State-level Public Health Research Articles

The Weight of Numbers: Counting Border Crossing Deaths and Policy Intent

Executive Summary This article explores how undocumented border crosser (UBC) deaths are counted as well as mis- and under-counted across the US southwest, and proposes a suite of policy remediations to standardize this process. An accurate count of UBC recovered remains is vital to understanding the scope of fatalities associated with border crossing, providing evidence accounting for the reciprocal relationship between US border enforcement and the incidence of migration-related death. To meaningfully intervene, it is insufficient to advocate only for more robust individual death investigations, though this is pivotal to forensically identify UBC decedents and unite them with their loved ones. Though identification and reunification of UBCs are the elements of forensic care most commonly attributed as humanitarian, the relationship between forensic investigation and international humanitarian principles is equally about accumulating primary evidence for policy intervention and justice claims on behalf of those who wrongfully die. Even if existing counting mechanisms do not provide the means for establishing this attribution between border-crossing deaths and border enforcement policy, this article lays out an argument for why they must do so and it makes recommendations for how this can take place. Necessarily, this article begins with a critique of existing mechanisms for counting UBC deaths, from the federal observation of such deaths by Customs and Border Protection, to the bureaucratic mechanisms for the collection of vital statistics authored at the local level. It then suggests means for improving accurate counting using the US Standard Certificate of Death. It particularly explores two aspects of the certificate, Manner of Death reporting and a section that asks death filers to describe how the death occurred, sections 37 and 43 respectively. Finally, it explores historical precedent for altering the standard death form at local and then national levels, positing that select amendments to the existing death certificate would be useful for standardizing how medicolegal death filers across the border and beyond can more accurately enumerate and characterize UBC deaths. Policy recommendations include the following, in order of immediacy: ● Jurisdictions across the US southwest must adopt standardized criteria for counting fatalities believed to be associated with undocumented border crossing. ● Despite some local formalization of UBC counting, current means of representing UBC status in vital records remains ad hoc across the US southwest and existing mechanisms for counting elude wider scale national recognition in vital statistics. The most straightforward and reliable method of standardization to ensure systematic representation of UBC deaths across the borderlands would be a UBC checkbox on the death certificate. This would require cooperation with state-level public health departments and legislatures. Precedent exists for changing the death form at the state level, facilitating, in some cases, for eventual inclusion of new components of the death certificate to be adopted on the US Standard Certificate of Death. This is recommended as a longer-term goal. ● Finally, there must be a means to characterize the deadly relationship between UBC fatalities and US border enforcement policy and practice in vital records where UBC Manners of Death are most often characterized as “Natural” or “Accidental.” Both are inaccurate. Unilaterally ensuring an accurate count leaves room for a trend already well underway in which agencies associated with border enforcement have cast UBC deaths as simply due to unfortunate heat-related accidents, resulting in legislation aimed to mitigate deaths that fails to address the role of border policy in causing deaths. This paper recommends that a new Manner of Death category could be useful beyond the border to represent non-capital crimes enforced by leveraging bodily harm.

Evolving Disparities in Cannabis Use Among Youth by Demographics and Tobacco and Alcohol Use in the U.S.: 2013–2021

IntroductionThe current study investigated the prevalence of past 30-day cannabis use among US youth by cigarette use, alcohol use, demographics and state-of-residence cannabis legal status in 2021, and examined whether changes in prevalence were modified by these factors from 2013 to 2021. MethodsData were drawn from the 24 states that collected cannabis use data participating in the Youth Risk Behavior Surveillance System (YRBSS) from 2013-2021. Logistic regression analyses estimated past 30-day cannabis prevalence in 2021 and produced adjusted odds ratios (AOR) by current cigarette, alcohol, state-of-residence cannabis legal status. The same method was used with year as the exposure, adjusting for sex, race and ethnicity, to assess trends in prevalence from 2013 to 2021. ResultsIn 2021, cannabis use was more common among female (16.75% vs. 13.83%, AOR=1.26 (95% CI: 1.16, 1.37)), Non-Hispanic (NH) Black and Hispanic youth relative to NH White youth (17.19%, 16.14% vs. 14.60%; AOR=1.25 (95% CI: 1.12, 1.39); AOR=1.16 (95% CI: 1.04, 1.29)), respectively. Cannabis use was much more common among youth who reported any past 30-day cigarette or alcohol use (44.90% vs. 6.48%, AOR=11.80 (95% CI: 10.57, 13.18)). Declines in cannabis use were observed independent of state-level cannabis law from 2013 to 2021 and cannabis use prevalence did not differ significantly by state-of-residence cannabis legal status among the 24 participating states in 2021. ConclusionsPublic health officials should carefully consider the potential differential impact of expanding commercialization of cannabis and US state government endorsement of cannabis as a “wellness” product on youth, especially with regard to co-use with tobacco and alcohol. National and state-level public health education on cannabis use and youth-oriented prevention of cannabis uptake are long overdue.

State-level public health preparedness indices as predictors of COVID-19 mortality outcomes: results from the United States of America in 2020.

This study evaluates associations between state-level preparedness indices and reported COVID-19-related mortality outcomes in all 50 states and the District of Columbia in the United States of America during three distinct time periods throughout the first year of the COVID-19 pandemic. State-level preparedness data for the year 2019 were gathered from the National Health Security Preparedness and Trust for America's Health Indices, and COVID-19-related mortality data for March-December 2020 (i.e., excess mortality and reported COVID-19 mortality rates) were collected in May 2022. Linear regression analyses were conducted to examine associations during three distinct time periods. Statistically significant positive associations were observed between both indices and reported COVID-19 mortality rates during the first time period. A statistically significant negative association was observed between one preparedness index and excess mortality during the second time period. No other significant associations existed for the outcomes or time periods considered in this analysis. These results demonstrate that state-level preparedness indices were not well attuned to COVID-19-related mortality outcomes during the first year of the pandemic. This suggests that current measures of state-level preparedness may be underinclusive and require a reconceptualization to improve their utility for public health practice.

Achieving a Healthy Oklahoma: Cross-Sector Cooperation to Improve Public Health Preparedness and Pandemic Response.

In response to the COVID-19 pandemic, the University of Oklahoma Hudson College of Public Health launched the Achieving a Healthy Oklahoma (AHO) initiative in 2021. The goals of AHO were to assess lessons learned in Oklahoma from COVID-19 and set the foundation for enhanced public-private community collaboration by developing recommendations to prepare for future public health crises and promote health across all major economic sectors. Over 700 stakeholders were engaged in surveys, interviews, workgroup meetings, community listening sessions, and steering committee meetings over 8 months to accomplish these goals. Stakeholders produced 60 sector- and stakeholder-specific policy recommendations to address the major issues uncovered during the initiative. The AHO team then distilled them into 5 recommendations: (1) invest in the future of Oklahoma's health workforce to include critically needed public health professions in Oklahoma's healthcare loan repayment programs; (2) establish contracts between higher education institutions in Oklahoma and state and local health departments to monitor health sector workforce needs and provide training; (3) strengthen the delivery of coordinated public health services within local communities during emergencies and daily operations by dedicating health department roles to coordinate public health projects and services; (4) improve preparedness by coordinating annual emergency management exercises across local and state health departments; and (5) emphasize the efficiency and effectiveness of cross-sector collaborative efforts between public, private, and tribal partners. The AHO initiative serves as an action guide for assessing and improving state-level public health emergency responses and strengthening public health infrastructure. Implementing the recommendations in Oklahoma and assessing and addressing similar needs across the nation are necessary to prepare the United States for future public health emergencies.

An Assessment of State-Level Planning for Physical Activity Promotion in the United States.

The prevalence and attributable risk of disease due to physical inactivity require it to be made a public health priority. Public health planning allows for prioritization and resource allocation, particularly at the state and local levels. The extent to which state planning efforts for physical activity exist in the United States is unknown. The purpose of this paper is to describe the scope in which physical activity is incorporated in state-level public health plans in the United States, with an emphasis on alignment with the national guidelines and the National Physical Activity Plan. A standardized internet search audit was developed and conducted for each of 50 US states and the District of Columbia between May 2017 and January 2018 to determine the prevalence and characteristics of health planning documents that include physical activity. Data abstracted for analysis used a standardized search protocol that included the components of the Physical Activity Guidelines for Americans and the US National Physical Activity Plan. Results found that most states had between 4 and 6 chronic disease prevention and control plans that mention physical activity; however, it was inconsistently aligned with recommendations from both the Guidelines and the National Plan. Only 2 states had stand-alone public health planning documents explicitly dedicated to physical activity promotion. No state planning documents addressed children and adolescents, adults, and older adults simultaneously. To be maximally effective, state public health planning for physical activity should be made a priority and these efforts should align as much as possible with current guidance from the Physical Activity Guidelines for Americans and the US National Physical Activity Plan.

State Public Health Communications and Public Compliance during the Pre-election SARS-CoV-2 Pandemic: Interpreting the Effectiveness of Messaging Guidelines Utilizing Moral Foundations Theory

Background: State-level public health messaging during the pre-election coronavirus pandemic was very inconsistent. Moral motivational content of the messages, as characterized by moral foundations theory, may have contributed to the degree of compliance in particular states. More attention to this content might result in greater compliance and a lessening of the pandemic's severity. Methods: A comprehensive review of official state messaging in six U.S. states (California, Florida, Massachusetts, Mississippi, New York, and Texas) was reviewed for the number and distribution of moral foundations as described by moral foundations theory. A search was done for state-level data concerning compliance with mask-wearing and social distancing, the primary public precautionary measures during the pandemic. Rates of compliance by the state were compared with messaging content and analyzed for associations and correlations with the known partisan leanings of the states. Examples of messages with balanced moral foundations, which might be prospectively employed for greater acceptance, were presented. All data were gathered prior to the introduction of the first available vaccine. Results: Message review and compliance data suggested that the quantity and proportion of coronavirus-related official messages and the utilization of a balanced combination of moral foundations were associated with higher levels of compliance with the recommended public health measures and lower infection rates. The political orientations of states did not align with the use of known conservative/liberal preferred moral foundations as previously established by Moral Foundations Theory. Conclusion: Adjusting messaging with attention to the balanced employment of moral foundations can lead to wider acceptance of and compliance with preventive public health measures.

Access to information research in the digital era

Access to information research in the digital era

The polarization of politics and public opinion and their effects on racial inequality in COVID mortality.

Evidence from the early months of the COVID-19 pandemic in the U.S. indicated that the virus had vastly different effects across races, with black Americans faring worse on dimensions including illness, hospitalization and death. New data suggests that our understanding of the pandemic’s racial inequities must be revised given the closing of the gap between black and white COVID-related mortality. Initial explanations for inequality in COVID-related outcomes concentrated on static factors—e.g., geography, urbanicity, segregation or age-structures—that are insufficient on their own to explain observed time-varying patterns in inequality. Drawing from a literature suggesting the relevance of political factors in explaining pandemic outcomes, we highlight the importance of political polarization—the partisan divide in pandemic-related policies and beliefs—that varies over time and across geographic units. Specifically, we investigate the role of polarization through two political factors, public opinion and state-level public health policies, using fine-grained data on disparities in public concern over COVID and in state containment/health policies to understand the changing pattern of inequality in mortality. We show that (1) apparent decreases in inequality are driven by increasing total deaths—mostly among white Americans—rather than decreasing mortality among black Americans (2) containment policies are associated with decreasing inequality, likely resulting from lower relative mortality among Blacks (3) as the partisan disparity in Americans who were “unconcerned” about COVID increased, racial inequality in COVID mortality decreased, generating the appearance of greater equality consistent with a “race to the bottom’’ explanation as overall deaths increased and substantively swamping the effects of containment policies.

Achieving Reductions in Opioid Dispensing: A Qualitative Comparative Analysis of State-Level Efforts to Improve Prescribing.

To determine whether any combinations of state-level public health activities were necessary or sufficient to reduce prescription opioid dispensing. We examined 2016-2019 annual progress reports, 2014-2019 national opioid dispensing data (IQVIA), and interview data from states to categorize activities. We used crisp-set Qualitative Comparative Analysis to determine which program activities, individually or in combination, were necessary or sufficient for a better than average decrease in morphine milligram equivalent (MME) per capita. Twenty-nine US state health departments. State health departments implementing the Centers for Disease Control and Prevention's Prevention for States (PfS) program. Combinations of prevention activities related to changes in the rate of prescription opioid MME per capita dispensing from 2014 to 2019. Three combinations were sufficient for greater than average state-level reductions in MME per capita: (1) expanding and improving proactive reporting in combination with enhancing the uptake of evidence-based opioid prescribing guidelines and not moving toward a real-time Prescription Drug Monitoring Program; (2) implementing or improving prescribing interventions for insurers, health systems, or pharmacy benefit managers in combination with enhancing the uptake of evidence-based opioid prescribing guidelines; and (3) not implementing or improving prescribing interventions for insurers, health systems, or pharmacy benefit managers in combination with not enhancing the uptake of evidence-based opioid prescribing guidelines. Interview data suggested that the 3 combinations indicate how state contexts and history with addressing opioid overdose shaped programming and the ability to reduce MME per capita. States successful in reducing opioid dispensing selected activities that built upon existing policies and interventions, which may indicate thoughtful use of resources. To maximize impact in addressing the opioid overdose epidemic, states and agencies may benefit from building on existing policies and interventions.

Health Status and Access to Healthcare for Uninsured Migrants in Germany: A Qualitative Study on the Involvement of Public Authorities in Nine Cities

Non-governmental organisations (NGOs) regularly report data on their work with uninsured migrants (UM) within a (so-called) parallel health care system. The role and involvement of public authorities therein have yet been underrepresented in research. Our aim was to gain a better understanding of public authorities’ role in the parallel health care system and their view of the health situation of UM. We conducted qualitative semi-structured interviews with 12 experts recruited by purposive sampling from local public health authorities (LPHAs), state-level public health authorities (SPHAs), and social services offices (SSO) in nine cities, recorded, transcribed, and subjected the data to qualitative content analysis. LPHAs are more often directly involved in providing medical services, while SSOs and SPHAs function as gatekeepers for access to social benefits, including health insurance, and in grant-funded projects. NGOs keep substituting for the lack of access to regular health care from public institutions, but even in settings with extended services, public authorities and NGOs have not been able to provide sufficient care through the parallel health care system: Experts report gaps in the provision of health care with respect to the depth and height of coverage, due to the fragmentation of services and (ostensible) resource scarcity. Our study highlights the necessity for universal access to regular health care to overcome the fragmentation of services and improve access to needed health care for UM in Germany.

Crafting Successful State-Level Public Health Interventions to Vaccinate Homeless Populations During COVID-19.

Crafting Successful State-Level Public Health Interventions to Vaccinate Homeless Populations During COVID-19.

Will the economic growth benefit public health? Health vulnerability, urbanization and COVID-19 in the USA.

Economic growth has a significant impact on health vulnerability primarily through the process of urbanization. This paper conducts a pioneer study by analyzing the impact of regional economic growth and urbanization on the public health vulnerability in the 51 states and territories of the USA from 2011 to 2018 with a fixed-effect panel data regression model. We construct an epidemiological vulnerability index (EVI) using regional smoking, diabetes, obesity, and hypertension, collect CDC social vulnerability index (SVI) as state-level public health vulnerability status, and use COVID-19 to test the actual effect of health vulnerability. The preliminary results show that higher regional economic growth is related to lower EVI and SVI, while urbanization is positively associated with regional health vulnerability and the severity of COVID-19 from case rate and death rate. Robustness check with unemployment shows the same result. We conclude that economic growth is related to lower public health vulnerability, and urbanization has negative public health benefits. Our finding indicates an urgent need to balance the externalities generated by economic development and urbanization trends on public health vulnerability by promoting reasonable medical resource distribution, health practices and safety, improving social and environmental justice, and other health management measures.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00168-021-01103-9.

Past local government health spending was not correlated with COVID-19 control in US counties

ContextWide variation in state and county health spending prior to 2020 enables tests of whether historically better state and locally funded counties achieved faster control over COVID-19 in the first 6 months of the pandemic in the Unites States prior to federal supplemental funding. ObjectiveWe used time-to-event and generalized linear models to examine the association between pre-pandemic state-level public health spending, county-level non-hospital health spending, and effective COVID-19 control at the county level. We include 2,775 counties that reported 10 or more COVID-19 cases between January 22, 2020, and July 19, 2020, in the analysis. Main outcome measureControl of COVID-19 was defined by: (i) elapsed time in days between the 10th case and the day of peak incidence of a county's local epidemic, among counties that bent their case curves, and (ii) doubling time of case counts within the first 30 days of a county's local epidemic for all counties that reported 10 or more cases. ResultsOnly 26% of eligible counties had bent their case curve in the first 6 months of the pandemic. Government health spending at the county level was not associated with better COVID-19 control in terms of either a shorter time to peak in survival analyses, or doubling time in generalized linear models. State-level public spending on hazard preparation and response was associated with a shorter time to peak among counties that were able to bend their case incidence curves. ConclusionsIncreasing resource availability for public health in local jurisdictions without thoughtful attention to bolstering the foundational capabilities inside health departments is unlikely to be sufficient to prepare the country for future outbreaks or other public health emergencies.

Public health spending, primary care, and perceived risk promoted vaccination against H1N1

The purpose of this study is to examine factors affecting the intent to vaccinate during the 2009 H1N1 pandemic and to leverage the results to inform public health policy decisions aimed at increasing vaccine uptake during the COVID-19 pandemic. Using the National 2009 H1N1 Flu Survey data and state-level administrative data, we employ logistic regression and mediation models to estimate the association between vaccine uptake and state level public health spending, political ideology, and H1N1 case and death rates as well as a set of individual and household characteristics. We find that higher public health spending can significantly increase the intent to vaccinate, mainly through raising concerns about the pandemic and promoting vaccine relevant doctor patient interactions. We conclude that physicians, especially primary care physicians, should play more important roles in the ongoing vaccination efforts against the COVID-19 virus.

U.S. long‐term services and supports, Covid‐19, & dementia: Impacts and opportunities for policy change

BackgroundThe COVID‐19 pandemic brings the many historical challenges of the long‐term services and supports (LTSS) system in the United States (U.S.) into clear focus. Inequalities across race, ethnicity, and socioeconomic status (SES) as well as an increased burden on family care partners have been amplified by the pandemic. In spite of multiple reform attempts and an increasing population of older adults living with multiple, chronic health conditions including Alzheimer’s disease and other forms of dementia (ADRD), who will need some form of long‐term care during their lifetime policy reform has remained elusive. Primary blame for the high rates of COVID‐19 infections and deaths have largely been assigned to formal LTSS care settings. Yet, more systemic problems have become clear during the pandemic: the failure of coordination of the U.S. public health system at the federal level and the effects of long‐term disinvestment and neglect of state and local level public health programs. Taken together, these failures contributed to an inability to coordinate with the LTSS system and act early to protect residents and staff in the LTSS care settings.MethodWe analyze several impacts of the COVID‐19 pandemic on the U.S. LTSS system and existing policy arrangements.ResultPolicies U.S. policymakers can implement include uniform public reporting of COVID‐19 cases in licensed LTSS settings, identifying and supporting unpaid care partners, increased support for the direct care workforce, increased coordination between public health departments and LTSS agencies and providers, enhancing collaboration and communication across health, LTSS, and public health systems, further reducing barriers to telehealth in LTSS, and providing incentives to care for our most vulnerable populations. The analysis also demonstrates that comprehensive reform is required in order to build the LTSS system that is needed through comprehensive workforce development, universal coverage through comprehensive financing reform, and the creation of an age‐friendly public health system.ConclusionThe COVID‐19 pandemic has exposed the deficits of the U.S. LTSS system and made clear the interdependence of LTSS with public health. Several policy responses to the pandemic would help provide the LTSS system that is needed to care for people living with dementia.

Epidemic Location Intelligence System as Response to the COVID-19 Outbreak in Bosnia and Herzegovina

The outbreak of COVID-19 is a public health emergency that caused disastrous results in many countries. The global aim is to stop transmission and prevent the spread of the disease. To achieve it, every country needs to scale up emergency response mechanisms, educate and actively communicate with the public, intensify infected case finding, contact tracing, monitoring, quarantine of contacts, and isolation of cases. Responding to an emergency requires efficient collaboration and a multi-skilled approach (medical, information, statistical, political, social, and other expertise), which makes it hard to define one interface for all. As actors from different perspectives and domain backgrounds need to address diverse functions, the possibility to exchange available information quickly would be desirable. In Bosnia and Herzegovina, a joint state-level public health institution has not been established, but is covered by entity competencies. In this sense, a geoportal has been developed as an epidemiological location-intelligence system (ELIS) that supports the exchange of such information between the entities and the cantons. For its development, open source software components in the cloud were used as a working platform with all the necessary functionalities. The geoportal provides an entry point for access to geospatial, epidemiological, environmental and statistical data used for analysis, geocoding of confirmed COVID-19 cases, identification of disease dynamics, identification of vulnerable groups, mapping of health capacities, and general modeling of infection spread with application support for communication and collaboration between all institutions and the public. The paper describes the challenges and ways to overcome them in the development and use of ELIS.

A Scoping Review of Data Sources for the Conduct of Policy-Relevant Substance Use Research.

Existing administrative and survey data are critical for understanding the effects of exigent policies on population health outcomes related to opioid, cannabis, and other substance use disorders (SUDs). The objective of this study was to determine the state of the data available for evaluating SUD-related health outcomes. We performed a scoping review of national and state government data sources to measure and evaluate the effects of state policy changes on substance use and SUD-related health outcomes and health care use. We used Massachusetts as a case study for availability of relevant state-level data as well as national datasets with state-level indicators available to measure outcomes. We compared key features of each dataset to assess their usefulness for research and policy evaluation. We conducted our review during November 2018-March 2019, and we updated data availability as of March 2019 for all data sources. We identified 11 survey datasets, 12 national administrative datasets, and 10 state administrative datasets as being suitable for policy-relevant research and practice purposes. These datasets varied substantially in their usefulness for evaluation and research. Despite substantial data limitations, including prohibitive regulatory and monetary costs to obtain the data and limited availability, these data can be mined to examine a diversity of policy-relevant questions. Findings provide a comprehensive resource for using survey and administrative data to evaluate the health effects of SUD-related policies and interventions. The construction of state-level public health data warehouses or record linkage projects connecting individual-level information in state data sources is valuable for analyzing the effects of policy changes. Understanding strengths and limitations of available data sources is important for ongoing research and evaluation.

Comparative Analysis of State Level Health Policy Support for Opioid Abuse Mitigation in Rural America

In rural America, opioid use disorder (OUD) continues to adversely impacted familial, public, and economic systems, creating extraordinary societal and financial burden. This comparative analysis of state-level public health policy and practices in rural opioid use abatement promotes the development and implementation of contextualized evidence-based comprehensive policy initiatives. Policy analysis across select highly affected states (Indiana, Kansas, Kentucky, and West Virginia) and exemplar OUD policy response states (Colorado, Massachusetts, Ohio, and Vermont) was performed using a systematic review of literature, legislation, plans, and policies. Findings included close alignment between states’ OUD policies and public health best practice standards; minimized differences between exemplar and highly affected states policy responses; and resource driven gaps in opioid epidemic legislation, regulation, guidelines, strategic plans, and initiatives. Furthermore, it is advocated that public and private stakeholders committed to health equity must seek reductions in opioid related disease and mortality through increased resource allocation.

Patterns and correlates of mis-implementation in state chronic disease public health practice in the United States

BackgroundMuch of the disease burden in the United States is preventable through application of existing knowledge. State-level public health practitioners are in ideal positions to affect programs and policies related to chronic disease, but the extent to which mis-implementation occurring with these programs is largely unknown. Mis-implementation refers to ending effective programs and policies prematurely or continuing ineffective ones.MethodsA 2018 comprehensive survey assessing the extent of mis-implementation and multi-level influences on mis-implementation was reported by state health departments (SHDs). Questions were developed from previous literature. Surveys were emailed to randomly selected SHD employees across the Unites States. Spearman’s correlation and multinomial logistic regression were used to assess factors in mis-implementation.ResultsHalf (50.7%) of respondents were chronic disease program managers or unit directors. Forty nine percent reported that programs their SHD oversees sometimes, often or always continued ineffective programs. Over 50% also reported that their SHD sometimes or often ended effective programs. The data suggest the strongest correlates and predictors of mis-implementation were at the organizational level. For example, the number of organizational layers impeded decision-making was significant for both continuing ineffective programs (OR=4.70; 95% CI=2.20, 10.04) and ending effective programs (OR=3.23; 95% CI=1.61, 7.40).ConclusionThe data suggest that changing certain agency practices may help in minimizing the occurrence of mis-implementation. Further research should focus on adding context to these issues and helping agencies engage in appropriate decision-making. Greater attention to mis-implementation should lead to greater use of effective interventions and more efficient expenditure of resources, ultimately to improve health outcomes.

Continued Counseling for the Relationship Between State-Level Medicine and Public Health

Public health and organized medicine have operated somewhat independently of each other since the early 1900s. In the wake of the COVID-19 pandemic, the necessity of healing any divide between organized medicine and state and local health officials seems self-evident. Using the recommendations abstracted from a 2005 article by Dr. Ronald Davis, "Marriage Counseling for Medicine and Public Health," this cross-sectional study explores the formal relationships that existed between state-level public health and medical practice across the U.S. at the end of 2019. A questionnaire was distributed to every state's senior public health official and medical society executive (N=104) between August and December 2019 to examine the extent of these entities' partnerships. Analysis was completed in January 2020. Among the respondents, 40%-63.1% (n=65) currently engage in the recommended activities, with 1 exception: state health departments infrequently invite medical society executives to speak at major conferences or meetings (26.2%). The majority of respondents (71.1%-85.9%) judged that each recommended activity would improve the practices of medicine and public health. Survey results illustrate a desire for reconciliation, but poor implementation of recommended strategies aimed at building a healthy marriage between the 2 sectors. More formal efforts are needed among state medical and public health organizations to capitalize on the current climate of rapprochement. The burden of COVID-19 on the national health system could provide a worthy cause around which these efforts would coalesce.