The local perspective on America’s public health landscape

Oct 19, 2020
Local health departments act as the chief health strategists for their communities—how are they weathering the pandemic, and what needs to change? 

The public health leader plays a role akin to a corporate CEO, with the bottom line of community impact and the ability to change outcomes, rather than profits. Local public health departments are on the front lines, dealing with fragmentation that existed long before the pandemic, and must establish (and maintain) community trust.

How can the framework behind CDC’s 10 essential public health services be modified to serve our communities equitably? How can local departments of health influence their state counterparts? How can public health workers dealing with divisive rhetoric bring a community back together?

In this podcast, hosted by David Speiser, Ph.D., executive vice president at ICF, and Nicola Dawkins-Lyn, Ph.D., MPH, a behavioral scientist at ICF, we speak to Lori Freeman of the National Association of County and City Health Officials (NACCHO), a membership organization representing the nearly 3,000 local health departments across the country, on the role of the public health system during—and after—the pandemic. 

The conversation covers topics such as:

  • Fragmentation and the disparate strategies and priorities of different regions across the U.S.
  • Ways to engage with rural public health organizations.
  • Equity factors that contribute to a person’s overall health, and systemic barriers health departments must work to remove.
  • How to keep the population healthy during such a polarized time.
  • The crisis of a decreasing public health workforce, especially in the field of nursing.


Full transcript below:

Dave: Welcome, everybody, and thanks for joining us in another of our series of podcast interviews on the extended public health enterprise. I'm Dave Speiser, the executive vice president of corporate strategy at ICF. And I'm really excited to have two great guests today. First of all, I have a colleague, and I'd like to ask her to introduce herself.

Nicola: Hi, everyone. I'm Nicola Dawkins-Lyn, and I am vice president in our public health business.

Dave: Great. And thanks for joining me, Nicola. It's great to have somebody in the conversation that knows a lot more about public health than I do. Our guest of the week is Lori Freeman, CEO of the National Association of County and City Health Officials. Welcome, Lori.

Lori: Thank you. Great to be here with you.

Dave: I really appreciate you joining us today. Before we get started, can you just describe NACCHO a little bit to us and its membership, its mission, and what you're all about?

Lori: Sure. So NACCHO is a national nonprofit organization. We represent the nearly 3,000 county and city health departments across the country. Our mission is really to improve the health of communities by strengthening and advocating for our local health departments. And we do this, ultimately, with a goal and a vision towards optimal health equity and security for all people in all communities across our country.

Dave: That sounds like a really important mission. Obviously, that's why we're so glad to have you with us today. One of the through lines of all the discussions we've been having here on this series of interviews is the extended public health enterprise. In other words, the superset of all of the official organizations that have a role in public health at whatever level of jurisdiction of the sector. One of the things that we've heard from other guests is this notion of fragmentation, and the notion that things are done very differently in different parts of the country. Since it seems we don't have a single approach that's prescriptive around the country, how do the strategies and priorities of different geographies differ? And what does that mean for NACCHO as the umbrella for all local public health organizations?

An updated approach to public health

Lori: Sure. You know, you're absolutely correct. Of the nearly 3,000 local health departments across the country, many of them serve different sizes and types of community. In fact, a lot of people don't realize that about two-thirds of the local health departments are actually rural and serve communities with populations of 50,000 or less. There's only about 6% of health departments--maybe around 30 across the country--that serve over half of the population of the country. So, there's this big, wide, and diverse group of local health departments serving different communities. NACCHO considers them all crucial to the infrastructure of our governmental public health system. And we support them all. But we do apply different approaches. Sometimes the smaller rural health department’s public health issues versus those of larger urban big city health departments--even health departments that serve suburbs can have different issues. But the common core among them all is that they serve their communities to improve the health of the entire community, not just one individual at a time. There are practices that can be scaled up or down or modified to fit the needs of the community. And strategies that are used to prevent things like chronic disease that impact the lives of so many often need to be done everywhere, just a little bit differently.

Dave: What are some of the differences in the ways that NACCHO engages with some of those rural-focused public health organizations?

Lori: With them, we try to understand their unique needs, and sometimes it depends on the issue that they're trying to address. When you have a health department serving a rural community that's spread out in large geographical areas, things like access, easy access to care, access to travel facilities--or if you're having a baby, making sure you can get to a location that you can safely have your child. So, there's lots of different issues that affect them in different ways. And their resources are also different, and how they're staffed is different. We try to pay attention to some of these differences but also some of the commonalities that exist with other health departments that might be larger and, again...and try to fit the resources to their specific needs.

Dave: Gotcha. Now, the field seems to have aligned around the CDC, you know, "10 Essential Public Health functions." Is there any ongoing conversation on how local public health leaders might want to broaden or modify those because they seem to be either a little bit generic or not speak quite as well to the current moment?

Lori: This is a great question, and also a very timely one. NACCHO has been involved for about a year in a national advisory group to take a look at the 10 Essential Public Health Services and make sure they're still relevant. You know, 25 years ago--when the 10 10 Essential Public Health Services framework was developed and released--it was a very big deal. NACCHO very proudly, even back then was involved in its initial development to make sure that that framework truly represented the actualities of what local health departments were either currently doing in their communities, or maybe even reflected the bars of achievement that they could strive towards. It really served this purpose of explaining to all sorts of stakeholders--public health organizations, public health curriculums at schools, community partners, healthcare government, community members themselves--the many roles that public health plays in communities across the country. And over those 25 years, the essentials framework has been used by local health departments in these same ways, but also to inform their strategic planning. But 25 years is a long time. A lot changes in our country, and the overall landscape of health has changed a lot during that time.

We've learned so much more about the factors that contribute to our health, and that they have everything to do with the things that are not mentioned on that original framework. Things like “did you graduate from high school? What was your housing like, your income? Did you have access to safe streets?” But our local health departments have been strategically working on these issues around health equity and those determinants that impact health equity for a very long time. So, in this revision, centering equity was extremely important. And as recent events have also highlighted, in order for these services to be effective, we need to remove systemic instructional barriers--like racism, poverty, and gender discrimination, for example--that directly impact health. Our local health departments are really facing challenging times now. And this is a moment when these essential public health services can be quite fortuitous to us in helping us stand up and protect public health in these essential functions as well. A lot of good work has been done, and that equity piece has been added.

Nicola: And that's a really interesting point, Lori, and a great segue into thinking about the social determinants of health. You know, we've come to understand that health outcomes are really heavily driven by the social determinants of health. But how can local public health organizations help to influence the social determinants of health beyond their primary statutory capabilities?

Lori: Well, as we learn more about disease, we're learning more about how the patterns of inequity and the distribution of disease and illness correspond to patterns of political, social, and economic inequality. Our local health departments address health equity and social justice every day in some way. These health inequities are systemic, systematic, patterned, unjust, actionable--but they're not inevitable, they're not random or accidental, and so we can actually eradicate them. So, local health departments are the chief health strategist for their communities. They're responsible for understanding all the dynamics of their communities, working across sectors--like health systems, education, law enforcement, REMS, housing, food, and agriculture--on tactics to address these social determinants to create health equity in the community. They focus on things like improving access to healthcare and social services, ensuring that they work to eliminate food deserts in neighborhoods that currently are only served by fast-food restaurants, ensuring safe and affordable housing, working to rid communities of housing blight that contribute to safety, working with city planners to create safe streets where kids can play safely or adults can safely exercise. The local health departments work across these many spectrums with community partners to create the conditions that make health and wellbeing an easier choice for folks. And the ultimate goal is making it the only choice and removing these other barriers.

Dave: One of the things you mentioned was the role that NACCHO plays in improving capacity of local public health organizations. How has that played out over time, right? You talked about 25 years since the last original 10 Essential Public Health functions and how the public health landscape has changed. And I know you guys have been engaged over that entire time. How have you all played an active role in kind of changing the capacity and capabilities of those organizations to include but maybe going beyond addressing the social determinants?

Lori: As with any great endeavor, with time and experience, you always learn quite a lot. And with new knowledge, new science, new data points, public health enterprise learns more and more about what contributes to good health and what detracts from it. So, our local health departments continue to learn. Just with this pandemic alone, think about what we knew eight months ago versus what we know today and how that has altered our views and behaviors individually and collectively as a country. I think one of the greatest pieces of the evolution of public health is our understanding that we actually have the capacity to impact the health of many people at once through changes to policy and our systems and the environment that surrounds us. We actually now have the experience and outcome data to show that a small change can make a big difference in a health outcome for many, many people. And I always think about smoking. When I grew up, smoking was everywhere, including in my own home. I was exposed...

Dave: Me, too.

Lori: I was exposed to a tremendous amount of secondhand smoke for most of my childhood. And not just at home, at restaurants, public functions, even on an airplane up until the late '80s, if you can remember that.

Dave: It was horrible.

Lori: It was. But through some rather sweeping legislation federally, and then that got picked up through many states, a lot of our country has places now where children and adults don't have to ever breathe secondhand smoke. They have clean air to breathe. And although no state had a comprehensive smoke-free law back in 2000, by 2010, 25 states did and 16 states were enacting comprehensive smoke-free laws. So, that policy alone changed our whole environment, changed health outcomes. The taxes on cigarettes further created better outcomes. And now we're at a 50-year-old time low point for adults and a 25-year low point for high school students in smoking. So, those things help us to grow and evolve our public health enterprise. NACCHO helps local health departments improve their capabilities and capacity by providing things like technical assistance to them, serving as a resource for information, education, research tools, and really promoting that spread and scaling of evidence-based practices and policies, and providing trainings and ongoing education to help them navigate changes in the field as well. And we will fight to ensure that they have the resources to do their good work on the ground.

A community divided on public health policy

Nicola: That's great. You know, these kinds of health policies really have the potential to make such a tremendous impact, as you said, on health for the broad population of Americans. A lot has been written lately about sort of the divisions in American society. And the policy lever, just as an example, is one that can sometimes generate greater division. Some of those kinds of divisions are apparent in the responses we see, for example, to the current pandemic. How did NACCHO members experience this phenomenon of the division? And does it have impacts on their professional or personal success?

Lori: Yes, tremendously because local public health departments work on the ground, on the frontlines of the community. These divisions that we are seeing--and really that we've experienced over long periods of time, if you think about it--are divisions in the very communities they're collectively serving. So, the impact is direct to them. There were already deep differences among populations of the same community in terms of their health and their health outcomes, their ability to be safe and feel that they have control over their own destiny in terms of their health. And some of these divisions, I think, we see them also having the threat to widen the divisions even more and make this work much harder. Things like establishing and maintaining community trust in the governmental public health system is very difficult right now. And at this moment in our history and time, we just can't afford to have the trust diminish in any way when we're still in the middle of a pandemic response--trying our best to keep people healthy and safe and free of infectious disease. This work is done best when we can come together as community and overcome our differences and get rid of this divisiveness and be on the same page in terms of listening and adhering to public health advice.

Nicola: Absolutely.

Dave: Lori, I'd like to ask you a couple questions about some of the nuts and bolts of the public health system at the local level. Because obviously, that's the area where you guys have more expertise than probably anybody in the country. We've been trying to understand in all of our conversations with experts like yourself both the lay of the land and at some point in the future, how things may want to be rethought. To start out with, how can we understand the connection between a local public health organization and the other functions of local government that they're a part of? And you'll probably want to tell us a little bit about how that might differ in those different geographies that differ so much and the role of their public health organizations?

Lori: Sure. Sure. Well, public health is a governmental function, and so it sits squarely in the wheelhouse of other governmental public health functions--such as local housing, and labor, and transportation, parks and recreation, all of those areas. I think what's interesting about public health is that about 70% of our local health departments have a local board of health that the local health official actually reports to. And that board of health does things like a broad oversight of the public health function policy development, some legal authority work, improvement, resource stewardship, and partner engagement, those types of things. These boards of health are typically appointed--or sometimes elected--from the community members themselves and include members from all kinds of sectors. Health systems, business, community organizations, philanthropic, and they also include elected officials like mayors, county commissioners, and the like. Public health officials are unique in terms of government function in that they are already engaged across a lot of sectors just through these boards of health and whom they have to work with in the community to make policy systems and other environmental changes. So, there's a constant connection there. And the health official would typically be serving at the highest level of local government alongside the heads of some of these other agencies that are well-respected position in normal times. It's been a little challenging during the pandemic. I think we might be talking about that later. But they are often just really well-respected pillars of their community.

Dave: The notion of having that extra governance model of that local board of health seems to me a potential great asset, if it's high functioning--and a real potential problem, if negative behavior seeps in. Is it, on a whole, a positive aspect of governance or is it more of a mixed bag?

Lori: On a whole, it's positive. I would say where we've seen some kinks occur--in this year, in particular--is the extra layers outside of the board of health where they connect with the county commissioners and the mayors and the elected officials. And we just had some interesting circumstances around this pandemic, where elected officials are often used as the medium and the pathway to the community and those elected officials sometimes have different agendas. They're elected, so they're working with their constituencies and interested in getting voted in the next time perhaps. So, public health hasn't always been working alongside that structure in the way it should be either at the state or the local level. And the current administration uses governors a lot in their work in their direct contact, and that filters down through to the community--through the mayors and the county commissioners--and public health has had to fight their way to decision making during this response as a result.

The makings of an effective public health leader

Dave: Obviously, the role of local public health leader, --whether the title is county public health director or some other variant,--clearly, they are what we in the consulting business would call a critical job, right? They're the critical link in the chain exerting leadership and influence. What would you say are the most important qualifications for those local public health leaders?

Lori: You know, the interesting thing is that they have to be well-trained beyond the principles of public health, and their role is sort of the chief health strategist for their community. They need a really wide and variable toolbox of skills that embraces things like business management, budgets, workforce development, human resource management, understanding how to lead a community and be a convener, be a long-term strategist, and dealing a lot with conflict in constant and sometimes unplanned interruptions to their work--like pandemic, for example, or outbreaks. So, they are often the underpaid equivalent of a corporate CEO, is what I like to consider them to be. They are on every level doing the same work as a corporate CEO but doing it for their community. And their bottom line is not profit necessarily. It's community impact and ability to change health outcomes.

Nicola: I love that term, Lori, the chief public health strategist for the community. It really does a lot to convey the breadth of responsibility that falls on their shoulders. Where does the talent for local public health organizations come from? Is it local, or do people move around the country? And what are their educational backgrounds to sort of prepare them for that level of responsibility?

Lori: Sure. There is movement. There's a little bit more movement now than we'd like to see, of course, due to the stressors of the job. But the interesting thing that I find about the current workforce condition of public health is that there are many, many young people in public health programs across the country. They might be at their highest enrollment ever. I don't know that for a fact, but there's a lot of people enrolled in public health in the colleges and universities across this country. But not all of them are going into governmental public health. So, they do move around, and they take jobs where they want. The nice thing about taking a job in public health, you can pick your community. You could go back to your hometown, or you could try something new--go do rural or urban. So, they do move around.

And what we know from our national profile of local health departments is that the larger urban public health departments typically have many, many staff, hundreds of staff. And those are typically led by a doctor level, MD level person. But when you get down to those rural and small health departments, those are usually public health nurses leading the health department. So, there is a big variation in who is employed by health departments depending on their size. But they move around. They have different skills. And a large public health department has a lot of different types of skilled workers on its workforce, environmental health, health educators, preparedness staff, nutritionists, public health physicians, community health workers. It varies the smaller you get, but they're a pretty diverse workforce.

Nicola: And with that great diversity, are there particular areas or perhaps in particular areas within the different types of geographies where you would say our current public health workforce is fairly spread thin? Are there particular places where we really need to bolster our public health staff?

Lori: I think we are seeing a crisis within a crisis within a crisis. It's an overall crisis, for example, with the public health workforce being diminished by 21% over a decade, and this is quite challenging and alarming even as we headed into pandemic about, "Okay. We're 20% down. How are we possibly going to be able to do the kind of work that's needed to stop a pandemic?" But even within the workforce, though, one of the more alarming workforce reductions has been with public health nurses who've lost something like 36% of their workforce over that same period. We need these public health nurses. They're really important aspects of this job. Well, first, nurses rock in general, because they have this multi-skilled ability to do not just clinical work, but just lots of very practical skills as well. And so that's an area that we're really suffering in right now, the loss of our nurses.

Nicola: You talk about the skills that these public health nurses bring. Are there particular skills that we need to be investing in for the public health workforce broadly?

Lori: Yes. Public health schools--we hope they're learning this over time as we're learning about what skills are lacking in the workforce--but those critical skills of leadership, business management, staff management, budgeting, strategic thinking, policy change, those are things that haven't always been in the curriculum of schools of public health. And some of those are learned at the school of hard knocks, on the job. But as we've seen with this crisis too, things like conflict management, how to work in a hostile environment--whether it's with your own public or with your elected officials or those within [inaudible]. Those are critical skills that these public health leaders need, just as I said before, just like the corporate world.

Nicola: Absolutely. And definitely not the kinds of things that you might traditionally think, you know, that you're going to be trained in when you go to a public health nursing program, for example.

Lori: Yeah. I would also add IT and informatics because as the world becomes more technologically advanced--and data needs to travel at the speed of sound-- there's a resource issue with regard to trained informatics and technology and IT folks at the local level as well. A greater workforce challenge there is just the ability to pay comparable pay to the corporate counterparts in that world too.

The status of public health data

Nicola: Very interesting. And so, you're talking there about those informatics and use of data capabilities. Similarly, with respect to data systems--because the collection, analysis, and communication of public health data really seem to be an important driver of performance--how would you characterize the current state of the data systems that are being used by local public health organizations?

Lori: Not ideal. No. We have a long way to go. You know, our country tends to invest in things that it can see. Like, if you see a road that has a pothole, maybe fix the pothole. If you inspect a bridge that can't handle the traffic, you fix the bridge. But this underlying infrastructure in public health--including the technology piece--is really lacking. There just has not been investment in it. And because of how public health is structured, when we started out our conversation, we talked about you know, we don't do everything the same way across this country, across all these health departments. The same holds true for this public health data and infrastructure piece. Local health departments do things different ways, and even within a local health department, because money comes and goes, systems are implemented for specific needs, and then multiple systems become layered upon that. And there's not a lot of interoperability in place among these various systems--sometimes even within the same health department. So, local health departments really need the expertise and skills to navigate this complex landscape of public health data modernization. In particular in the areas like data sharing, governance, infrastructure, information technology systems.

We struggle because some policies that don't explicitly call out local health departments as a data recipient can lead to really conservative interpretations that make it challenging for local health departments to access certain types of data. So, if things aren't building from the start at the state level or at the federal level that allow for data exchange and access for local health departments, then we're at another deficit point. So, there are so many challenges. I could probably spend an hour talking about just data modernization. However, the good news is that this is being recognized as an area that we have to make some headway on.

Nicola: What would you characterize as sort of the top priority for NACCHO's membership around improving or modernizing public health data?

Lori: Well, investing in the workforce first of all. Many local health departments aren't able to use the systems that are available, and they don't have the talent expertise. Understanding the details and complexities of the systems that exist--particularly at the local level--making sure those are known to the other chains of the data command, whether you're going up towards the state and to the CDC or back down. I think really helping health departments and the national partners that serve them to understand that the work it will take to modernize surveillance systems and the facilitators and barriers to doing that. Having these conversations are really important and exploring with health departments the implications of shifts in our environment--like a pandemic or other shifts in health, like what impact they have on data availability, access, and surveillance. And then overlaying all of this is just the issue of personal data and HIPAA requirements. And making sure that we are always able to maintain that trust with the public in terms of their information and their data so that we don't lose it during the times when we need it most, like right now.

Public health communications then and now

Dave: That notion of kind of public trust and the ability of the broad public to appreciate the work that public health organizations do--to have faith, right--that they'll keep their privacy safe, that they have their best interests at heart, obviously. You've talked a little bit already about how that's been challenged by the polarization that we see out in the environment today. Obviously communications broadly is one of the main tools that these folks wield. They have statutory powers, and they have a very small amount of resource generally, it seems, to actually implement actions on their own. But public communications is such an important tool for public health officials. How do public health officials get their messages through to the public so that the entire population can be healthy in such a polarized time?

Lori: Yes. It requires constant attention. And we can't afford really to go back in time. You know, I like to think about the history of public health a little bit here, and sometimes, we need to return to some of those routes so that people understand their role in healthy communities as well. Paul Revere was like the very first public health official back in 1799. He was Austin's first health officer. And back then, there was a board of health--believe it or not--formed to fight a potential outbreak of cholera, and the health officials posted signs on lampposts. They held meetings and led public information campaign to reduce deaths to cholera, and they did this by explaining to the public who up until that time thought that they had no control over with regard to illness. They just met the illness with a degree of resignation, that they're probably going to die from it without understanding the role that an individual plays collectively in their community to promoting health, so that social commitment to the health of the community.

I think we need to go back to that about explaining at the very basic levels about what we all can do to help during times when our country is so divided and during the time of pandemic. Communications are always not a thing where you can just create a simple, single communication. We have to really target communications to different audiences and meet them where they are, in terms of their understanding of things--the trust level that they have with officials and with the government and where they are in their lives. And if somebody is struggling, and they're hungry, and they don't have housing, they might be on the streets, are they really going to care about getting a vaccine? They just care about getting their next meal or maybe get some shelter over their head. So, the communication strategy is complex and deep and takes a lot of work. Luckily for us, our public health departments know this. They know their communities. They know what they have to do and how they have to do it differently for different components and populations within their communities.

I would just add it's just a tough time for them now because they've always been so trusted in their communities. And now that their broader advice is being ignored or polarized or politicized, it becomes harder for them to do their job when usually it just was taken for granted. You know, if somebody told you to boil your water because your water could make you sick, you weren't going to say, "I'm not going to boil my water. I don't believe you." You usually just boiled your water. But now public health officials are just trying to keep us safe by giving this advice, and unfortunately, it's being turned into something else and politicized. So, communications are more important than ever to get right, and to try to rebuild that trust that the public should have in their public health officials. They're apolitical. They don't have any reason other than making sure their communities are healthy and safe. And we have to try to get back to having people understand that.

Dave: Well, amen to that. You know, before we let you go, Lori--and we really appreciate your taking the time with us today--of course, NACCHO is not the only organization that acts as kind of an umbrella beneath the federal level. Your focus is obviously on, as your name implies, county and city officials. But there's an organization that we're going to be speaking to next week that deals with states and territories, ASTHO. Do the two organizations talk, or how do you stay aligned, and what's the relationship between the two?

Lori: Sure. So ASTHO we consider to be a sister or a brother organization. We are in the same family of governmental public health. We have similar workforces. We just work at different levels of the government. And we do work together on plenty, plenty of projects. The one thing that we do to assure that we are able to work on things strategically at the highest levels of our agencies are through what we call joint council, which is a collective of the leaders of ASTHO and NACCHO. And we get together quarterly at our board levels to talk about, "What are the things that we can work on that will effectively impact and improve governmental public health as a system from the federal state to the local level?" We both are excellent partners with CDC, HHS, ASPR, and the major federal agencies. You know, how do we work better with our federal agencies to represent the needs of our collective state and local health agencies? And what do we need to be doing strategically to promote governmental public health in every way--whether it's improving outcomes, reassuring that the system is working well and together, and functioning as partners to improve the health of communities? Things like that. So, we do do it, and we consider it very serious business, and we look forward to working with our partners.

Dave: That's perfect. I'm glad to hear that. I mean, clearly, between the two organizations, you have the vast majority of the public health enterprise in your care in a certain sort of way.

Lori: Absolutely.

Dave: Yeah. Well, Lori, we're about out of time. I can't thank you enough for joining us. It's been a fascinating look into the kind of the working face of our public health enterprise. Any last words that you would like to leave our listeners with before we sign off?

Lori: Trust your public health officials. Their whole job is to keep you safe and healthy.

Nicola: Fantastic.

Dave: Well, hey, again, we really appreciate you taking the time, and it's been a fascinating conversation. Thanks, everybody, for joining us, and be on the lookout. After this episode, we'll be talking next with the chief medical officer of the association for state and territorial health officers. So, it should be another fascinating conversation. Lori Freeman, thanks. Nicola, I can't wait to join you in the next conversation. And take care, everybody.

Meet the authors
  1. David Speiser, Executive Vice President, Corporate Strategy

    David is an expert in strategic development and corporate strategy with more than 20 years of experience. View bio

  2. Nicola Dawkins-Lyn, Senior Partner, Social Marketing

    Nicola is a behavior change expert with more than 25 years of experience helping clients effectively promote public health. View bio

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