can put into the chat; we had a blog write-up of some of these policies a few months ago. So it's not as big as some of the other policies. But we definitely are seeing those steps moving forward.

Yeah. Thank you. I just saw in the chat, once in a lifetime funding ultimately does not sustain infrastructure or workforce. 100% agree, 100%, yes. And hopefully, it's a step in the right direction. But yes, this is not--this is not a one-time--there's not a one-off solution here.

Lonias, do you want to weigh in here on thinking--looking forward like, what can we do about some of these issues we've raised? I was actually in a room with some of our members recently. And one thing that came up and really generated a lot of discussion is while it's true one-time funding is not going to sustain--it won't on its own, but the experience and strategy of the public health leaders who now have this money in hand can.

So while I'm not suggesting that it's easy, this funding largely in part because it is not prescriptive as others have been, right? And it's allowing states and locals who receive this funding directly to really tell the funder how they're going to spend it as opposed to being only required to respond to performance measures. That's huge. That's allowing a lot of things to happen at once. But one thing it's allowing them to do is to be strategic about all streams of funding and to think about how to make this funding catalytic for whatever they can accomplish in their infrastructure.

So no, it doesn't fix every problem. Obviously, it's hard to talk sustainability when you know funding has an end date. But it does not prevent us from being strategists for us to think about how to improve our ability to be sustainable by using this funding to do so. We might have to respond in a more emergent way maybe in the first year. That first tranche might have to just be fire hose type things. But we--but I really do believe and I heard some really great ideas, again, being among our members this past week that there is a way to use this funding in a strategic way that will help us create a run--there's all kinds of really nice analogies, create good runways and get us to really catalyze a future.

Another thing--one last thing I will say, and I will not suggest I'm good at this, but there's also this way of being able to use funding in order to think about what you need in the future. We talk a lot about how this--it would be better if it were continuous funding. I don't actually disagree with that. But there is some evidence that when big pots of money get dropped on us we're not always ready for that. And so when we have resources, especially to even bring on other strategies, promote people in our workplaces so that they can strategize with us, we might actually create opportunity for sustainability even if this funding does not do it on its own.

Just a quick note on the funding piece, too, I think--and to the sustainability point, I think this has been a good opportunity for federal funders to really take a step back and assess some of the inflexibility of funding, some of the limitations on funding, particularly for local health departments and smaller health departments. So it's true, we do have the sustainability question. But this is also a great opportunity for us to reassess how we move forward and get to a better job of meeting jurisdictions where they are from a funding standpoint.

Sam, I'm just going to follow up with you for one sec because I know you talked at a medium high level about workforce supports, et cetera, like as we transition to this solutions-oriented part of the conversation, but anything like you want to just hone in on the more specific, if not mine, just curious if you have thoughts. I know you've done a lot of workforce development work.

I think--so right now in my current role, I'm doing a lot of high-level thinking around workforce development. But I've taken away a lot of great learning, particularly--most recent--so one of the things that's been top of mind for me is how do we do a better job of providing technical assistance to help the department. So we can't always, at the large institutional level coming from CDC, how do we be responsive to what health departments are telling us. And everyone on this call is engaged in some of that work of being there to answer questions and engage directly around funding mechanisms, around public health challenges and how to be responsive to them, around framing public health work, around translating health equity concepts into--in ways that can be more accessible or clear for a diverse range of audiences.

And I think one of the things that's been really top of mind, civic engagement, democracy, the state of our public institutions is a really critical feature of this work. And so for me and I think in some of the work that we're doing at CDC and in the infrastructure center was really trying to be more responsive to jurisdictions that are saying, we just want to know, understand our laws better, and understand our local policies better, and be able to find them, and read them, and interpret them, and explain them to people because that will help us to better understand our authority. That will help us to better understand how we can connect what the law gives us the authority to do or doesn't and how we can translate that to people and fill gaps around that work. So I think there's--I think there's a real--in addition to all the workforce development stuff around like fellowship programs, creating opportunities for researchers and scientists to get support in working and health department settings or working at the federal level, but that--focusing on how--what kinds of tools can help to--the question here is, what is public health capacity, right? And when we're investing in the workforce, we're really talking about building the capacity of public health practitioners and the institutions they work in. And that's really about strengthening, building public health power. And so I think just going back to some of that work around how we educate public health practitioners but then also really be responsive to their desires to understand local policies and come up with better communication tools, I think that feels particularly prescient.

Yeah. Thanks, Sam. I think that's a good--just looking at the time, I want to get to some of the themes that have been coming up in the chat. And we've talked about some of them already but maybe direct them in a little bit more pointed way. And I think this first one is like directly related or at least related if not directly to what you just said, Sam. And any of you should feel free to respond to this. But I feel like, Adam, you might have particular thoughts just given where you sit.

So there's a whole theme in the chat and some of the questions about trust and fostering trust. And particularly in rural communities, how do we foster trust in this system? And maybe somewhat relatedly, how do we get over a feeling of resignation when talking about this work with people who have chosen to politicize public health in the absence of reason? And just in talking to you, Adam, I feel like you've dealt with this a lot and have seen it a lot in the work that you've done. And so other folks, please feel free to think about this in a way but curious if you want to respond to that.

Sure. So I would just--the trust point in the way that we increase trust is allow people to be able to see each other again and understand that we have more in common. And that means that sometimes we shift our language. So when we talk about vaccinations in Oklahoma, we tend to use language like shots instead, just because a lot of the public health authority stuff was just captured by--we had a very robust--let me start here. And we had a very robust anti-vax, pro-homeschool movement in Oklahoma. And I believe that these are all tied to what is the government allowed to tell me to do with my children and with my body and bodily autonomy. So I think building cooperation around language like, can you do your part, can you be asked to just do your part, stuff like that. And then we also found in protecting public health authority, it was very compelling to talk about local control and the people closest to the problem or the people closest to the solution. But we just don't like the message that comes from social work, God forbid, but just using some of those brains that are helpful to us. And then I've mentioned a lot about tribal leadership. Tribal governments, I've been coming in the communities that have had hospital closures and all the folks that are turning around and reopening hospitals in those communities and rebuilding their community partnerships and relationships. So I think that as we look to the future, that gives me a lot of hope for what can be possible.

Yeah, go ahead, Maggie.

Yeah, to build on what Adam was saying about the trust, something that we've done a lot of work with our members on is helping identify trusted messengers because sometimes, the public health department and government are not the people that share the message. There are just certain communities where they are inherently skeptical of the government for a variety of reasons and historical backgrounds. And building partnerships with those trusted leaders that get the need for having, say, strong vaccinations that can help advocate for better resources or say, keeping a rural hospital open, that is really critical and something that we have spent a lot of intentional time of helping build the capacity of health departments, both to be able to identify those trusted messengers and to help build those relationships, because the trusted messengers aren't just people to go out into the community. They are partners in the broader public health framework.

Yeah, I think that's such a great point. It's not just what you're saying but who's saying it. Lonias or Sam, either of you want to weigh in here. I can throw another related question into the mix which is just like the global influence of or intersection of political systems, and forces, and processes, and all of the things that we've been talking about. But I think we're talking about that already. Also another more specific question, I can ask if--OK, so there was a question about the link between public health authority and health outcomes. And looking at whether there was any research that showed effects of health outcomes in areas that had challenges to public health authority, I think during COVID, I know, Sam, I think some of your peers have published some stuff in that realm. I don't know if you want to weigh in on that. I know the purpose of gathering the information about the changes in the law and some of the [?LawAtlas?] work that Maggie talked about and I think some folks dropped in the chat earlier is to enable that research to connect policy changes to health outcomes. Sometimes there's a short-term effect, and sometimes it's longer term. But does anyone want to weigh in on that?

I think there's a question about the--I think there is research on that. I was--I've been mulling it as we've said here. I think from a method standpoint, I'm not sure we've identified great research that has really made those connections out well. But I think anecdotally, we could probably find some good examples of how encroachment on public health authority have had local impacts. But I'd want to circle back about that specific question. And just on the trust, just on the trust point, I think there's a lot of decentralization than we were thinking about how to--I keep saying that because it feels very cute. And I think there's--but we're all having this conversation, this group and the folks who are joining us. And we're thinking about how to come up with collective approaches to engage better. And so some of the things we've been thinking about are what are some strategies to strip all of this stuff down right and how do we--we're very different across the country. But we have some--there are some baseline places where we can connect with each other and speak the same language. And that feels like not just something we should within public health practice be talking about as a good idea. It feels like--it feels like a task that really is tied to the 10 essential public health services and some of the other frameworks that we use to guide our practice. And I'm hopeful that we can continue to do that work and support that work. I don't know that I could sum it up better. I might use that to close us out, Sam.

Yes. Agreed what she said. So I'm conscious of time. And I want to make sure we can move folks to their next item of the day in a timely way. So I first just want to thank you all for your insights. I feel like we could have just kept talking for another hour or more. And I would have found it fascinating. I really appreciate everything that you've brought to the conversation. I do want to just get to a couple of resources and business items. So if we could pull the slides back up, that would be great. Thank you. And now I need to get to the right place here.

OK, so just in terms of resources, I've noted this before, we have a number of helpful resources available on a lot of the topics that we've discussed today on our website as well as some of the partner organizations that I mentioned in terms of public health authorities. So you can find links to the legislative tracking. We have actually some messaging information that's come up a lot today as well. All of the webinars and trainings we've done are archived there. We have a mailing list that you can sign up for to receive more information about this. In the next few weeks, our partners at The Network for Public Health Law are going to be publishing a resource with examples of laws and policies in six areas that strengthen the public health system. So that looking forward, keep an eye out for that.

Shifting to workforce resources, so we have over 2,000 resources on our website aimed at demystifying the law for public health professionals, including the blueprint that Shauneequa mentioned at the beginning. We have preemption resources, resources on equitable enforcement, specific public health issue areas. And then we also have the Public Health Law Academy that I mentioned earlier supported by CDC that just has basic trainings on public health law concepts across a wide variety of legal areas, and resources for faculty, as well folks that are teaching in these spaces. And then if you are interested in becoming a public health law fellow or would like to host a law fellow at your organization, there's a link there as well.

As we noted earlier Shauneequa said, this was an installment of our Equity in Action series. So if you miss the earlier conversations and you would like to listen to them, they are on our website. And we will be hosting our final session on equity-focused policy making and rural communities tomorrow. So there was actually a lot of chatter about rural issues that came up today. It's highly relevant to what we are talking about today. And so my colleague will drop the link to register for that in the chat. When you close out here, you will also be directed to a survey. It would be great if you could take a moment to share some feedback about this session. And then I just want to share folks' contact information if you have follow-up questions or want further information. I also want to make sure to thank my ChangeLab Solutions colleagues who were busy in the chat and busy behind the scenes, making sure that we were all set today, so Becky, and Becca, and Chassidy, Bernard, Dana, and Shauneequa who all joined in, in various ways to make this event happen and then, again, just to our speakers and to all of you for joining us in this important conversation. You will get an email with a link to this recording and all of these resources as soon as they are all ready. And thank you again for taking the time to join us today. It's been a great conversation.