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INSIGHT & INSPIRATION FROM APHA’S 2012 MIDYEAR MEETING
“Earlier today, the Supreme Court upheld the constitutionality
of the Affordable Care Act — the name of the health care reform
we passed two years ago. In doing so, they’ve reaffirmed a
fundamental principle that here in America — in the wealthiest
nation on Earth — no illness or accident should lead to any
family’s financial ruin.
I know there will be a lot of discussion today about the politics
of all this, about who won and who lost. That’s how these things
tend to be viewed here in Washington. But that discussion
completely misses the point. Whatever the politics, today’s
decision was a victory for people all over this country whose
lives will be more secure because of this law and the Supreme
Court’s decision to uphold it.”
— President Barack Obama, June 28, 2012,
in reaction to the U.S. Supreme Court upholding most of the
Patient Protection and Affordable Care Act
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Letter from Dr. Benjamin
Dear fellow public health practitioners, researchers, educators and supporters,
On Saturday, Nov. 7, 2009 — the first day of APHA’s 137th Annual Meeting in Philadelphia —
the U.S. House of Representatives passed its version of a bill that would eventually lead to the
historic passage of real health reform. It was a pretty good day for public health. Fast forward
to June 28, 2012 — the closing day of APHA’s Midyear Meeting in Charlotte, N.C. — when the
Supreme Court upheld nearly every provision of the Patient Protection and Affordable Care Act.
That was a very good day for public health.
Hearing the long-awaited news surrounded by hundreds of fellow public health workers —
the very people who are bearing witness to the law’s real impact on people’s health and wellbeing — was incredible. But in typical public health fashion, after a few minutes filled with
celebratory cheers, ecstatic hugs and audible sighs of relief, the conference room quickly
filled with that determined energy to make a difference. It was time to get back to work.
The Supreme Court’s decision was good news, but the Affordable Care Act and its landmark
investments in public health and prevention are hardly on sturdy ground. Attempts to repeal the
law or strip the law of funds to implement it will likely continue. This comes on top of serious
cuts to federal, state and local public health budgets. At the same time in our communities,
people are still becoming sick and disabled, and are dying from preventable disease and injury.
Significant health disparities persist, shining a glaring light on our moral obligation as a nation
to eliminate health inequity. The need for public health is clear, but — as was heard again and
again in Charlotte — our resources and capacity are truly in peril.
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It’s time to adapt, something public health has always excelled at doing. It was certainly the
call to action that threaded its way throughout June’s Midyear Meeting. Whether the topic
was building coalitions, adopting new technologies or developing the workforce, the need to
maximize efficiency and quality — to adapt to a quickly changing health landscape — was everpresent. As Lydia Ogden, director of the Centers for Disease Control and Prevention’s Health
Reform Strategy, Policy and Coordination Office, said during the Midyear Meeting’s closing
session: “Let’s evolve and let’s do it together.”
We hope this report from the Charlotte proceedings will help you on that journey. In the
following pages, we’ve tried to capture the valuable insights and lessons learned that emerged
during three days of public health presentations and conversations. Sharing our success stories
— as well as our not-so-successful stories — is essential to empowering all communities with
the opportunities for good health and well-being.
Because as public health practitioners can attest to, we’re all in this together.
With best and healthy wishes,
Georges C. Benjamin, MD
Executive Director
American Public Health Association
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Executive Summary
Hundreds of public health practitioners from across the nation
gathered at the Westin Hotel in downtown Charlotte, N.C., for
APHA’s 2012 Midyear Meeting, which took place June 26–28.
With a theme of “The New Public Health: Rewiring for the Future,” the meeting zeroed in on equipping public health workers with the tools, knowledge and insights needed to thrive —
and survive — in a challenging environment. Presenters also
brought with them encouraging stories from the frontlines of
community prevention, most notably the positive outcomes
already unfolding thanks to support from the Communities
Putting Prevention to Work and Community Transformation
Grants programs funded through the Patient Protection and
Affordable Care Act.
As the theme language hints, meeting sessions did indeed
cover rewiring in a very literal sense, such as North Carolina’s
impressive success implementing health information exchange technology. It also covered rewiring in a more metaphorical sense, such as the efforts of Nebraska’s Douglas
County Health Department to transform how communities can
work together to improve population health and create the
conditions that afford good health to all.
Presenters also brought to the table helpful tips for advocating
on public health’s behalf, engaging with nontraditional public
health partners and elevating an evidence-based, healthin-all-policies approach. The topic of communicating public
health’s good works received attention as well, with speakers
calling on attendees to gather the data and craft the stories
that illustrate the role of public health in people’s lives and the
critical part that a robust public health system plays in improving health and curbing health care spending.
The Charlotte Midyear Meeting welcomed session presenters
from state and local health departments, federal public health
agencies, schools of public health, private sector public health
partners as well as research, policy and advocacy organizations. Topics ran the gamut, from community prevention and
health disparities to partnering with the clinical sector and
ensuring quality public health services. Of course, throughout
the nearly three-day meeting, fingers were crossed about the
most popular topic of the day, the soon-to-be announced Supreme Court decision on the constitutionality of the ACA. The
caveat “if the law is upheld” could be heard on more than one
occasion in the days before the ruling came down.
For public health, the June 28 ACA ruling was not only a victory for the millions of Americans without access to affordable,
quality health care; it was also a victory for the millions of
Americans who will benefit from landmark community health
investments via the ACA’s Prevention and Public Health Fund.
In fact, many meeting presenters discussed the new opportunities to promote prevention that are unfolding thanks to
health reform.
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Unfortunately, they also discussed the challenges of tightening budgets, shuttered programs and lost staff. The meeting’s
host, North Carolina, was the perfect example of the ups and
downs of public health work. During the meeting’s opening
session, North Carolina State Health Director Laura Gerald
praised the state’s public health quality improvement efforts,
such as a new directive requiring local health departments to
achieve accreditation. She also reported on the recent slashing
of the state’s tobacco prevention funds — from $18 million to
$2.7 million — and voiced concerns over the state’s continuing
ability to sustain hard-fought declines in tobacco use.
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This report, a collection of lessons learned from presentations
during APHA’s 2012 Midyear Meeting, provides insights, tips
and hopefully some inspiration as you navigate the new opportunities and challenges of today’s evolving public health practice. The report is divided into five topic chapters with input
from various Midyear Meeting sessions. Each area is footnoted
so readers know during which meeting session a presenter
spoke. Every chapter is also followed by a list of active recommendations, titled Steps for Action. In between chapters is
coverage from some of the meeting’s general sessions, and
the report includes a list of helpful resources and a roundup of
take-home action steps.
“Public health is going through amazing changes,” said APHA
Executive Director Georges Benjamin during the meeting’s
opening session. “This is a time for public health to begin reenvisioning itself.”
Attendees at APHA’s
2012 Midyear Meeting
react to the news that
the Affordable Care Act is
constitutional and will be
upheld.
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Public Health In Action:
Key Recommendations
From APHA’s 2012 Midyear Meeting
ADAPT AND THRIVE: By no means does this mean public
health practitioners should sit back in silence as life-saving,
evidence-based programs land on the budgetary chopping
block. But neither should we let the current fiscal environment
— or future fiscal environments — be the driving force that
shapes our work, our goals and the health of our communities.
It’s time to adapt, innovate, step outside our comfort zones and
even take some risks. It’s also time to ask the hard questions:
Are we being efficient enough? Does this activity or service
still provide good value and is it worth our limited resources?
Adaptation has always been a strong suit of the public health
practice and now is the perfect time to put it to use.
CHAMPION HEALTH IN ALL POLICIES: Public health can’t do
it alone, especially when it comes to changing and creating
the conditions that afford good health for all. This idea isn’t
new for public health practitioners, however it might be quite
new for those outside the public health field. Take the time
to reach out to transportation planners, land-use decisionmakers, school administrators, business owners, parks and
recreation officials, housing authorities, etc., and engage them
in improving community health and offer your expertise. Not
only is this an effective public health strategy, it’s a smart way
to leverage existing community resources and infrastructures
for improving health.
ENGAGE THE MEDICAL COMMUNITY: One of the many
great aspects of the Affordable Care Act is that it views
health in a holistic sense, acknowledging through policy and
investment that good health happens both inside and outside
of the doctor’s office. More and more, those in the medical
community are realizing this too and are reaching out to public
health practitioners for help. In fact, many physicians are
realizing that precisely what’s missing from their toolbox is the
public health approach. Reach out to the medical community
and include them as partners in your efforts. As was heard
multiple times at the Midyear Meeting, creating a new health
system means integrating health care and public health.
PICK A PARTNER: Behind nearly every success story told
in Charlotte was the critical role of partnerships. Of course,
building partnerships and coalitions isn’t new to public health;
in fact, it’s one of our great strengths. But in a time of limited
resources and competing priorities, building community-based
partnerships that engage and empower stakeholders may be
the surest path to sustainability. Plus, it’s a great way to teach
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more people about the power of public health and the need to
speak up on its behalf.
SHARE @PUBLICHEALTH: New technology and communication
tools are already proving transformative for public health.
From Twitter and mobile phone apps to information exchanges
and electronic health records, we’ve only just begun to wield
these new tools on behalf of public health. Learn about how
these tools can help you reach the different communities you
serve. Think about innovative ways to use new and growing
amounts of data to create opportunities for better health
outcomes and quality care. Technology is a powerful tool, but
only if we know how to use it.
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DEMONSTRATE VALUE: Our communities will continue to
look toward public health for help, guidance, oversight and
care, but they will also be asking: Is this worth it? The answer,
unequivocally, is yes. But, it’s up to us to make that argument.
That means collecting the data and telling the stories that
illustrate the value of public health in people’s lives. And
not only the value in terms of better health and longer lives,
but in terms of reducing medical spending and preventing
unnecessary and costly hospital care. It is also important to
define what “value” means. In other words, the value of public
health work cannot — and should not — always be measured
in dollars and cents. Surveys show that Americans believe in
and support prevention; let’s capitalize on that momentum.
EMPHASIZE EQUITY: Improving the nation’s health can’t come
about without addressing the health inequities that persist in
our communities. More than a matter of access, health equity
is a matter of justice and fairness. Continue to fight for policies
and resources that create the opportunities for all people to
live healthy and prosper, and shine a light on the disparate
social, economic and environmental conditions that propagate
such inequities. Continue to be a voice for justice.
E. Winters Mabry, director of health at
Mecklenburg County Health Department
in Charlotte, N.C., welcomes attendees to
his hometown.
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SURVIVE & THRIVE:
ADAPTING TO A
CHANGING ENVIRONMENT
“We need better care, better health and lower
costs at the same time. Better care we can get
done through the care system...But we need
the public health community really mobilized
around achieving better health. How to do that
in an environment of decreasing resources
when the customer of public health is a little
more vague — that’s a very tough problem.”
— Donald Berwick, former administrator of
the Centers for Medicare & Medicaid Services
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A State’s Perspective
“Decimated” is the word session presenter Frances Phillips used to describe her state’s public
health budget during the last five years. The cuts have been terrible for local health departments and hundreds of jobs have been lost, reported Phillips, deputy secretary for public health
at the Maryland Department of Health and Mental Hygiene. But instead of pulling back, Maryland’s public health community is quickly adapting to the new environment and making real
progress toward improving health as well as health care — and it has “nothing to do with the
budget,” Phillips said.
“What is happening locally now is truly phenomenal,” she said. “And that’s really where people’s lives change and where health happens.”
Phillips reported on three areas that are helping Maryland public health workers do “more
with less.” The first is building collaborative relationships and embedding public health goals
into momentum already happening at the community level. As of summer 2012, 17 local health
improvement coalitions were working within a new framework created by Maryland’s recently
launched State Health Improvement Process. The process marshals energy around 39 health
objectives and sets short-term health improvement targets to be met by 2014. Phillips said
that each goal must be backed up with locally available data, noting that it’s not good enough to
reference state-level data “unless we can break it down locally where the health improvement
action happens.”
The state health department assists local coalitions by providing localized data, hosting a
convening website and supporting the role of the local health officer in chairing the coalitions.
Phillips emphasized that the state health department had zero funding to take on the coalitionbuilding endeavor. But the department capitalized on a “mutual understanding” with hospitals
about the role that community prevention plays in helping hospitals come into compliance with
ACA directives on quality care. It eventually led to the state hospital association providing about
half a million dollars in start-up funds for local health improvement coalitions.
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The second area that’s helping Maryland do more with less also involves hospitals — specifically, leveraging new ACA-related financial incentives aimed at improving health care delivery
to strengthen community-based care. For example, Phillips said, there’s a lot of pressure on
hospitals to avoid preventable readmissions and better manage services for high-cost health
care users. In turn, hospitals are looking toward community partners, such as public health
departments, to help empower residents with the tools and services they need to stay healthy
at home and they’re providing the financial support to help make it happen. Phillips noted that
it’s a tremendous opportunity to illustrate public health’s critical role in curbing health care
spending.
Lastly, Phillips turned to technology, which she predicted would help “advance public health in
ways we haven’t even imagined.” Maryland is home to a robust health information exchange,
with all 46 acute care hospitals signed on and sending in data. And while the data flowing
through the exchange is certainly a boon for the clinical treatment of patients, its potential to
enhance public health surveillance and intervention is “huge — it’s almost unthinkable,” Phillips told attendees. So, with funding from a private foundation, the Maryland health department
launched the Maryland Health Data Innovation Contest, calling on people to submit innovative ideas on using the exchange data to address public health challenges. The winner, who
received a $5,000 prize and worked at the Maryland Poison Center, proposed marrying data
from the medical examiner on overdose fatalities with poison control center data on overdose
fatalities and near-misses. The combined data can help public health workers conduct needs
assessments and better measure the impact of interventions. Maryland’s health department
continues to host a website where people can continue the brainstorming process.
“We see the role of public health at the state level as a convener of good ideas,” Phillips said.
From session 2001/2006, All In This Together: Public Health Community Benefit, June 27
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Revitalizing the
Public Health Workforce
Will public health have the people, skills and training to excel and adapt in the new century? It’s
an issue that the nation’s top public health agency is tackling head-on.
Widening the pipeline into the public health profession, investing in emerging public health disciplines, and strengthening the linkages between public health and health care are top priorities at the Centers for Disease Control and Prevention. Session presenter Denise Koo, director
of CDC’s Scientific Education and Professional Development Program Office, said the majority
of the agency’s workforce development efforts falls into five categories: recruiting new talent;
training workers in new disciplines; training the existing workforce; providing services and
technical assistance; and developing a workforce strategy. Much of the attention is going toward
recruiting new talent, Koo said, highlighting CDC’s service and learning fellowships.
“In this day and age, we really feel that the deep experience that (students) get through fellowships is needed more than ever,” Koo told attendees.
CDC has created a virtual one-stop shop for fellowships at cdc.gov/fellowships. Koo reported
that nearly 300 fellows have been assigned to work in the field with local and state public
health agencies. The fellowships are two- to three-year training programs that are similar to
the medical residency model, but unique within the public health field. She noted that there
are more than 8,000 residency opportunities for physicians, but really only a handful for public
health practitioners. Today, about 75 percent of CDC fellows go on to secure a job in the public
health field.
North Carolina State Health Director
Laura Gerald speaks at opening session.
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One of the challenges, Koo noted, is moving from a one-on-one to a population-based approach
to workforce development. To help move this framework forward, the agency hosts the online
CDC Learning Connection at cdc.gov/learning. The site hosts a wealth of learning and training
opportunities, from those that offer continuing education credits to what CDC calls Quick Learn
Lessons, which are lessons that take 20 minutes or less and that users can access via mobile
devices. Koo said the agency is also developing core curriculums for the public health sciences,
such as “public health 101” courses in epidemiology, informatics, surveillance and more. Unlike an academic setting, Koo said the CDC offerings are meant to be short courses that people
can access when they have a few minutes to spare.
CDC is also working to develop a long-term strategy regarding public health workforce development, with a big focus on how to more effectively bring together the public health and health
care sectors. Through CDC’s Public Health Workforce Development Initiative, Koo said the
agency has been engaging a variety of stakeholders to gather input on what CDC’s future workforce priorities and strategies should entail. During the meetings, stakeholders are discussing
factors that are transforming the practice of public health, such as the massive amounts of
data now coming into health departments via multiple sources and how public health workers
can wield this data to improve health. CDC has also learned from stakeholders that the core
competencies of the “new” public health are: convening and collaborating (not just doing); improved monitoring of community health status to aid community engagement; leveraging policy
change; and employing clear communications, including the use of social networks.
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What are some of the emerging skills public health partners tell CDC they need? Practitioners with policy skills, systems thinkers with a broader definition of public health, liaisons to
strengthen public health-health care partnerships, and workers skilled in informatics. (“Informatics skills, informatics skills, informatics skills. (It) keeps coming up over and over again.
How do we leverage technology but still in an evidence-based way to support public health,”
Koo asked meeting attendees.)
In fact, for the first time, Koo reported that CDC placed nine fellows in the field to focus on informatics. Also, with Prevention and Public Health Fund dollars, Koo said CDC is keeping more
graduates in epidemiology and placing them at the intersections of medicine and public health
— “that is the future, we need people who can do that boundary spanning,” she said. CDC is
also looking for opportunities to implement a systems-based approach to workforce development and garner more recognition for public health as a discipline.
For example, the agency recently finished the first phase of a collaboration with
the U.S. Department of Labor, which has designated CDC’s public health informatics fellowship as an official federally registered apprenticeship — it’s a first for
a professional public health fellowship as well as a first step toward having public
health informatician as a standard occupational code, Koo reported.
“We don’t want a public health system and a health care system,” Koo said.
“What we want is an integrated health system and public health is a critical piece.”
From session 1001, Who Will Keep the Public Healthy?: Building the 21st Century
Workforce for Public Health, June 26
“We as a public health system need to adapt; we need to
transform,” said Judith Monroe, director, CDC Office
for State, Tribal, Local and Territorial Support
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New Times, New Partners
Breaking down the barriers between the public health and clinical sectors received significant
attention at the Midyear Meeting. In fact, over and over again, speakers noted that engaging
medical partners and helping them meet new health care delivery directives under ACA will be
critical to elevating — and sustaining — public health’s role in a time of health reform. It’s not
just public health that must adapt to new times; the clinical sector must also adapt to a new
framework of prevention and it needs public health’s help to do it.
Janet Wright, executive director of the Million Hearts initiative, spoke on how bringing together
public health and clinical players is key to reducing two of the nation’s top killers: heart disease and stroke. The Million Hearts initiative, which is led by CDC and the Centers for Medicare
& Medicaid Services, launched in 2011 with a goal of preventing 1 million heart attacks and
strokes by 2017. Wright began her Midyear Meeting presentation with what she called a confession: She is not a public health practitioner.
As an interventional cardiologist, she said she struggled with trying to change patients’ health
trajectory, while patients struggled with a culture that was driving them in the wrong direction — “toward disease as opposed to health.” She was frustrated with her ineffectiveness as
a clinician to change people’s behavior. She would often ask patients who were successful in
losing weight, stopping smoking or adhering to treatment: How did you do this? Oftentimes,
the answer was that they got connected with a wider, community effort. She said she started
to realize that she was missing a big chunk of training needed to turn around health outcomes,
and that training was in public health.
“I am becoming very slowly...a public healther,” Wright said. “I am enormously devoted to this
initiative and to the successful marriage of clinical practice and public health around cardiovascular disease.”
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The goal of the Million Hearts initiative is an audacious one, she said, but it is achievable
through the combined efforts of many diverse organizations. Wright said the architects of
Million Hearts are very purposefully aiming to integrate clinical and community-based prevention to create an environment in which both are seen as critical to preventing heart attack and
stroke. For example, among the key components of Million Hearts is getting the ABCS (aspirin,
blood pressure, cholesterol and smoking cessation) embedded into clinical care mechanisms,
while also changing environments to support heart healthy habits, such as instituting smokefree policies and reducing sodium in the food supply. (Interestingly, Wright noted that she met
with food manufacturers about sodium content. Manufacturers told her that putting a lowsodium label on a product was the “kiss of death” for a product’s success. In other words, they
would consider decreasing sodium content if they could still sell the product — they need more
public demand. Wright called the situation a “public health puzzle.”)
Today, Million Hearts boasts an impressive array of public and private health and public health
partners. Wright noted that state health departments are signing on as partners and developing
state-based plans bringing their clinical and public health sectors together — “all with data, all with
targets and a will to change the current cardiovascular health of the nation one state at a time.”
One of the “coolest” outcomes of organizations making a public commitment to the goals of Million
Hearts is partners hooking up with partners, she told attendees. For example, WomenHeart, an organization of hundreds of “champions” who lead community efforts and educate women on cardiovascular disease, wanted to do more work on blood pressure, but they didn’t have the expertise. In
turn, the Preventive Cardiovascular Nurses Association put together some educational materials on
blood pressure that is now going out to communities around the nation via WomenHeart.
“I need you...to be ambassadors for Million Hearts and to guide this initiative,” Wright told session attendees.
From session 3000, Strange Bedfellows Make Powerful Champions: Emerging Partnerships in Public Health, June 28
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STEPS FOR ACTION:
• DON’T let budget problems
define your work. Find
creative ways to adapt to
new fiscal environments
and leverage public health
success stories and
relationships to continue
momentum toward healthier
communities.
• TAKE advantage of
workforce training and
development opportunities,
especially those that will
help your department thrive
in a new era of efficiency and
technology.
• REACH out to clinical
partners. Many are just
as frustrated as you with
rises in preventable health
conditions and are looking
for more comprehensive
approaches to patient care.
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2012 Midyear Meeting Opening Session:
‘The Biggest Risk Of American Health Care Today Is That It Will Fail The Moral Test’
Donald Berwick, former administrator of the Centers for Medicare &
Medicaid Services, started his opening session keynote address with an
admission: He wasn’t sure how to address the question of how public
health can thrive in today’s changing health care world. The question,
he told attendees, doesn’t have an easy answer.
The Affordable Care Act, he said, does essentially two things: It attempts to make health care a right, and to make health care sustainable
via improvements in quality and delivery. The question of how to define
what improvement means — and what we should expect — in an era
of health reform is what motivated Berwick as he worked to transform
CMS to align with the goals of the now-famous “Triple Aim:” Better
care, better health, reduced costs. However, the framework also stresses the importance of equity — an overriding goal of public health work.
According to a 2008 Health Affairs article Berwick co-authored, the “Triple Aim is an exercise in balance and will be subject to specified policy
constraints, such as decisions about how much to spend on health care
or what coverage to provide and to whom. The most important of all
such constraints, we believe, should be the promise of equity; the gain
in health in one subpopulation ought not to be achieved at the expense
of another subpopulation...A health system capable of continual improvement on all three aims, under whatever constraints policy creates,
looks quite different from one designed for the first aim only.”
“The biggest risk of American health care today,” he told opening session attendees, “is that it will fail the moral test.”
Berwick said, in part, it didn’t matter how the Supreme Court ruled on
the health reform law, as the “health care evolution agenda” had already left the station and is quickly moving toward improved care coordination, better transparency, patient-centered care and the adoption of
health care technologies. And the opportunity to provide input as health
care evolves doesn’t depend on your ties to Washington, D.C., he noted
— it’s a community affair.
But what does it all mean for public health? Berwick said he wasn’t
entirely sure. Public health faces real challenges, he said, especially
in communicating its value to the public and to policymakers. It’s that
classic problem of how do you tell the story of a person who didn’t get
sick or injured because of a successful public health intervention? How
do we communicate the value of prevention, even if it doesn’t always
save health care dollars?
So, while Berwick began his keynote not sure about what advice he
could offer, he did end with what he called a prescription for public
health: When possible, reduce costs within public health; cooperate and
don’t work in silos; reach out and partner with nontraditional organizations and systems; get involved in reducing health care costs and waste;
and mobilize support for public health.
“Public health needs mobilization too,” he said. “If there isn’t political
force behind the public health endeavor, it will remain frail.”
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ALL IN THIS TOGETHER:
LEVERAGING THE ACA TO
PROMOTE PUBLIC HEALTH
“The boundaries are blurring...everyone needs
to improve the health of their populations.”
— Lisa Simpson, president & CEO,
AcademyHealth
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Community Collaboration
Together again. That’s how Julie Trocchio described the emerging collaborations between
health care and public health. The senior director of community benefit and continuing care for
the Catholic Health Association of the United States, Trocchio began her presentation with a
little history of Catholic health care in the United States.
She told the story of six nuns who left France in the early 1700s and came to New Orleans. They
began visiting the city’s sick and poor, supporting their work through begging and eventually
receiving a house where they cared for residents. Trocchio said it was among the country’s first
hospitals and maybe even the first group of public health nurses. About 100 years later, Henriette DeLille, a woman of color, began visiting slave quarters in New Orleans, caring for ill and
aging slaves. Similar to her predecessors, she was eventually given a house where she took
patients in — Trocchio said DeLille’s work may very well have been the country’s first nursing
home and hospice. This is our history, she told session attendees.
“Those stories tell us...that we share a common mission — not-for-profit hospitals and public
health agencies — in that we were created to deal with the problems in our communities in
the times when they were happening,” Trocchio said. “I have heard about collaboration since I
walked into this hotel’s door, every session is talking about the importance of collaboration. We
can’t do it without our friends. The last thing (these stories) tell us is there’s never been enough
money to go around.”
Every not-for-profit hospital was started to address a community need, and so conducting community health needs assessments is often already part of the mission. However, the ACA has
formalized the process, creating a legal imperative. ACA now requires hospitals to do such assessments and develop implementation strategies to address the needs identified. The directive
has been codified in an Internal Revenue Service notice, which also states that such an assessment must be done in collaboration with community partners, especially those with knowledge
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and expertise in public health. Trocchio said that in conducting an assessment, the community
served is typically defined by geography, but that a hospital cannot gerrymander its definition in
a way that excludes certain populations.
Trocchio noted that the IRS leaves much of how an assessment is done to the hospital’s discretion; however, the agency is specific about gathering input from those who represent community interests — “this is to be a collaborative process,” she said. The same collaborative intention frames the implementation strategy hospitals must develop to address the needs identified
during the assessment phase.
“Increasingly, hospitals are realizing that the health and the cost problems that we have really
do have community-based solutions,” Trocchio said.
From session 2001/2006, All in This Together: Public Health Community Benefit, June 27
Donald Berwick, former administrator of the
Centers for Medicare & Medicaid Services, was the
the keynote speaker at APHA’s Midyear Meeting.
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Community Transformation Grant:
The North Carolina Experience
In 2011, North Carolina received the nation’s fourth-highest Community Transformation Grant,
or CTG, a federal program created by the ACA and focused on community-level interventions to
reduce rates of chronic, preventable diseases. Today, the state’s public health practitioners are
using the grant to truly leverage transformational change toward better health for all.
North Carolina’s CTG work is targeted in four areas: limiting environmental tobacco smoke; improving active living by design; promoting healthy eating; and improving clinical preventive services, which is focused on reducing the risk factors for heart disease and stroke via the Million
Hearts campaign. Just a few examples of the state’s goals are to: promote smoke-free regulations in affordable housing and on university campuses; increase the number of corner stores
that sell healthy, affordable foods; and up the amount of community support for residents living
with high blood pressure and high cholesterol, and those who use tobacco.
“No pilots; we want to begin at scale,” said session presenter Jeffrey Engel, then a health policy
advisor with the North Carolina Department of Health and Human Services. “When you know
that this works, let’s just get beyond the pilot and move it to scale.”
Engel said that the state’s CTG work will also build on efforts to eliminate the “health disparities that plague our state,” noting that the state Office of Minority Health and Health Disparities
has been fully incorporated into the CTG community so that such inequities will be considered
in all interventions.
Successes to date include the proliferation of smoke-free policies and more fresh food at local
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convenience stores. However, the new resources are also allowing public health practitioners to
pursue a health-in-all-policies approach — “finally, public health is getting a seat at the table
with the broader policymakers. This is the beginning of the health-in-all-policies philosophy
we’re trying to permeate through the state,” Engel told attendees. For example, in North Carolina’s Pitt County, community health has been officially identified as a goal in the county’s 2030
land-use plan. CTG funds are also promoting linkages between community health resources
and clinical preventive services “in a way that really puts boots on the ground,” Engel said.
“This is real transformational change for public health in North Carolina, to be working closely
with our clinical partners and doing the things we know work on a population basis, but in the
clinic,” he said.
The North Carolina health department is using a regional approach to its CTG work, leveraging existing regional infrastructures. For example, workers in existing Area Health Education
Center regions are partnering with clinical practices to implement Million Hearts. Using such a
regional approach means North Carolina’s CTG work can have the farthest reach possible. For
instance, the state’s Mecklenburg and Wake counties were not funded during the first round
of CTG grants. But because the state is taking a regional approach to CTG work, the two large
communities still have a seat at the table and will be able to take advantage of new efforts even
without direct funding.
“Leveraging our existing infrastructure is really the only way we can go about this in such a
large state,” Engel said.
From sessions 2004/2009, Innovations in Community Prevention, June 27
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STEPS FOR ACTION:
• HELP bring public health
and medicine back together
again. Health care systems
are busy working to meet
new ACA directives and are
realizing that communitybased solutions will be key.
• LEVERAGE existing public
health structures and
resources to make the most
out of new ACA prevention
and public health funds.
Use new grant funding to
build capacity outside of
traditional public health
services.
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FRIENDS FOR HEALTH:
THE IMPORTANCE OF PUBLIC
HEALTH PARTNERSHIPS
“If you want to be understood, seek first
to understand.”
— Lydia Ogden, director, CDC’s Health
Reform Strategy, Policy and Coordination
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Prevention & The Private Sector
The flu. A preventable disease that, despite an effective vaccine, thousands of Americans die
from and become ill with every year. But today, with the help of a well-known pharmacy chain,
the nation’s top health agencies are beginning to make additional inroads.
While overall adult flu vaccination rates aren’t as high as public health officials would like,
certain populations bear a disproportionate burden of the virus’ effects, said session presenter
Jamila Rashid, associate director for research and policy with the Office of Minority Health at
the U.S. Department of Health and Human Services. According to the Office of Minority Health,
not only are flu vaccination rates considerably lower among black and Hispanic adults, the
populations also have higher rates of flu-related hospitalizations. Among the barriers to flu
vaccination are a lack of insurance and access to care, misinformation about flu vaccine safety
and complacency, Rashid said.
To tackle the problem, HHS formed a number of workgroups to tackle low vaccine rates,
among them a workgroup dedicated to closing the vaccine disparity gap by widening access to flu shot opportunities. The effort partnered with a wide variety of organizations, from
churches to health care providers to fellow federal agencies. However, the work received an
extra boost when a pharmacy chain familiar to many Americans agreed to join. That familiar
storefront was Walgreens.
J. Michael McGinnis, a senior scholar at the
Institute of Medicine, discusses how public
health and prevention can be better incorporated
into clinical care settings.
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The partnership was new territory for federal health workers, Rashid said, so the 2010-2011
flu season effort got off to a late start, kicking off around Christmas. That season, Walgreens
donated 350,000 flu vouchers, which were distributed to state, local and regional health agencies. Unfortunately, not many people took them — the effort wasn’t working, Rashid said. But in
typical public health fashion, organizers convinced federal leadership to give it another go. During the 2011-2012 flu season, organizers provided Walgreens with a list of potential community
partners and encouraged the company to reach out. It was a success: Walgreens reached out
to more than 700 community organizations and agencies to help plan and host flu shot clinics
with the help of Walgreens’ pharmacists and trained vaccinators. By the end of that flu season,
Walgreens had distributed 300,000 free flu vouchers to the uninsured and vaccinated more than
51,000 uninsured or underinsured residents. Rashid said CDC is continuing to lead efforts to
recruit more pharmacies to join.
“What was most valuable and important was getting Walgreens to go out into communities, to
work with local community partners and set up those clinics,” she said. “Now, we’re saying to
other pharmacies, ‘Hey, look what happened with Walgreens — don’t you want to also participate in this process?”
From session 3000, Strange Bedfellows Make Powerful Champions: Emerging Partnerships in Public Health, June 28
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Empowering Community Partners
Building partnerships means more than gaining buy-in for a particular cause or action; it also
means empowering community players with the tools and knowledge to make a difference and
become leaders for change. In fact, empowerment may be the key to whether an effort lasts the
test of time or slowly fades into the distance.
Terrence Roche, senior director of organizational and community change at the YMCA of the
USA, told session attendees about his organization’s experience in driving healthy change at
the local level. The renewed efforts date back to 2002, Roche said, when people began asking:
“Where is the Y?” It seemed people were noticing that the familiar organization was missing
from national, and some local, discussions about serious health problems, such as obesity and
diabetes. In response, YMCA developed a variety of efforts that shift the organization from working with people who are already proactive about their health to reaching out to those struggling
with their well-being. The shift also meant getting out into communities — bringing healthy
choices to the people, Roche said.
Lauren Sogor, discusses the success of
Text4baby, a free mobile information service
designed to promote maternal and child health.
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“We’ve changed a lot over the years and have adapted to the needs of communities across our
country as well as across the world,” he told meeting attendees.
So, the YMCA began building and improving their capacity to not only make internal changes, but
to work externally and empower community groups to become agents for healthy change. One
example was the Y’s Healthier Communities Initiative, which works to build community partnerships that advocate for systems, policy and environmental changes that support healthy living for
all. In communities that take part in the initiative, the YMCA plays the role of convener, bringing
together a variety of stakeholders, such as schools, public health workers, insurers, elected officials, media and business leaders. Among the tools that community coalitions can use is YMCA’s
Community Healthy Living Index, an easy-to-use assessment tool that anybody can use to
measure how well their community supports healthy living. Roche said that even though YMCA
isn’t able to provide the kind of funding support that federal agencies can, the focus on building
community-wide partnerships puts local efforts on a good path toward sustainability.
Roche reported that thanks to YMCA efforts, more than 200 communities have contributed to
more than 26,000 policy, system or environmental changes that have impacted up to 46 million
people. Just a few examples are: More than 100 new farmers markets, nearly 500 new community gardens, nearly 200 new walking trails and sidewalks, and more than 1,000 schools and
workplaces with new food and vending policies that favor healthy choices.
“A decade ago, it was sort of like ‘Where is the Y’ and we weren’t at the table,” Roche said.
“But a decade later, we’ve actually set the table.”
From sessions 2004/2009, Innovations in Community Prevention, June 27
Larry Cohen, founder and executive director of the
Prevention Institute, speaks during APHA’s Midyear Meeting.
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Bringing Health Care Into the Fold
In 2000, an Institute of Medicine report stated: “It is unreasonable to expect that people will
change their behavior easily when so many forces in the social, cultural and physical environment conspire against such change.” Larry Cohen, executive director of the Prevention Institute, couldn’t agree more.
During his Midyear Meeting presentation, Cohen talked about an emerging approach to improving health known as community-centered health homes. The approach grows out of the fact
that medical care alone cannot solve the nation’s health problems or close disparity gaps, nor
is medical care the primary determinant of a person’s health. Public health practitioners must
help health care providers recognize and address the broader contributors to poor health, injury
and disease.
“This is really the first time that we intentionally said ‘How do we bridge prevention and health
services,’” Cohen said. “And we did it, frankly, from the perspective that health care has most of
the resources, most of the credibility, most of the weight in our health system, and if we want to
focus on health, not health care, it must be done as a very thorough partnership.”
In 2011, the Prevention Institute published “Community-Centered Health Homes: Bridging
the gap between health services and community prevention,” which outlines how community
health centers can offer quality care while also addressing the roots of patients’ health problems. Cohen told attendees he was surprised at the level of enthusiasm the concept received
from the health care community, noting that “we need medical participation to make things fair
and that’s why the environment is a key opportunity for prevention.” In other words, changing
people’s environments must be part of a physician’s role too.
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Cohen said that clinicians’ existing skills set — patient intake, diagnosis and treatment — can
also be applied outside the clinic doors to community prevention, which requires inquiry,
assessment and action. Clinicians already engage in inquiry (in medical terms, cataloguing
symptoms and vital signs; in public health terms, gathering relevant data); assessment (in
medical terms, diagnosis; in public health terms, measuring community conditions); and action
(in medical terms, treatment; in public health terms, engaging in work to change community
conditions and create opportunity.)
Understanding the link between a person’s health and their environment means taking two
steps back, Cohen said. For example, in addition to prescribing medicine for a patient with
a stomach ailment, a community health center clinician should also take two steps back by
inquiring about underlying behaviors and then what environmental factors contributed to that
behavior.
“We can speak up for community change,” Cohen said.
From sessions 2002/2007, Best of Partners: Reconnecting Public Health and Clinical Care, June 27
John Auerbach, 2010–2011 president of the
Association of State and Territorial Health
Officials
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STEPS FOR ACTION:
• DON’T be wary of
approaching the private
sector. Their familiar brands,
not to mention financial
resources, can be a real
boost for public health goals.
• EMPOWER organizations
and residents with the tools
and data to take ownership
of their communities’ health.
This strategy will also
increase the chance that
efforts will sustain over the
long term, despite the ups
and downs of funding.
• ADVOCATE for new models
of clinical care that take
into account a patient’s life
outside the doctor’s office
and utilize a populationbased approach to health
and prevention.
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PREVENTION, OPPORTUNITY
& EQUITY: STAYING TRUE TO
PUBLIC HEALTH VALUES
“We think we can make a difference in closing
the gap by the medical model — and I think
it’s important to recognize we don’t need to be
an adversary to the medical model — but the
medical model is not going to close the gap
in excess death. It has to be one based upon
social justice and the notion of human rights.”
— Adewale Troutman, APHA President,
2012-2013
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Keep the Focus on Inequities
“Child health is rural wealth.” That’s what the banner reads in an old picture from 1923 of the
country’s first rural health department, which actually began as a pilot project to see if it was
possible to bring the urban protections of public health to a rural setting. The session speaker
behind the picture was Michael Meit, co-director of the Walsh Center for Rural Health Analysis
at the University of Chicago, who reminded attendees that rural communities continue to face
barriers to good health. And on the flip side, public health workers continue to face barriers in
reaching rural communities.
“The challenge that we face in rural public health is how do we provide equitable public health
services — basic public health services — to a population that is dispersed,” he asked.
First, what is rural? There are more than 70 federal definitions of rural, Meit said, from small
towns to frontier, which is defined as six or fewer people per square mile. About 20 percent of
the U.S. population lives in rural areas, and most of the nation’s landscape is rural even though
most people live in urban settings. Rural residents face a number of social determinants that
impact their health, from lack of access to health care and public health services to isolation
and poor local economies. Meit noted that per capita income is about $10,000 less in rural
areas than in urban areas; about 31 percent of food assistance recipients live in rural communities; and 48 of the 50 U.S. counties with the highest child poverty rates are rural.
Meit said that disparities worsen even more when taking into account the racial and ethnic
make-up of rural regions. Hispanics are the nation’s fastest growing rural population; the
American South is home to large rural black communities; and the Plains and southwestern
states are home to large American Indian communities. All such groups suffer from documented disparities in access and disease rates.
“A lot of the health disparities we see are an interplay between geography and race and ethnicity,” he said.
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But bringing effective public health interventions to rural residents is no easy task. For one,
data gathering is a serious challenge, Meit said. He noted that in 2001, CDC’s annual “Health,
United States” report focused on rural populations for the first and, so far, only time. And data
collection is so difficult in rural areas that health workers are still using the old CDC data when
creating grant proposals today. Also, many rural communities simply have no public health
infrastructure and strengthening what infrastructures do exist is a big challenge, both in terms
of financial resources as well as in recruiting and retaining workers.
“This is critical because we think that public health is everywhere and it’s not,” he said.
Complicating matters is the perception in many rural areas that public health is simply a waste
of taxes and a form of government intrusion, Meit said. So, how do we tip the scales, he asked
meeting attendees. We must build grassroots support for public health and develop messaging
that communicates the benefits of strong public health services in a way that resonates with
rural residents. Meit said that “public health does itself a disservice by not engaging rural communities because rural people and rural organizations are the best advocacy groups there are.”
“If we all want to have food and fuel and timber and a lot of the resources that are provided by
rural communities, we need to figure out how to care for rural residents,” he said.
From session 1003, Achieving Health Equity: Solutions from the Field, June 26
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The Value of Public Health
The question of public health’s value may seem like a no-brainer to the practitioners who get
to witness the discipline’s outcomes as they unfold on the ground. For decision-makers and the
public, however, the value may be less clear and often, it isn’t clear at all. In today’s fiscal environment, being able to effectively communicate the value of a robust public health system is an
essential component in moving forward to promote prevention and eliminate disparities.
Glen Mays, a professor in health services and systems research at the University of Kentucky,
has been doing such value-oriented data gathering, though he notes that research remains
scarce and imperfect.
“There’s not enough of this kind of research currently going on within our nation and our communities and there’s still lots of uncertainties,” he told meeting attendees. “But hopefully, this
kind of research can give you a taste of what’s possible and certainly what we need to be doing
more of to produce the evidence to make the case with the policy community and with the public
at-large.”
First, Mays remarked that the United States is falling further and further behind other comparable nations in terms of health indicators, despite spending the most on health care. He said
there’s a “real dysfunction and lack of logic” in how we deploy resources in relation to what is
known about the major drivers and determinants of health. For example, more than two-thirds
of health care spending goes toward chronic disease, much of which is preventable; yet less
than 3 percent of resources are directed toward public health activities that target chronic disease prevention.
“There are lots of targets for realizing value in public health spending that spill over into the
medical care system,” Mays said.
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Fortunately, the ACA recognizes this connection via the Prevention and Public Health Fund.
Still, the fund remains somewhat controversial, Mays said, because we don’t have a lot of sound
evidence on the return on investments in public health. Mays and his colleagues are gathering
that evidence, however, and here’s what they’ve found.
Communities with higher public health spending saw larger reductions in preventable mortality
measures, such as cancer, heart disease, diabetes and infant mortality. Also, communities at
the bottom levels of per capita public health spending have the highest levels of per capita medical spending. The findings illustrate the real health returns associated with growing investments in local public health as well as the chance to offset medical costs. Mays projected that
the additional federal spending authorized via the Prevention and Public Health Fund works out
to about a 1.2 percent increase in public health spending in communities over 10 years. Every
new dollar in federal public health spending will get back about 87 cents in Medicare spending
over a decade — “that’s a fairly sizeable economic impact suggesting that, yes, public health
spending can be useful in reigning in medical cost growth,” Mays told attendees.
Such federal spending can also avert nearly 180 preventable deaths in an average community,
resulting in about 1,800 life years gained. Public health, he said, “is a good buy.”
“We’re certainly just at the tip of the iceberg in terms of our current research technology for
estimating these benefits,” Mays said. “But we think this, in part, shows us what’s possible
not only with expanded investment in public health, but also what’s possible with expanded
research into helping us look at the benefits and return from investments in the public health
system.”
From session 3003, Public Health Funding: Why Should They Care?, June 28
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Refocus on Social Justice
Eliminating health inequities is a daunting task, even for the most well-funded health department.
Such is the case in Boston, where black residents experience disproportionately higher rates of
illness and death, despite near-universal access to health care services in Massachusetts.
“Black residents have worse health and the neighborhoods in which they live also have the
worst health outcomes,” said Barbara Ferrer, executive director of the Boston Public Health
Commission, the nation’s oldest health department.
To address the problem, the commission restructured its work to zero in on the social determinants that shape people’s health outcomes with a strong focus on racism, which Ferrer said has
an “impact on pretty much every other social determinant of health, including people’s access
to education and jobs, the healthy environments where they live.” In fact, eight years ago, Boston’s mayor convened a task force dedicated to ridding inequities in health outcomes. So, what
does that mean for a health department?
“We alone can’t fix much of anything,” Ferrer told meeting attendees. “It is our job to acknowledge that the reality is that it is those very conditions that’s going to affect people’s health
status and then align ourselves up as institutions to really put our work in places where we’re
going to make a difference in those social conditions.”
The health department developed a set of core strategies and guiding principles to support
activities designed to achieve equity through community, policy and systems change, with an
explicit commitment to racial justice. To build institutional capacity, Ferrer said every program
at the commission must now integrate the elimination of health inequities into their goals.
The health department also realigned its resources to achieve three overarching goals within
five years: reduce the gap in low birthweight rates, reduce obesity/overweight disparities, and
reduce the gap in chlamydia incidence. In addition, all employees must take training focused on
racial and social justice.
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“If we say we’re interested in promoting the health equity agenda, it only makes sense that we
actually do something to narrow the gap,” she told attendees.
Here’s an example of how Boston public health workers are doing things differently. The commission began working in five neighborhoods with the highest rates of violence, providing
funds so that community-based groups can hire community organizers and block captains. The
community workers engage residents, connect people to support services and work to make
improvements in the built environment. To facilitate the last point, leaders from various city
departments meet regularly with each group about fixing problems that residents have identified, such as broken-down buildings and littered playgrounds. The process results in immediate gains in the built environment, said Ferrer, who added that the effort is based on “engaging
residents who are there to come up with their own plans for building a culture of peace.”
Ferrer said one of the biggest vehicles for change has been policy, adding that “we can, in fact,
change the landscape.” For instance, in 1999, about 85 percent of dumpster storage lots, junkyards and transfer stations were located in communities of color. So in 2001, the local board of
health passed a regulation requiring all such facilities be inspected and permitted. Ten years
later, the number of such businesses has dropped dramatically and fewer than 40 percent
remain in neighborhoods of color.
“It’s not how can we promote healthy behavior; it’s how do we target dangerous conditions and
reorganize land-use policies and transportation policies,” Ferrer said. “It’s not how to reduce
disparities and the distribution of illness; it’s how to eliminate inequities in the distribution
of resources and power. It’s not what social programs and services are needed; it’s what kind
of social change is needed to really make lasting change. It’s not how can individuals protect
themselves against health disparities; it’s what kind of community organizing and alliance
building and partnerships do we need to create that would actually protect our communities.”
From session 1003, Achieving Health Equity: Solutions from the Field, June 26
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STEPS FOR ACTION:
• ENGAGE communities in
culturally competent ways
so that they will become
supporters of strong public
health systems.
• COLLECT the data
and stories that not only
illustrate the value of public
health in improving people’s
health, but its critical role
in curbing medical costs.
Americans value prevention,
but it’s up to us to show
people why public health is
worth the money.
• ZERO in on social justice
and the environmental
conditions that contribute to
poor health and premature
mortality. Recognize that
eliminating health inequities
takes looking beyond
traditional public health
services.
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STRATEGIES FOR HEALTH:
EMBRACING TECHNOLOGY,
MEDIA & ADVOCACY
“We are in a fight for our lives. Plain and
simple...And this is just the beginning. We
are facing the biggest threats we’ve seen in
decades.”
— Emily Holubowich, executive director,
Coalition for Health Funding
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Speak Up for Public Health
The ability to advocate effectively doesn’t come naturally; like many things in public health, first
you have to build the capacity.
Lora Wier, director of Montana’s Teton County Health Department, told meeting attendees
about the experience of the Montana Public Health Association in becoming a force for public
health. It began in 2004, when the governor appointed a new director to lead the state’s health
department. At the time, Weir was serving as president of the state association and received a
call asking for its position on the appointment. She said she didn’t really know what to say. But
then she thought: If anybody should have a position, it should be us. In response, the association contacted the governor’s office and met with staff (she said the association was concerned
the appointment wasn’t a good fit for the health department). It was the association’s first foray
into advocacy and policy.
From there, capacity continued to grow. The association assembled a committee dedicated to
advocacy and policy and got active during the 2007 state legislative session — we did what we
could with limited experience, Wier said. They also tried to engage association members and
along the way, learned a lot about their capabilities and barriers. Wier said members didn’t
know how to advocate and were insecure about trying. In turn, the Montana association began
offering advocacy education during all of their annual meetings.
Feeling good about its state-level work, the association moved to the federal level. And as they
got more active, they became more visible in Montana, attracting new partners and strengthening their role as a voice for public health and prevention. When it came time to take part in
APHA’s 2011 Public Health ACTion (PHACT) grassroots advocacy campaign, they were ready.
Along with their organizational partners, the Montana association sent out letters to the editor; had guest opinion columns published in four of the state’s seven major daily newspapers;
had four congressional district meetings; and organized a public health call-in day, asking its
members to call their national representatives and show their support for the ACA’s Prevention
and Public Health Fund.
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Offering advocacy education at every opportunity was the biggest lesson learned during the
campaign, Wier said. Provide potential advocates with prepared talking points, tips and information — make it easy for them, she suggested.
“Don’t assume someone else will act. We are the grassroots, we are the boots on the ground.
Make it easy to act — I can’t stress that enough,” Wier said. “If you don’t speak up for public
health, who’s going to speak up for public health?”
From session 3002, Successful Advocacy: The How, What and Where, June 28
Attendees at APHA’s 2012 Midyear Meeting
react to the news that the Affordable Care
Act is constitutional and will be upheld.
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Building Systems for Action
The impact of health information isn’t in its collection; it’s about how the information is put to
use. And putting it to use means sharing, collaborating on and creating systems that leverage
health resources and workers already on the ground.
That was the big message from Dan Jensen, associate director at Olmsted County, Minn., Public Health Services. Introduced as an “evangelist” for health information technology, Jensen reported that the agency is in the midst of working to become “informatics savvy.” In other words,
transforming data into effective practice. But to make electronic health records and information
systems “work for us,” information technology must be connected to patient outcomes — that’s
where we’ll drive change, Jensen told session attendees. But what was the “secret sauce” to
making that happen, he asked.
The answer was building communities of practice. Today, the public health agency works
with three such communities: one consisting of large medical providers, another of mid-sized
providers (which includes local public health) and the last of under-utilized organizations and
workers, such as nursing homes and school nurses. But coming together as general communities of practice wasn’t good enough, Jensen said; it’s critical to engage all stakeholders, including residents.
“We’re used to bringing people together and having these conversations,” he said. “Now, we
don’t have the dollars that primary care providers have...but public health does have a lot of
experience in bringing communities of practice together, working together to build systems.”
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Using this model — information + communities of practice = improved outcomes — is already
seeing success. One such area is in childhood asthma. Of the 84,000 schoolchildren in southeast Minnesota, 5,000 had high enough levels of asthma to warrant having an asthma action
plan on file with their schools. Unfortunately, at the time the public health agency took up the
issue, there were less than 400 paper-based action plans on file — “that’s pretty scary,” Jensen
said. It meant that school nurses didn’t always know how to protect students’ health or even
which students were living with asthma.
So working within a community of practice of schools, providers, public health and parents, the
effort first took aim at improving the flow of paperwork, which resulted in adding thousands
more asthma action plans to school files as of 2012. Jensen and colleagues are now working
to build an electronic school nurse portal called “Kids eHealth,” a health information exchange
that will initially focus on asthma but could be used for kids with seizures, allergies and diabetes too, Jensen said. In talking with 14 focus groups of diverse stakeholders, Jensen said they
learned that parents were comfortable in letting asthma action plans be included in the portal, as long as it was only public health staff and nurses who had access. With the new portal,
school nurses will be able to log in no matter what school they’re at, view the asthma action
plans relevant to that school and be prepared in case of an asthma attack.
“We can build better systems,” Jensen said.
From session 2003/2008, Technological Strategies to Advance Public Health, June 27
Lydia Ogden, director of health reform strategy
at CDC, speaks during the closing session.
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Brave New (Public Health) World
Public health 2.0: It’s the future and it’s time to get on board. That was the message from presenter Jay Bernhardt, a professor in the Department of Health Education and Behavior at the
University of Florida, who called on attendees to start — and continue — leveraging new social
and communications technology to improve people’s health.
First, Bernhardt provided a quick overview of today’s trends, which further illustrate that using new media isn’t so much a choice anymore; it’s becoming key to successful public health
efforts. As expected, Internet use in the United States is very high, with young people using it
most, but other age groups steadily climbing. And understanding what people do when they
venture online is important as well. Social networking, watching videos, playing games, searching for information — different age groups use the Internet for different reasons.
“The Internet is not a channel,” he told attendees. “It’s a diverse media platform that people do
all kinds of different activities on.”
However, Bernhardt cautioned that not all Internet access is created equal. To truly take advantage of the Internet today, people must have home broadband (high-speed Internet connection),
he said, noting that dial-up access doesn’t offer nearly as rich of an experience. This digital
divide means that public health campaigns that rely solely on the Internet will be missing those
residents who can’t afford such access. The alternative, however, is mobile and cellular technology, the fastest growing technology out there.
People use their cell phones for much more than phone calls; in fact, data shows that actual
phone calls are taking a back seat to text messaging. Bernhardt noted that households with cell
phones only — no landline — have gone up from 8 percent in 2005 to 27 percent in 2010. And
nearly half the cell phones sold in the United States are smartphones, which Bernhardt said
hold huge potential for public health.
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The nation is becoming home to more screens and smaller screens. If what you’re creating
doesn’t look good on a small screen, you might be wasting your time, Bernhardt said. (He noted
that he’d previously seen a presentation by Google’s chief technology officer who predicted that
in the coming years, 95 percent of all Internet searches will be via mobile devices.)
So, what does it all mean for public health? Bernhardt took to the 10 essential public health
services to show how new media and communication fit — and are already fitting — into each
category. For example, in monitoring disease and health status, public health workers can mine
social media sites, like Twitter, to see who and where people are reporting symptoms and talking about illness. In mobilizing partnerships, public health can help keep members active via
online activities. And in the world of health promotion and education...well, the possibilities are
nearly endless.
“Health promotion folks are all over the new media space,” Bernhardt said.
He ended his presentation with a powerful analogy to John Snow, the British doctor often referred to as the father of modern epidemiology and famous for tracking the source of an 1850s
cholera outbreak to a water pump. If he were alive today, Bernhardt said, he probably would
have detected the cholera epidemic via an uptick in bar code scanning data for toilet paper and
Kaopectate. He’d use the info to help pinpoint certain geographic hotspots and look for Twitterers complaining of gastrointestinal distress. He’d examine data coming out of health care
settings and check Foursquare to see who checked in at the suspicious water pump. And then
he’d send out his own tweets on Twitter (along with a specialized Twitter hashtag) telling his
followers to stop drinking the contaminated water.
From session 3001, Engaging Fans, Followers and Friends: Using Social Media for Improving Health,
June 28
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STEPS FOR ACTION:
• ADVOCATE for public
health and learn how to do
it effectively. Even if you’re a
public employee, there are
ways you can support public
health. As a constituent, you
can make a difference, but
you have to make your voice
heard.
• EMBRACE new health
information technologies and
use them to leverage public
health skills and systems to
expand the field’s reach.
• MAKE social media
your friend. Online and
mobile communications
and networking hold huge
potential for helping to
improve people’s health, and
public health can’t be on the
cutting edge without it.
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2012 MIDYEAR MEETING CLOSING SESSION: ‘WE HAVE SOME VERY HARD CHOICES AHEAD’
The Charlotte meeting’s closing session started out with a bang. And
hoots and hollers and tears of sheer joy. It was the same morning the
Supreme Court released its ruling upholding nearly every provision of
the Affordable Care Act. It was an absolutely joyous moment.
But by no means did it secure public health’s future — “we have some
very hard choices ahead,” said Lydia Ogden, the closing session’s first
speaker and director of the Centers for Disease Control and Prevention’s Health Reform Strategy, Policy and Coordination Office. There
are strong forces driving change in the health system and public health
needs to get prepared and adapt, Ogden said. For example, she said,
about 10,000 Americans celebrate their 65th birthday every day — and
that trend will continue for nearly the next two decades.
“This is a profound change,” Ogden said.
But perhaps an even bigger question comes down to spending and
today’s new fiscal environment. With the feds borrowing about a third of
every dollar it spends, Ogden said one of the most fundamental questions public health must ask itself is this: Is what we’re about to do
worth it?
“We owe it to the people we serve that what we’re doing is of the very
highest value,” she told attendees. “We don’t do ourselves any favors by
asserting that everything is worth doing.”
Speaker Joseph Thompson, Arkansas state surgeon general and director of the Arkansas Center for Health Improvement, called on public
health workers who organize and provide clinical health services to
start figuring out how to bill for them. He said it’s going to be incredibly
difficult to maintain revenue and funding supports for such services and
“we have to have a viable future.” Thompson said he doesn’t use the
term “public health” outside of public health circles, as the term often
comes with preconceived notions that may cause important audiences
to simply tune out. But that doesn’t mean people aren’t interested in
joining the prevention cause.
“We have new players who are thinking about denominator medicine,”
Thompson said. “We don’t need to argue about whether it’s public
health.”
Among those new players is the private sector. Session speaker Cara
McNulty, a senior group manager with Target tasked with improving
the health and well-being of hundreds of thousands of employees, said
even though Target isn’t in the business of health, it has a direct interest in keeping its workers healthy. And it needs public health’s help to
do it. She called on attendees to invite business leaders to the table and
educate them on the policy, systems and environmental changes that
keep people healthy.
“Health isn’t our primary business and we need your partnership,” McNulty said. “Help us understand what you’re trying to achieve because,
believe me, as employers, we want to improve health.”
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THE NEW PUBLIC HEALTH
Is public health facing difficult and uncertain times? Yes. Does that mean we can’t move forward to improve community health and eliminate health inequities? Definitely not. But it will
take a sincere dedication to adapting today’s public health practice to new constraints, resource
levels and an era in which quality, efficiency and results reign. This isn’t to say that devastating
public health budget cuts are justified or sensible, especially in a time when everyone is talking
about curbing health care spending and preventable chronic diseases continue on an upward
tick. These cuts most certainly threaten public health capacity as well as hard-fought gains in
community health.
But public health doesn’t easily back down from a challenge. Our history is packed with lifesaving success stories that were only possible thanks to public health’s keen ability to adapt
and see the bigger picture — to see the wider connections that create the opportunities for
some people, neighborhoods and communities to thrive against disease and poor health and
for others to not. This public health framework for better health is beginning to permeate even
deeper at the highest levels of government and health care systems. So even though today’s
funding levels might not always reflect it, the role for public health and the opportunities for
prevention and equity may actually be bigger than ever.
We hope this report chronicling insights from APHA’s 2012 Midyear Meeting will help you navigate today’s tricky new territories. Public health works — but it’s up to us to prove it.
To learn more about APHA meetings, visit www.apha.org/meetings.
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RESOURCES FOR AC TION
& INSPIRATION
AMERICAN PUBLIC HEALTH ASSOCIATION
CDC LEARNING CONNEC TION
APHA Public Health ACTion Campaign:
www.apha.org/advocacy/tips/PHACT+Campaign.htm
www.cdc.gov/learning
APHA public health advocacy tools: www.apha.org/advocacy/
CDC QUICK LEARN LESSONS
APHA Center for Public Health Policy: www.apha.org/
Center+for+Public+Health+Policy.htm
www.cdc.gov/training/quicklearns
APHA public health policy capacity tools: www.apha.org/programs/cba/
CBA/default
MILLION HEARTS CAMPAIGN
APHA health reform resources:
www.apha.org/advocacy/Health+Reform
millionhearts.hhs.gov/index.html
APHA Public Health Newswire:
www.publichealthnewswire.org
COMMUNITY TRANSFORMATION GRANTS
www.cdc.gov/communitytransformation
MARYLAND HEALTH DATA INNOVATION CONTEST
themarylandprize.maryland.spigit.com/Page/Home
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YMCA HEALTHIER COMMUNITIES INITIATIVE
PUBLIC HEALTH ACCREDITATION BOARD
www.ymca.net/healthier-communities
www.phaboard.org
PREVENTION INSTITUTE
www.preventioninstitute.org
PUBLIC HEALTH & SOCIAL MEDIA
www.cdc.gov/socialmedia
UNNATURAL CAUSES
(Resources for addressing health inequity)
NET WORK FOR PUBLIC HEALTH LAW
www.unnaturalcauses.org
www.networkforphl.org
PUBLIC HEALTH VALUE RESEARCH
CENTER FOR INNOVATION AND
TECHNOLOGY IN PUBLIC HEALTH
(An article from APHA’s American Journal of Public Health)
ajph.aphapublications.org/doi/full/10.2105/AJPH.2007.127134
COALITION FOR HEALTH FUNDING
publichealthfunding.org
citph.org
FRAMEWORKS INSTITUTE
(Changing the public dialogue about social problems)
www.frameworksinstitute.org
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