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Looking to state leaders as the drivers of public health

Oct 27, 2020
State departments of health are critical to the nationwide public health enterprise. How can they be further empowered and supported?

There are inherent challenges in helping public health officials in 50 states and 14 territories—plus the District of Columbia—deliver a cohesive public health program. This fragmentation across the U.S. public health enterprise causes issues, but it also opens the door to opportunities for each community to find a tailored approach to its public health needs.

Why is it an asset to have so many physicians in public health roles? How do issues like housing fit into public health decisions? What’s the role of pharmacists in the public health conversation? And how might the vitriol against public health decisions today negatively impact public health going forward? 

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 Dr. Marcus Plescia, the chief medical officer at the Association of State and Territorial Health Officials (ASTHO), a national nonprofit organization that tracks, evaluates, and advises public health professionals across the U.S. and its territories to provide guidance and technical assistance.

The conversation covers topics such as:

  • What state and territorial public health departments can do to influence social determinants of health.
  • The connections between state departments of health and other state government agencies.
  • What the public health enterprise can do to unite the country around better public health outcomes.
  • The difference, from a state public health leader’s perspective, between working in centralized and decentralized public health systems.

Full transcript below:

David: Welcome, everybody, to the latest in our series of podcast discussions on the extended public health enterprise. I'm David Speiser, executive vice president of corporate strategy at ICF. And once again, I'm excited to be joined by my colleague, Nicola Dawkins-Lyn. Say hi, Nicola.

Nicola: Hi everyone. This is Nicola Dawkins-Lyn and I am in our public health business.

David: And we're both delighted that today we have with us Dr. Marcus Plescia, Chief Medical Officer of the Association of State and Territorial Health Officers, otherwise known as ASTHO. Welcome, Dr. Plescia. Could I ask you to say a few words on your own background and how you arrived at ASTHO?

Dr. Plescia: Yeah, sure. Thank you so much for having me on the show today. So, I'm Marcus Plescia. I'm the Chief Medical Officer at the Association of State and Territorial Health Officials, which we refer to as ASTHO. My background is in medicine and public health. I trained in family medicine and practiced medicine in an academic setting for about 10 years. But during that time, I ended up doing more and more public health work. And then I moved into more of a formal public health career and I've spent quite a bit of time in governmental public health. I worked for a while in the North Carolina State Health Department, mostly managing their chronic disease programs.

I also worked within North Carolina as the local public health official in Charlotte, which is Mecklenburg County. And then I spent about five years with the Centers for Disease Control where I ran the National Cancer programs. I came to ASTHO about four years ago as the chief medical officer. I was really attracted to it because I had done so much work in state, local, and federal government that I thought it'd be a really good opportunity to find ways to support that work--and look at ways that we can help the people out in the field be more effective. That's really what we do at ASTHO. We represent the leadership of state and territory health departments in a number of ways.

We try to help get them up to speed. Some of them have fairly short tenures just by the nature of their jobs. So, we try to support them and help them figure out how to be effective as quickly as possible. We provide technical assistance and really work with them through various grants that we get from Centers for Disease Control around specific programmatic work. And then we also lobby for them and represent them with Congress and around federal issues.

The pros and cons of a federalist public health system

David: Well, it's certainly important working kind of at the coalface in terms of the current public health emergency we're facing. One of the topics that has emerged from all of our prior discussions on the public health enterprise in the U.S. is the fact that we have a somewhat fragmented approach. You all, I'm sure, have direct experience with that on a day to day basis in terms of the different structures and approaches in different states and territories around the U.S. How does that show up in the work that you do and what does that mean for ASTHO as an umbrella advocacy organization?

Dr. Plescia: To begin with, we have I guess what I would describe as a federalist public health system. It's really most of the public health work and interventions are directed through the state level. A lot of it is done locally, but the main unit is the state public health department in each state and territory with a lot of guidance and oversight and leadership from the federal government--particularly from the Centers for Disease Control. But when you have 50 different states and seven districts and territories, it can be challenging because different states are set up different ways. They have different philosophies; they have different political parties in power.

So, trying to bring that together as more of a cohesive whole is one of the things we try to do at ASTHO. But we generally don't move forward unless we have consensus from all of our membership. That can be a little challenging as well. The other side of that, though, is the advantages of a state-based system--and particularly, a state-based system with a lot of local support and work--is that you can fine-tune what you're doing in public health to the specific populations that you're working with. And we all know that the United States is a diverse nation and people are very different depending on the different regions that they live in.

And so, the idea behind that is that we are ultimately better able to meet the public needs. I'd say that it's just a balance. There are some beneficial things about it and then there are some things that are quite challenging about it. But it is what we have right now, and I'd like to point out that we're not going to change that in the middle of a pandemic.

David: No, no, certainly not. Certainly not. No, we're riding the bus we're riding right now for sure. Absolutely. Dr. Plescia, as part of ASTHO's work, I don't know if you get much insight into working with opposite numbers from other nations. If so, is there one feature of another nation's public health system that would be first on your draft list for something that you could import into the U.S.'s public health system?

Dr. Plescia: Well, yes, there are. I mean, it is challenging to look at international systems because of how different other societies are from ours. I mean, early in the pandemic--looking at how they handled it--in Asia, we know there is a very great difference in more autocratic societies than ours. I really don't think people would accept some of the government actions and regulations, which were very effective, but are not sort of things that we're willing to do. But that said, there are some basic lessons.

First of all, Asian countries have been able to use information technology greatly to their advantage. And some of it is their willingness to have their cell phones track their movements, which might be more challenging here. But others—it’s just the capacity to have these kinds of systems that can really help so that not everything has to be done human to human, face to face. Some of those capacity needs are really handled by technology. And I think Asian countries have done that very, very well. When you look to countries in Europe, particularly Western Europe, the thing that we constantly see is a medical care system that's organized. I mean, there is a system.

The challenge that we have here is we really don't have a very cohesive system. And so that makes any kind of public health issue that leads to medical illness-- whole challenge of interfacing with medical care and getting people access to medical care--it makes that very difficult. If we can find more ways to make that more cohesive, and to also make it more inclusive and uniform so that people have access to medical care when they need it, that would take a lot of burden off of the public health system so we don't have to spend so much time on that--and so that we only focus on the broader issue. You know, how do we keep people healthy or from a situation like this? How do we really focus on the preventive side and not have to get caught up in the medical treatment side? But that's not the situation that we're in now.

So, I think those are some of the lessons. Those are the main things that come to mind outside of just sort of issues of what we value in society, which are very different. And I would say that a lot of the European nations do model that principle that we were talking about just now, a societal commitment to common good and are willing to make individual sacrifice for the good of others. I think they often do that well, and we could, maybe, look for some lessons from that.

The value of an interconnected healthcare delivery system

David: As you point out, a lot of the actual work of course gets done at the local level and a lot of that work gets done in conjunction with the healthcare delivery system--which is substantially in private or nonprofit hands. How do you ask those leaders how they view their relationship with the healthcare delivery system, and are there aspects of that relationship that they would like to change?

Dr. Plescia: Well, that relationship is very, very important--and we see that playing out now with the pandemic, which clearly has a huge medical response component. But in normal times, it's very important as well. Particularly when you think about that big public health issues really are chronic diseases, diseases like heart disease and cancer. And a lot of the interface for those diseases occurs in the medical care system. So, having close relationships is really important. I would say that most state health departments would say that they vary in the quality of those relationships. But they would all probably like to find ways to make them even closer still.

Most state public health officials, I think 75% of them, are physicians. And not that I think that's the only kind of leadership that we should have in states, but it is one place where there's a benefit. When you have physicians leading state health departments, many of them are very, very well connected into the medical care world. Many of them worked in medical care settings before they became the state health official. So that that helps. That's a real asset that I think that many of our leaders have. And the big thing is, they can convene. When we need to work closely with the medical care system, they can bring the right people to the table, they can generally bring the leadership for medical care systems into the table. That's very important particularly when we face significant challenges like the one we're in now.

Looking at social determinants’ effect on health outcomes

Nicola: Absolutely. And with the importance of the healthcare delivery system is certainly a clear central, yet we've also increasingly learned that a sizeable proportion of health outcomes are really heavily driven by what we call in public health the social determinants of health. What do you think state and territorial public health departments can do to help influence the social determinants of health?

Dr. Plescia: I think social determinants of health are probably the thing that's most top of mind with all of our state public health leadership--and local public health leaders too. I mean, you really can't work in public health for very long without realizing how much some of these underlying social determinants--things like poverty and housing and access to food and social support--those are the things that really ultimately determine health and good health. So, everybody wants to work on those. It can be very, very challenging to do that work, though, and I speak here from behalf of our members but also from personal experience.

It's one thing, when you're a leader of a public health entity, you're speaking about particular medical issues, that's fine. When you start talking about behavioral or other risk factors--environmental risk factors for medical conditions--that's fine. When you start talking--particularly to the public and to political leaders--about social determinants, sometimes the response you get is “why are you bringing this up? That's not your area. You're talking about the importance of housing; housing is not the area that you oversee.” And so, it's a real challenge to understand how to really communicate that issue well with many of the people who make decisions around these things.

The other thing that I think is really challenging is that there are two different leadership styles or ways that public health leaders can influence things. One is through direct influence. Obviously, if we're running programs, we have specific influence on it. If we're trying to change a health-related behavior, we have a lot of authority over that. That's the thing. In cases where we have authority--where it's pretty clear-- nobody is surprised when a public health official speaks up about tobacco use in smoking. That's considered to be very much within our purview.

The challenge is that with a lot of social determinants, we don't have direct authority but we do have influence. And I think the thing that good public health leaders learn how to do is how to use that influence. How to use that influence with their peers who maybe do have the authority, how to use that influence with elected leaders who have a lot of authority.

David: One of the areas that you pointed to earlier is the fact that we have this federalized public health system in the states--as you were describing--the leaders of states addressing both directly and indirectly the different drivers of public health. When you view the system as a system, collectively with the federal players, state players, local players, private providers--and all of the other organizations and sectors of society that play and you consider the skills and capabilities of that entire enterprise--what would you say that overall enterprises is good at? And where do we fall short?

Dr. Plescia: I think that the public health part of the enterprise at least is, they're good at trying to base decisions on data, whether that's surveillance data and understanding of health statistics and health trends, or whether it's also really trying to begin to understand where the best evidence is for interventions around those things that would work. The evidence-based intervention piece, I still think we can improve on. But I've seen a lot of progress in that over the course of my career. And then public health really is very surveillance and population-based data oriented. --It's going to sound a little odd because I'm sure later in this interview, I'm going to talk about the real challenges we have with some of our information systems and some of the inadequacies of some of the data systems we have.

But ultimately, we do have a lot of existing systems that we've had in place for a long time. Very basic data like mortality data, hospital discharge data, and infectious disease data. And we do very well at using that data to determine where the problems are and what we need to do. We try to base our actions on a clear understanding of that. And I think that's where we provide the most added value to medical care systems. We understand population health, we center our work around population health--whereas medical care systems, they're much more engaged with individual health, which is appropriate. That's what one would hope they would focus on. But somebody needs to bring this broader attention to the table of, how do we improve the health of our communities overall? How do we really create environments and situations where the population health is really optimized?

Nicola: That broad understanding of population level health and improvements and ways to capture information about and work to improve broad community health, I completely agree. That feels really central to what the public health enterprise really adds in value to society. Yet, a lot hasn't been written lately about the kinds of divisions in American society. What do you think that the extended public health enterprise can do to help coalesce the country around a more shared appreciation for and commitment to better public health outcomes?

Dr. Plescia: Getting to that place is clearly the challenge, and we seem to be so divided right now. I think that our earlier discussion about social determinants of health--the more that people can understand that it's really some of these underlying social and economic factors that play such a big role in how healthy people can be, and that if those factors are lined up poorly for you, then your opportunity to live a full and healthy life is extremely limited. I think there's so much of an emphasis on individual decision making but sometimes, people forget about the context that people are having to make these decisions in.

The other thing is the environment that we provide for people to be healthy. The more we can try and make it easy for people to make decisions that are healthy decisions, the more we can do that, the better. So, if we want people to exercise regularly, make it easy to exercise. Have resources in the community that allows them to do that. If we want them to eat well, make sure they have access to healthy food no matter where they live in the community. And if we don't want them to smoke, make it difficult for them to smoke. That's kind of a negative one, but then, a lot of the really effective stuff is focused on those kinds of interventions as well.

Reinforcing a civil dialogue on public health

David: Obviously we're living in quite a dynamic environment and I know that today, Dr. Plescia, you and ASTHO published a letter urging, in some ways, people to take the temperature down around the environment we're currently in, and to really try and get everybody to recommit and coalesce around this shared view of what's good for the country. Can you just say a couple of words about what led to that letter and how that connects with ASTHO's overall efforts to be an advocate?

Dr. Plescia: Yeah. Well, I mean, our number one goal is to support our membership, and our membership are having a difficult time right now. I mean, they are under a lot of pressure. They're making decisions or recommending actions that are ultimately helpful for us to manage the pandemic, but that do cause other people to suffer. I mean, some of the things we've had to do around restricting certain businesses has been a hardship for the economics of people and their livelihoods. So, they're having a difficult time. This is not unusual. I mean, public health decisions often are somewhat controversial. So it's not that our leadership aren't used to dealing with controversy and dealing with some criticism--some pushback on some of their recommendations or decisions--but what we're starting to see now is much more insidious than that.

We've had people be threatened with their lives. We've had people have demonstrators turn up in the front yards and driveways of their homes. We've had public health officials be fired or forced to resign because of actions that they've taken--and it's just been this very nasty and negative response coming from a very, very small portion of our population, but a proportion that's very vocal. And now that we've seen all these things and we've seen people lose their job, we've also seen an enormous number of people just starting to step down. The request is too great of them and it's hard enough when you're more or less working 24/7 and struggling to try to keep the community healthy during a very difficult time.

But when you're doing that--and on top of that, you're facing some really vitriolic criticism and threats, that's asking a lot of anybody. And so, the letter that we wrote was actually a letter to community and national leaders, and it was about leadership. It was asking them, as leaders, to think about how hard it is to lead--and particularly to lead during times of adversity. And what we decided our leaders need right now is the support of other leaders from other sectors. We need people to come out and say, "some of this behavior is not acceptable."

Showing up in somebody's front yard and making their family and children feel afraid is not acceptable. Threatening people is not acceptable. It's a social norm thing. It's sending a very clear message that dissent is fine, but that kind of dissent is not. If we started to have some more consistent communication of that, from other leaders who must look at our leadership and think, “you know, that could be me in another type of setting.” The letter was a direct appeal for other people in leadership roles to step up and support their public health peers.

What can make a mixed system the better option

David: Well, I think it's a great way to exert leadership and support leaders that you represent. So obviously, we'd all stand behind that. ASTHO as an organization has some great resources for those of us who've been endeavoring to learn more about the public health enterprise, and you all have compiled some very useful atlases of information in terms of what states organize their governance models for public health in different ways--and which are centralized and which are decentralized, etc. Can you speak a little bit from the point of view of a state public health leader when they're working in a centralized versus decentralized system? And what the implications are for how they exert leadership in the mission?

Dr. Plescia: We have centralized systems. We have decentralized systems. We have mixed systems where some of it is centralized, some of it is not. In those mixed systems, it's often the more rural communities that are under the state's purview--and then some of the more urban ones are not. If you're in a centralized system, that means basically, the state public health entity really leads the entire system--and the people who are out in local communities work for the state. So, you have a lot more ability to influence what goes on in those settings because those are your employees and those are people that you supervise and report back to you.

In a decentralized setting, it's completely the opposite. They are kind of autonomous. And so, you have to lead in a different way. I would say they're never completely autonomous. Local communities depend on the state for a lot of things--and I don't mean depend in a negative way. There are a lot of things that the state tries to do for local communities. Oftentimes when a local community is facing some adverse situation or challenging situation, they'll go to the state with a subject matter expertise. Sometimes they'll go to the state for more resources and funding. So, there's a good relationship in both systems.

I have worked in North Carolina which is a decentralized system. And so--although I see the benefits of a centralized public health system, where you can have much more of a uniform response--I've also worked in a decentralized system where I understand that local communities and local leaders are much closer to what's going on in their community than somebody at the state level is. They understand how to interface, and they have the relationships with the health care sector and the faith community and the local political leaders.

So as much as it sometimes seems like the more centralized it could be, the better, there are probably pros and cons to each system. And in some ways, maybe the mixed systems are the most effective. In those, in rural areas where maybe they don't have as many resources, having that relationship--a direct relationship--with the state can bring a lot more opportunity and capacity. Whereas urban areas often have just a lot more resources and can fend for themselves; they don't need as much support from the state.

David: Well, they can access economies of scale and scope that rural areas probably can't, sure.

Dr. Plescia: And then there are some cities that are bigger in population than states, so you have to keep that in mind, too. So, I mean it is a complicated organization.

David: That must then also play into the connection between the state public health organizations and kind of others, state government functions.

Dr. Plescia: Yeah.

David: How do those play out when you have a decentralized or a hybrid system and you have to work with a state housing department organized in a different way--or other state organizations that you need to coalesce with and coordinate with?

Dr. Plescia: It depends a little bit on the situation. Some of the partners that we've worked closely with in public health, a lot of that is most effective at the local level. If you're working with the school system--and you can deal directly at the local level with the superintendent of schools for that particular region or even some of the school principals--you can have very direct action. However, if you're at the state level--and you can deal with the education system at the state level in which it's organized--you can look at far reaching policies that affect everybody, and you can work with your peers in these other agencies to affect those kinds of changes.

It gets back a little bit to what I was talking about earlier about sort of the concept of leadership in public health. These are situations where state public health leaders are really living through influence. I mean, they can't make the school system--or the housing system or commerce or transportation--do anything. But they do have relationships that are very important, and their peers and they often serve in a cabinet for executives--and they'll probably go for the governor's cabinet together. Sometimes, they're most powerful in the areas they have influence over as opposed to the areas where they have direct authority.

The relationship between local and federal institutions

David: So if you turn your attention, then, from that kind of state and local interface and influence and you look instead towards Washington, DC and towards, in your case, Atlanta, the relationship within the federal government and federal institutions adds a layer of complexity on to this. What do you think is an optimal or the optimal role for federal institutions to play, given how much of that action is local? And when you think about kind of truly centralized functions like the Strategic National Stockpile and CDC's research and data management role, how do you think about the role of the federal government?

Dr. Plescia: Well, I think one has to start by acknowledging that the Centers for Disease Control--which is really the federal agency that we work with most closely--is a little bit under siege right now. I mean, things have not gone well with the pandemic. Some of it really does go back to some errors they made. There's been a lot of strife within the federal government and much of that has affected the CDC. So, things are different right now. But I would say for the most part, we in the state and local public--I'll speak for state public health right now--we really don't have any major issues with how we've interfaced with the CDC.

I mean, there are periods where things can become a little contentious around various aspects, but for the most part, CDC provides technical assistance to states. They provide guidance. They have excellent subject matter experts. They have the kind of scientists where, when you have a question about something unusual, you can find somebody at the Centers for Disease Control who's made that their professional interest. And they're very thoughtful and they're very methodical in the guidance that they provide. So, when you're given information or guidance or technical assistance, states tend to feel very confident in moving forward with whatever that guidance may be.

CDC also understands state public health systems and is an advocate for them, and as an advocate for them in the remainder of the Federal Public Health System. Now, the interaction between state public health agencies and the rest of the government is not as well formed or strong. They have relationships with HRSA and to some extent, with CMS and FDA. There's a wide range of things, but none of it is the kind of relationship like the one that states have with CDC. And I think that's been something we need to attend to in the future, because what's happened is the federal government has needed to come into the pandemic response.

There have been other agencies that are very capable and useful in dealing with some of the situations we faced, but these are organizations that we don't know as well and we don't have the same kinds of relationships and contexts. And I think that's led to some miscommunications and just lack of understanding about how each group works, which then leads to errors and frustrations.

The challenges facing a thinning public health enterprise

Nicola: As you think about how the different groups work--thinking about the public health workforce in particular--where would you say that it's currently sort of spread thin? Are there places where we particularly need to bolster staff? And perhaps related, what do you see in terms of a role for like an extended public health workforce through, for example, community health workers?

Dr. Plescia: Yeah. Unfortunately, I think the public health enterprise is spread thin really across all aspects. We haven't tended to put the emphasis on investing in public health systems and in public health capacity that we have in other sectors, like the medical sector. And so, the result is, I don't know that I can point to one specific workforce area that's problematic. I think we have major inadequacies around our information technology systems but that's technology, that's not people. I think with people, it's really an issue that we're spread thin everywhere. And we're concerned also on the other place that we're not spread thin yet, but we soon will be with some of our most experienced workers.

Many of them are reaching an age and a place in their career where they're going to start retiring, and there's a lot of concern about the leadership that will come in after them. I think there's some great and talented people out there--and people who actually are trained and understand public health--but a lot of them have not chosen to pursue careers in governmental public health anymore. The cohort that's retiring came into state and local public health--particularly state public health--at a time where you could really get a lot of stuff accomplished and have a lot of influence. And it's not like that anymore. It's not as attractive for that reason.

And so one of the challenges we have is there are more schools of public health and public health programs than ever before, but we're not seeing those people come into governmental public health--and that's a challenge we're really going to have to deal with. Now, the other thing that that you alluded to, community health workers, it's time to start thinking about, what's the workforce we have now and what's the workforce that we need or will need in the future. There's a lot of concern about nursing and there's been a nursing shortage across all sectors of public health medicine everywhere...

David: And health care delivery as well.

Dr. Plescia: And health care delivery, yeah, everywhere. Nurses have been a huge component of the success we've had in public health. But going forward, I'm not sure that we need the ground troop public health nursing workforce that we've had in the past. I think we need nurses to come in in more supervisory and leadership positions. And what we really need to start--and this is more local public health and state--but what we really need more of in local public health is referred to as lay workers or community health workers. You know, people who don't necessarily have that medical or nursing--or even public health background--but who are known in their community and are an influence in the community, most importantly, who are trusted in their communities. Because so much of the work we do has to do with engaging people and gaining their trust.

If we want people to take the COVID vaccine, particularly if we want racial and ethnic minority communities to participate in the COVID vaccine, we have got to win over their trust. And we're going to do that better with people who they identify with and who look like them and who they know, then we are with more highly trained professionals that we put so much emphasis on. That's not an important place for those kinds of highly trained professionals but it's time to start thinking a little bit differently. We have an opportunity actually to diversify our workforce right now, and we need to take advantage of that.

What the health workforce might look like in the future

David: As far as that goes, would you see a role for a uniform training or certification program, or would you envision that to be localized and highly diverse workforce that might look very, very, very different in different places in the country?

Nicola: Well, I would say both. I think that there are programs to help train people for these kinds of community health worker roles. A lot of them are very accessible through places like community colleges, so that building up some of the expertise and knowledge base that's useful is fairly accessible. That said, you don't want to control it too much or institutionalize it too much. Otherwise, you're on the risk that you're creating yet another healthcare employee who may not have that trusted relationship but somebody who's seen as a little more of a community worker or a lay worker. I do think the people that work in public health need to have some basic knowledge and expertise. But I think there are a lot of people who we haven't looked to recruit in the past who could fulfill those kinds of roles, and would come at it with a very different educational and training background.

And, when you talk about being trusted in your communities, it makes me think as well about now we're beginning to see a bit more involvement from an interest in engaging local pharmacists. What do you think about that developments and the role for pharmacists in public health?

Dr. Plescia: Pharmacists began to play a lot more role in various aspects of public health and the place that we had been seeing it the most is around chronic disease control. People who have medical risk factors for chronic diseases--like high blood pressure or high cholesterol levels or even diabetes--they interact with their pharmacists a lot because they're going to get their medications filled. And sometimes, the pharmacist has a little more time to really talk to them about some of the lifestyle changes--and also just some of the “how do you take this medicine” and “how do you adhere to the medicine regimen you're on, when do you know if something's wrong,” that you need to look into.

I am a physician myself. I think physicians are very, very important in that communication chain as well. But pharmacists bring a different angle to it--and have maybe a little bit more time to really help people with how they are personally going to manage the condition they have once they're back out in their communities. So, we've started to really think about pharmacist as being helpful with chronic diseases. I think with COVID, we've begun to realize just how much access pharmacists have, and how convenient they are to people in communities. Also, often they work for big pharmacy chains that are able deal with some of the logistics of moving supplies around.

And so for things like vaccines--and particularly for the COVID vaccine--we may see that pharmacists and pharmacies play more of a bigger role in some of our attempts to get people vaccinated. We've seen it in the past. And I think in the situation we're in, we really need to look for creative ways and other workforces that can help us get the job done. It's a big job to take on right now, and I don't think that state and local health departments can do what's ahead of us on their own.

Nicola: That's so interesting. You probably are seeing a bit of the test case for that right now. I think even the local supermarket pharmacies are--with the flu vaccine as just an example-- promoting, come get your flu shot here. You could certainly envision a similar kind of thing rolling out when vaccine for COVID is available and needs broad distributions. It's very interesting.

Dr. Plescia: Yeah. There's a balance. I know that sometimes the medical community becomes concerned about scope of practice issues with pharmacists, and I think some of that is accurate. We want to be careful that--in the attempt to make things convenient for people--we don't end up undermining the importance of getting people in to see a physician once in a while. Because they can talk about, you know, they can deal with all kinds of things. And we also don't want to undermine local public health departments. We don't want an atmosphere of competition between local health departments and pharmacies. I think there's room for everybody. It's just a matter of thinking through who may be able to do what best, and who can be most helpful particularly in this situation that we're in right now.

David: Of course, the best provider is the one that you can actually get to. So, their breadth of contact has a lot to recommend it.

Making modernization a priority for public health data

Nicola: You alluded to this a little earlier, but we would love to hear your thoughts on how data systems are working in your view. Noting that the collection analysis and communication of public health data really are, in many ways, a critical driver of performance. How would you characterize the current state of data systems that are used by the state public health organizations? And what would you say are the top priorities for ASTHO's membership, when it comes to improving or modernizing public health data?

Dr. Plescia: I think that the public health data system is just not acceptable for the society that we live in. We hold so many other entities or aspects of our society at a place where there's just been so much more investment in this. I mean, we have some local health departments that are still sharing data across different sites by faxing it, in this world that we live in where everything's computerized. We still have people having to fax things back and forth to each other because their systems are just so antiquated. And it's also extremely disparate domain. Affluent states that have significant revenues, their public health departments have much stronger and better public health data systems than in those states that are not as affluent.

We need to have a little bit more of a uniformity across all of that. It's a problem. It's a problem for all states when you don't have the ability to communicate across states because people don't just stay within their state; they move around, they're very mobile. And I have to say as a physician, I've seen how much has been invested really in the last decade or two in medical information technology--things like electronic medical records. A lot of attention has been put into really bringing those data systems into the current age, but unfortunately, we did not do the same thing with public health. And so, these systems are old, they're not very easy to use. They're not very easy to understand.

It's very challenging when you go in front of an audience of policymakers--and try to persuade them to take on an issue--when the data you have about that issue is from last year. And it's very difficult to tell anybody whether we're making progress when you don't get your data in real time. We could do better than that in public health. I don't even think it would be that expensive to fix, compared to some of the other things we need to fix. But the good thing is that I think that the COVID pandemic--one of the few good things about it--has really pointed up how antiquated these systems are. And it's pointed out what, not just the risk, but what the outcome and harm has been not having to paid attention to these deficits in the past.

David: Who do you think the natural advocate for, like a real rethink of Public Health Information Systems, is that going to have to come down from the feds given the huge benefit to having consistency across the country?

Dr. Plescia: I think the federal government can set some standards. I mean, that's a little bit how they have brought up the information technology system in medical care practices They didn't come in and take over. It's HITECH Act.

David: It was the HITECH Act, yeah. They just said...

Dr. Plescia: They put money into it, they incentivized it, it was in everybody's interest to get on board with these new technologies and there were financial benefits to doing that. And there were disincentives too. There were financial disincentives if you didn't. So, I think really, it's the same recipe that we used in medical care setting just applying it to the public health system.

David: Yeah, no, that makes sense. I know from the discussions we've had with providers, they would very much support taking good advantage of all the investment they've made in electronic health record systems and being able to support a more robust approach to public health data. So, I think you probably have a lot of allies there.

Dr. Plescia: Yeah. It is also going to take some push from the top. One of the challenges with medical care systems is they often see the data that they have as proprietary, and they're very competitive with each other. And so sometimes the challenges we have is we can't get access to data. The health systems are concerned about sharing it and concerned about getting into the wrong hands--or concerned about it somehow putting them at a competitive disadvantage. So, somebody is going to have to make that okay for them. I think that is going to require federal action or in some situations, states may be able to provide the regulatory--or whatever other structure it's going to take--to allow some of that data that's out there and available, and just hasn't been really shared widely.

The challenges of changing societal norms

David: Well, one of the advantages, of course, is the states are--for the most part to my understanding--the keepers of regulation when it concerns medical licensing, etc. So, they do have a little bit of influence with provider organizations. One of the topics we've touched on kind of in various points in this conversation, Dr. Plescia, is what's happened during the pandemic and the polarization that we've seen. At the end of the day, how do state public health leaders--and, by extension, the local folks that they work with all up and down--get messages accepted by all members of the public? You know, we're learning--as if we needed to have learned it again--just how much none of us are healthy unless all of us are healthy. And how do public health leaders get that message across to folks in a way that they can take it on board?

Dr. Plescia: Well, some of this is about public health, some of this is about our society. I think that we've arrived at a place where we need more of a societal commitment to the common good. I mean, some of the things that we're asking people to do, there's a benefit to them but it really also has to be about looking out for each other. Something as simple as wearing a mask You get some protection yourself if you're wearing a mask, it protects you. But what's much more important is if you happen to be sick and you don't know it, it keeps you from giving that to somebody else. And I think somehow that's not come through strongly enough in this pandemic and we need to return to that.

And I don't know that public health on its own can't bring about that kind of changing societal norms. We have to--and I think we will after we've witnessed and experienced what we've been through--I think we will come to that but that's going to be very, very important for our society going forward. We like to say that states are the laboratories of democracy. I would say that if states--and particular state public health departments--are struggling, then I worry that democracy is struggling. So, we really have to kind of deal with that issue. And sometimes, it just has to get bad enough that it gets people's attention and it's certainly gotten bad with this pandemic.

And sadly, those of us who work in public health think it's likely to get worse as we move into the winter months and as we wait for some of the things that may help us--like the vaccine. But we really have to get to a place where we're willing to... We have this strong sense of independence in this country and that's part of what makes us unique. But we also have to think about sometimes when we have to sacrifice some of our independence and some of our freedoms, for the good of us all. I don't know that I have the answer of how to get there; I hope that people seeing some of what's happened over the last six months is going to create that environment.

Once we have that environment, I think that it's a lot easier. And we're not going to have that perfect environment. I mean, that's not who we are, but if we can get a little more acceptance of that from people, then it's a lot easier for public health to convey its message. Our public health leaders are getting attacked and having these sort of threats and things against them. The only thing that they are doing is trying to keep people safe, and there's not really any particular benefit in that for them. So they really are trying to act in the best interest of the public--and that's why I think we have been so disturbed by some of the really negative and nasty and threatening acts that we've seen.

Ultimately, we need to get to a place with leadership where that's not acceptable anymore. But we strive for a certain common good, and we look out for each other, and we listen to people when they're making recommendations--which are really about trying to get through a difficult situation together with the least number of people suffering the least amount. And that's the social norm issue. And we spend a lot of time working on changing social norms in public health and trying to influence social norms. That is ultimately going to be the thing that will help us get through the rest of the pandemic--and would also prepare us for pandemics that we might have in the future and many other public health issues that we face.

David: Well, hopefully, the letter that went out today can be circulated far and wide and we can get all sectors of society on board with holding ourselves to that standard of civilized behavior that we need to have in order to maintain an advanced society.

Dr. Plescia: Yeah.

David: Well, great. I appreciate that. And I want to say thank you so much for joining us today. I always learn a lot from these conversations and today is certainly no exception. Dr. Plescia, any last words you'd want people to take away before we say goodbye?

What makes an effective public health leader

Dr. Plescia: No, I really think we've kind of hit on everything to talk about. So, I'm looking over my notes and there's really not anything that's jumping out at me. Actually, I will speak to one thing that I had made some notes on-- the important qualifications for a public health leader. That is something we're very interested in and that is something that is going to be important for the future. And we need to make sure we can continue to attract public health leaders who are well versed in science--because we need to base public health on science--and who have political influence. Those are things that was really a very refined and much sought-after leadership skills.

We need to make sure we're creating professional paths that bring those kinds of people into public health. I think we have done that really, really well up until now. I am very, very impressed with the public health leaders who run our state public health state and 12 public health departments right now. But I'm also worried that some of them are getting tired, and some people are probably looking at the way they're being treated and thinking, "Do I really want to do that?" So, we need to pay attention to that because that leadership is probably the most important thing about the future of the public health system.

David: Well said and I share the concern about the future and how we're treating people and the messages that sends. With that, I think it's a good time to wrap it up. Dr. Plescia, thanks a lot for joining us. Nicola and I will look forward to our next episode of this conversation. And with that, thanks very much everybody and stay safe and mask up and be healthy. Take care.

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