Leveraging health taxation for public health gains in China

The emerging field of public health ethics

Applied public mental health: bridging the gap between evidence and clinical practice.

Has traditional medicine had its day? The need to redefine academic medicine

Advancing the Science of Delivery

BOOK REVIEW article Front. Public Health, 19 December 2014Sec. Public Health Education and Promotion Volume 2 - 2014 | https://doi.org/10.3389/fpubh.2014.00250

Strategies to Operationalize Health Equity in Island Area Health Departments.

Public health laws have significant impact to improve public's health and essential to achieving the sustainable development goals. Human Rights legislation and advancing the Right to Health approaches are seen as key to tackling social determinants of health and widening health inequalities. Health law is not just the work of lawyers, legislators and enforcers. There is growing expectations and need for public health practitioners and leaders to understand local and international legal systems and obligations and their critical role in improving and protecting the public's health, and to work in strategic partnership to improve population health through law and policy. Yet such issues are often neglected in educational and training programmes in public health and their practical implications poorly understood and appreciated by practitioners. The purpose of this workshop is to highlight the nature and key role of law in improving public's health in practice, and to share the work by NHS Scotland and Wales in considering human rights and right to health approaches in their day to day to day activities and projects in public health. It will highlight practical issues and ideas in advancing the political goal of public health law reform and getting the right to health approaches into day to day practice and activities. This will include options to include educational and training activities for the public health workforce, including its practical inclusion in public health curriculum. It will share case study of the innovative and powerful “Wellbeing of Future Generations Act” in Wales and its implications for public's health and practice. The panel for the workshop will be senior expert experienced public health legal scholars, practitioners and policy makers who will briefly share their expert perspectives on the issue and the projects. One of the elements of the roundtable workshop will be to reflect and consult with the participants around their experience and insights in considering public law and right to health approaches in their practice and the needs, opportunities and barriers to engage more systematically in strategic partnerships and activities around better understanding and use of public health law to protect and improve public's health and the training and educational needs to advance the agenda. Key messages Strengthening public health laws and advancing right to health approaches are vital to improving public’s health and tackling health inequalities. There is need to build capacity and competency of public health leaders and practitioners around public health law and strategic partnerships to improve population health.

COVID-19 Highlights Critical Need for Public Health Data Modernization to Remain a Priority.

Health Official Roles Attending the now virtual meetings of the Association of State and Territorial Health Officials (ASTHO) alumni society facilitates seeing old friends and meeting new members. However, attendance at the alumni society also signifies that someone is a former state or territorial health official (STHO). Often, membership in the ASTHO alumni society has occurred as a planned resignation (eg, retirement, new job offer), but recent experiences suggest a trend of health officials at the state, territorial, and local levels stepping down or being involuntarily removed.1–4 In the current political climate where science in general and public health science in particular has become politicized, the recommendations and decisions of state and local health officials are being scrutinized in the context of public opinion. Most people would agree that public opinion should not influence the interpretation of scientific evidence. However, because public opinion often influences politicians and because health officials commonly serve communities at the pleasure of an elected official, public opinion and politics can unduly influence scientific recommendations. The current COVID-19 pandemic has highlighted numerous instances where this has occurred.5–8 Public health response activities (eg, contact tracing), as well as recommendations regarding stay-at-home orders, social distancing, wearing masks, and other protective health measures, have all been influenced or scrutinized by public opinion and politics.9–12 Public health leaders are not exempt from these critiques. At the August 2020 meeting of the ASTHO alumni society, 5 new members joined the Zoom meeting of dozens of other former STHOs. While recent research shows that on average STHOs have relatively brief tenures (2.5 years) leading state public health agencies,13,14 many involved in leadership and related research have held the assumption that at least local health officials experience more stability and are thereby able to provide more consistent leadership. Alas, in the current age of a politicized COVID-19 response, it seems that no health officials are assured job security. In fact, according to data collected through personal communications and media reports, since March 2020 when the nation declared a state of emergency due to the COVID-19 pandemic, more than 55 state, territorial, and local health officials have become alumni and members of the group of former health officials. Some of this turnover is the result of planned retirements, but the decisions to step down, move on, or retire during the pandemic may be tied to the intense public scrutiny and literal death threats health officials have been receiving while accruing 70-80 plus weekly hours of nonstop public health response work.1–4 Mello et al15 detailed these attacks in their recent commentary, drawing attention to the need to protect public health leaders from violence and harassment. Similarly, this commentary intends to shine a bright light on the intense controversy and conflict public health officials experience in making policy recommendations to elected leaders and the public in the middle of the COVID-19 pandemic. Turnover During the COVID-19 Pandemic One of the first triggers that alerted the National Association of County and City Health Officials (NACCHO) that turnover was going to be problematic was when 3 board members turned over within 1 month early in the pandemic. At that point, NACCHO started tracking turnover more closely. ASTHO was doing the same. Since the start of the pandemic, 18 of the collective 59 STHOs have left office, with at least 33% of this turnover attributable to conflicts with elected officials and/or threats of physical harm/harassment from the public (e-mail with Michael Fraser, PhD, CEO of ASTHO, dated Aug. 9, 2020). Similarly, at the local level, of the 37 county/city health officials who have left office during the pandemic, 30% did so because of COVID-19 response conflicts with local politicians or public threats (e-mail with Lori Freeman, MBA, CEO of NACCHO, dated Aug. 24, 2020). This means that many public health agencies responsible for protecting the public's health are experiencing disruptions in leadership during the most challenging public health event of our lifetime. Leadership turnover is organizationally disruptive to a public health agency during routine operations, but when it occurs during a pandemic it can be especially difficult for the agency's response efforts. Given the many issues leadership turnover creates, it seems prudent that we support health officials staying in their roles as long as possible. Turnover of senior management roles within organizations, especially at the CEO level, is known to have a significantly negative impact on the organization's productivity and effectiveness, and transitions have to be well managed and communicated lest the agency performance deteriorate or stall. In a recent study, where former STHOs were asked to reflect on what would have helped them be more successful in their leadership roles, they reported needing a better understanding of the political process and how to relate to the governor's office before taking the job.16 Former STHOs also highlighted a need to better understand state government overall. The collective skill set of political astuteness appears to be critical for public health leader success, not just in retaining their jobs but also in tackling public health problems from a systems perspective and challenging policy failures and developing new policy approaches as a result.17 Findings from a qualitative study that assessed the perceptions of senior public health agency deputies (eg, those directly reporting to STHOs) suggested that being able to manage and meet gubernatorial expectations was a key characteristic of STHO success.18 However, many in health officer roles have no prior experience in politics and often come from clinical practice, academia, corporate settings, and organizations whose decision making is not determined by legislatures or chief elected officials. Making Improvements to Health Official Positions In an examination of the training and experiences of current and former STHOs, findings indicate that the majority (64.6%) are medical doctors. Approximately half of STHOs have public health degrees (48.3%), but only 21.8% have formal academic training in management or administration.19 While understanding public health issues is important, it is now increasingly clear that health officials require a skill set in operational management, strategic thinking, and change management. These are topics not traditionally covered in medical school, nor always consistent with health officials' expectations before taking the job.20 In fact, common reasons why STHOs reported they were involuntarily removed from their positions include difficulties in managing a situation or because they failed to understand or adequately manage the expectations of elected leadership. With turnover so common and the job so difficult, one has to wonder: who wants to be a health official? Fortunately, for the public's health, there are still individuals who seek the opportunity to serve their community and improve the health and well-being of the public. Given the recent turnover among health officials and experience of leading in a global pandemic, we suggest that now is the time to reach consensus on what success as a health official looks like. Having clear priorities and expectations can also facilitate the development of job descriptions that explicitly clarify what "good" means and how governors or mayors define "success" for their health official appointee.21 Perspectives of success may vary, but the skills necessary include being able to navigate conflict, managing partnerships, communicating effectively in crisis, and having political acumen. Could it be time to establish contracts, including assured term lengths and even severance arrangements for health officers, similar to those that exist for other public sector leaders such as school superintendents, university presidents, and other federal executive roles such as the surgeon general or the FBI (Federal Bureau of Investigation) director? Given the importance of this role, and the expertise needed, it seems unfair to require health officials to put their career and safety at risk every time they have to make tough decisions as part of their job without some protections for doing so. Leading the Way Out of the Pandemic The pandemic has caused a uniquely stressful and sobering time for our nation. In addition to division and unrest stemming from the pandemic, we have unprecedented attention on racism and an urgent need to recognize structural racism as a public health issue.22–26 We are also planning for unprecedented vaccine administration challenges, concurrently during continuing efforts to mitigate COVID-19, and addressing other public health challenges such as drug addiction and suicide that have amplified during the pandemic. State and local health department staff are working nonstop assignments without a light at the end of the tunnel. As many on the front lines of health care and public health response can attest, it is hard to sprint a marathon. To combat the fatigue and to ensure that the essential public health services can be seamlessly provided, agencies should consider crisis management strategies that manage COVID-19 operations separately but in consort with day-to-day agency activities by designating and authorizing a senior deputy to handle routine operations and give top leaders some breathing space. Such alternative "B-team" strategies, although not frequently seen in public health, are an example of an adaptive complex organizational strategy. Leaders can also benefit from leaning on each other and seeking help and advice from people who have done similar work before them, such as STHO alumni. Leadership, especially during a pandemic, can be lonely and difficult work, and no one leader has all of the answers. We need to work together and share ideas and resources and look to our national associations such as ASTHO, NACCHO, and the Big Cities Health Coalition for collective strength. Finally, there is no better time than now to unite the polarities of science and politics. We cannot easily end this pandemic if we do not follow science and allow scientific principles to guide and inform the path forward, while acknowledging the inevitable political pressures of the job. While politics and science often conflict, effective leadership should be supported and sustained in the best interests of health officials and, even more importantly, the communities they serve.

A call to action for public health nurses during the COVID-19 pandemic.

Back to table of contents Previous article Next article Health Care EconomicsFull AccessPublic Health Shifts Focus To Preventing Chronic IllnessMark MoranMark MoranSearch for more papers by this authorPublished Online:1 Dec 2006https://doi.org/10.1176/pn.41.23.0015American public health, long focused on control of infectious disease, is undergoing a fundamental change in outlook as it turns its attention to chronic disease, including mental illness.So said psychiatrist Neil Cohen, M.D., New York City's former commissioner of health, during a lecture on public health challenges in psychiatry at the APA institute on Psychiatric Services in New York in October.Cohen said the success of American public health measures over the last 100 years in controlling infectious disease, combined with the increase in prevalence of chronic conditions, is forcing a change in the priorities of public health departments across the country. And with this change has come a recognition of the pervasiveness of mental illness.Meanwhile, psychiatric epidemiology research has advanced to the point that risk factors can be identified. “Psychiatric epidemiology is not just about counting anymore,” Cohen said. “We are at the dawn of an era when we can now look at risk-factor epidemiology, examining the causes that contribute to—and the protective factors that decrease risks for—mental illness in communities.“The knowledge to be gained from modern-day psychiatric epidemiology is as much about psychopathology and understanding the roots of mental illness as it is about epidemiology,” he said. “The advances that derive from this approach allow us to look at subthreshold syndromes, at the number of factors at play that put an individual at risk for advancing pathology.”Cohen was the city's health commissioner from 1998 to 2002. In that post, he oversaw the public health responses to several crises: the outbreak of West Nile virus, the attacks on the World Trade Center, and anthrax-laced letters sent to media outlets in the city. He also served as commissioner of the New York Department of Mental Health, Mental Retardation, and Alcoholism Services, and he oversaw the merger of the health and mental health departments into a unified public health agency. He is currently clinical director and vice chair of the department of Psychiatry at mt. Sinai Medical Center and director of its Division of Community Medicine.Infectious-Disease Focus Has a PriceCohen noted that the significant extension of life expectancy for Americans during the 20th century was due not so much to medical advances as to the success of core public health activities such as improvements in nutrition and hygiene and the monitoring and control of infectious diseases.“But the preoccupation with infectious disease came with a cost,” Cohen said. “it slowed the development of measures to deal with stroke, heart disease, and diabetes. And it limited the amount of attention that was paid to curtailing high-risk behaviors that contribute to prevalence of chronic conditions.”The focus began to shift in the early 1990s, with the emergence of several lines of research demonstrating the profound effect of behavior on human health.“Despite the need for public health interventions to address behavior, only 5 percent of each health care dollar is devoted to behavior modification,” Cohen stated.Related to this have been the historic neglect of mental health and illness and the segregation of public mental health activities from the rest of public health and medicine. These too have begun to change in the wake of studies in the early 1990s by the World Bank and Harvard School of Public Health showing the enormous burden of disease related to mental illness.That research found that major depression trailed behind only ischemic heart disease in terms of lost years of productivity due to death or disability and that depressive disorders, taken together, are the leading cause of disability worldwide.Satcher Reports Changed ThinkingEven more powerful were the reports on mental health and illness by former Surgeon General David Satcher, M.D. Along with President Bush's New Freedom Commission on Mental Health and the enormous strides made in biomedical research on mental illness, the result has been a slow but certain realignment of priorities.Cohen said the threat of terrorism and bioterrorism has also galvanized the integration of mental health and public health. Drawing on his experience helping to coordinate the response to the terrorist attacks on September 11, 2001, Cohen said there has been an effort to “bring mental health issues to bear on the larger public health response” to the threat of terrorism and bioterrorism.And those threats have raised the profile of public health departments.“ In this post-9/11 world, the decades-long neglect of the public health system has been changing,” Cohen said. “Increasingly, the public and government are aware that a robust public health infrastructure is critical to the capacity to respond to a whole host of emerging threats.”Cohen believes that a principal public health challenge facing psychiatry today is to draw on the new power of psychiatric epidemiology to develop models that focus on maintenance of positive mental health and prevention of mental illness rather than merely the treatment of disease when it appears. And he cited satcher in pointing out that “successful performance really rests on a foundation of successful mental health.”Neil Cohen, M.D.: “Increasingly, the public and government are aware that a robust public health infrastructure is critical to the capacity to respond to a whole host of emerging threats.” Ellen Dallager“What I've been talking about is an alignment with the larger public health system and a greater focus on community well-being than has heretofore been our focus,” Cohen said. “The relationship between physical and mental disorders is profoundly influential with respect to morbidity and mortality and could very well be the core of a new model of public mental health...[that will] really take up the challenge of improving quality of life not only for individuals but entire communities.” ▪ ISSUES NewArchived

Solidarity is a concept increasingly employed in bioethics whose application merits further clarity and explanation. Given how vital cooperation and community-level care are to mitigating communicable disease transmission, we use lessons from the COVID-19 pandemic to reveal how solidarity is a useful descriptive and analytical tool for public health scholars, practitioners, and policymakers. Drawing upon an influential framework of solidarity that highlights how solidarity arises from the ground up, we reveal how structural forces can impact the cultivation of solidarity from the top down, particularly through ensuring robust access to important social determinants of health. Public health institutions can support solidarity movements among individuals and communities by adopting a lens of social justice when considering public health priorities and, in turn, promote health equity.

Expanding Conflicts of Interest in Public Health Research

Focus on Transformation: A Public Health Model of Mental Health for the 21st Century

The Campaign for Mental Health Reform: a new advocacy partnership.