CECILIA OREGON: Welcome everyone to today's
virtual policy forum, Public Health and the Delivery
System: Vital Connections. We're so glad that you could join us for the second conversation in our series. But today's theme being Building
a Stronger System for the Future. I'm Cecilia Oregon Sessy,
the Executive Director of the Kaiser Permanente
Institute for Health Policy. And at the Institute, we host
events and publish information to shape policy and practice
on important health topics. We often convene experts to share
knowledge, spark discourse, advance collective thinking and explore opportunities to cultivate
healthy communities and promote more accessible
high quality care. With that mission in mind,
we're hosting this forum to discuss public health
and the delivery system. As someone who has started her
career at Alameda Counties Public Health Department
here in California, I'm pleased to open today's conversation.
In the upcoming panel, we'll
hear from leaders who will both reflect on the challenges in
our public health system, many that were laid bare during
the pandemic and consider how we might learn from the current experiences
to build and sustain a better, more prepared public health
system for the future. But first, a few quick house keeping tips. During our panel, we'll
take questions from the audience and you can submit questions through the ask a question box on your screen at any point during the forum. And we'll also be pulling
in questions from those that were submitted
before the event.
But we might not have time
to get to every question, so we'll do our best. If at any point you experience
technical difficulties, please let us know, again,
using the ask a question box. This event is being recorded
and the video will be made available on the Institute for Health Policy's
website in the coming weeks. So, onto today's content. In this conversation,
our esteemed panel will speak to the importance of a strong, well-funded public health system, reflecting on the many
challenges and lessons that have emerged throughout the pandemic. We know that in order to respond
to future public health crises and support long term community
health, we need a strong, well-funded system, yet
the public health sector has long faced structural
and financial challenges.
Today, we'll consider how
we can support an effective public health system and how we might foster stronger connections
between public health and the delivery system moving forward. On Monday, we heard from delivery
system and public health leaders, including our own CEO, Greg Adams, Dr. Barbeau, Patti Hays, Dr. Perotti and Dr. Ramy, who share their experiences
responding to the pandemic. Many important challenges
and lessons learned were raised. The speakers pointed to the need to
improve messaging and communication between health care
and public health systems, as well as to the general public
to rebuild trust in the system, to build upon relationships between public healthcare delivery system and businesses.
We also talked about the need
to collect data and improve information exchange in
a bidirectional way. We heard from more than one speaker about the use of fax machines
to share information between health systems and public health departments early on in the pandemic. And we also need to keep thinking about our frontline staff keeping them safe, keeping them healthy
and especially now while they're dealing with high levels
of exhaustion and burnout. And we don't wanna lose sight of
the other challenges that we're experiencing right now with
exacerbated mental health issues, addiction and certainly
challenges related to people making the decisions
or needing to defer care. And critically, across all of these areas, we need to address racial equity
and elevate leadership from communities disproportionately
affected by public health challenges including
communities of color. So, I'll now turn this
to today's discussion. To get our panel started, I'd
like to introduce our moderator, John Auerbach.
John Auerbach is the director of
Intergovernmental and Strategic Affairs of the Centers for
Disease Control and Prevention. In his role, he's the lead
strategic advisor on CDC engagement with government
agencies at the federal, state, local, tribal
and territorial levels. Over the course of his 30-year
tenure, he's held a senior public health positions at the federal,
state and local levels. He's served as president and CEO
of Trust for America's Health, an associate director at CDC, the Commissioner of Public
Health for the Commonwealth of Massachusetts and Boston's
Health Commissioner. In addition to his government service, John was a professor of
Practice in Health Sciences and the director of the Institute
on Urban Health Research and Practice at Northeastern University.
He was also the director
of the largest women, infants and children
program in Massachusetts. We're so thrilled to have John
lead our panel discussion, so I'll turn it over to you now,
John, to introduce the panel. JOHN AUERBACH: Well, thank you so much, Sessy,
and thank you to Kaiser Permanente for focusing its attention
on this important topic. You're doing so at exactly
the right moment. This is a moment that's
filled with the evidence of the consequences of neglecting
the public health system. In the past 20 months, we've
seen and are continuing to see the cost and hundreds
of thousands of lives in the health of many
millions of people and in the well-being of virtually
everybody in this country. And we've seen the disproportionate
burden imposed by racism, by poverty and social
and economic conditions, which elevate the risk for
historically marginalized populations. But this is also a time
of enormous opportunity.
Policymakers are paying
attention to public health and making unprecedented
resources available. CDC is going to be releasing
a $3 billion grant opportunity to build a public health
workforce in the coming months. Half a billion will be spent to
upgrade the data information system of the public health
sector in the coming months, and there may well be
funding for public health infrastructure in future federal budgets. And we have forums like the one
today where people are debating what needs to be done
that will be meaningful, sustainable and focused
on upstream approaches.
And more and more people who
believe that the solution doesn't just reside in incremental change, by which I mean limited increases in funding to the public health system. So, it just looks like a somewhat better version of what it did in the past. Rather, there's a growing belief
by many in the public health sector that this is a time
for transformative change. That we need a public health
system that's nimble, able to focus on what's needed
to address key health issues, paying attention to strong partnerships, staffed by a highly skilled
and well-treated workforce, utilizing modern data systems that
are both timely and accurate, and also to tap many
different data sources. We also need a myriad of
communication capabilities that can function 24-7,
and we need policies, programs, funding
and staffing that reflect a deep commitment to equity and justice. But we have to take advantage
of the opportunities. They won't last forever. Our panelists will help us understand how to take advantage of those opportunities. They have been on
the frontlines of this effort and we're fortunate to have them join us. So, at this point, I'd like to bring
our panelists on to your screen.
They are: Anand Parekh, who'
the chief medical adviser at the Bipartisan Policy
Center, Mary Pittman, who's the president and CEO of the Public Health Institute and Lauren Smith, who is the chief health
equity and strategy officer at the CDC Foundation. Each of them is an expert in the field of public health and health policy. Each will offer their perspective
about where we are right now, drawing from some of the themes
that were raised on Monday. But their major focus will
be on where we need to go. After hearing from each of the panelists we'll engage them in a discussion, and that discussion will include you. So, please enter your
questions into the chat at any time during
the panelists presentations.
And in fact, some of you
have already done that. You've submitted questions,
and so we'll use some of those questions as we move to
that portion of the event. So, let me move on to our first speaker. He is Dr. Anand Parekh. He is Bipartisan Policy Center's
chief medical adviser, as I said, and he provides clinical and public health expertise across the organization. And prior to joining
the Bipartisan Policy Center, he served as the deputy
assistant secretary for Health in the US Department of
Health and Human Services. He is a board certified
internal medicine physician, a fellow of the American
College of Physicians, an adjunct assistant professor
of medicine at Johns Hopkins University
and an adjunct professor of health and management
and policy at the University of Michigan School of Public Health. So Anand, let me turn things over to you. DR. ANAND PAREKH: John, thank you so much for
that very kind introduction, and it's great to be with you
and great to be with Dr.
Pittman and Dr. Smith as well. I wanna thank Kaiser Permanente
and the Institute for Health Policy for convening
all of us on this just very important and timely
discussion about connectivity between the delivery
system and public health. I wanna spend just
a couple of minutes today discussing one report
that was unveiled just a few hours ago from
the Bipartisan Policy Center as a public health forward task force. This is a task force of 14 individuals, elected officials and multi-sectoral leaders who articulated a five-year vision for governmental public health in the United States and an actionable framework for state and local elected officials and public health
officials to achieve that vision. The work is really built around
a framework that centers health equity and advancing health equity, and to ensure that all
Americans have the opportunity to retain their highest state of health. This is work that has been ongoing
for the last six months or so, led by a coalition of
national public health associations as well as philanthropies.
And the question of why now I think all of us could probably answer that. There has been, as John has said, a significant infusion
of funds that has gone or that is going to
the public health system. It's critical that we
leverage that funding. It's not the long term sustainable
investment that public health needs. We'll talk about that, I'm
sure, a little bit later, but it is still a critical opportunity. We've also seen, unfortunately,
the politicization of the pandemic. And while public health
has been in the news and people are talking
more about public health, it's not always for the right reasons.
And so, this is
an opportunity that in many ways take back public health to educate the public and policymakers
about what public health is to transcend politics. And so, that was really that the impetus for this project public health forward. Again, focused at the state
local level, realizing that, of course, the federal government, the private sector and non-governmental
organizations have a huge role to play in ensuring that we advance
public health in our country. But there's a particular opportunity right now for state local elected officials, as well as public health officials. I hope that all of you will get
a chance to review that report.
It can be now found in
bipartisanpolicy.org. I think it's an opportunity
for policymakers to review all of the investments that are coming down to states
and localities right now, prioritize the recommendations that meet particular jurisdictions and then work with public and private sector partners to implement those recommendations. With respect to the interface between the delivery system and public health, I think that the report really
touches on many aspects of that.
And one of the themes
really is public health is not just a public
health responsibility, it's everybody's responsibility,
including the delivery system. And so, I think when we think
about sort of governmental public health and delivery system connectivity with
the continued acceleration of value based health care transformation and alignment in terms of
the incentives of what the delivery system is trying to do and what
public health is trying to do, I think that there are
a lot of opportunities.
And in fact, I think
the first part of the forum, the initial discussion brought
a lot of these topics to light. The first is, of course, data. We talk about the data infrastructure
on the health care side a lot. Public health data is, in many
ways, a bit more even antiquated. And so, ensuring that there's
bidirectional information flow between health care and public health
through electronic case reporting, through ensuring that demographic
information that is collected, through health care is then
transmitted to public health, all of that are critical
critical opportunities for governmental public health
and the delivery system. A second opportunity is, of course, whenever the delivery system is
embarking in community health needs, assessments and implementation
plans to improve community health. Governmental public health
really needs to be at the table, working hand in hand with the delivery system to improve community health.
And then finally, with respect to
health equity and health disparities, as much as delivery system
works at trying to reduce health disparities until it
works with the community and the public health to reduce
the underlying health inequities, it's very difficult to really
address ultimately those health disparities that we see
on the health care front. And so, I'm sure we'll
talk about many of these, but I think this is the right topic, this is the right time for
the delivery system and public health to start that,
not just talking about. We've been talking about
this for a long time, but now it's really a time for action.
And again, I commend Kaiser Permanente
for really convening all of us and rethinking in this moment of national crisis with the COVID-19 pandemic. It's time to rethink exactly how
we can improve the connectivity between the delivery
system and public health. So, John, I'm really looking
forward to the conversation. Thanks. JOHN AUERBACH: Oh, thank you very much, Anand, and congratulations on
the release of that report, which I think we're all eager to read. Next, we'll hear from Dr. Mary Pittman. Mary is the CEO and president
of the Oakland-based Public Health Institute, one of the country's largest
and oldest independent non-profit public health organizations. At the Public Health Institute
and throughout her career, Mary has been a nationally recognized leader in improving community health, safety net and Medicaid provision
of care for vulnerable populations, addressing health equities,
building the public health workforce and promoting prevention.
Mary is an expert and an advisor
in the field of population health, and she's a leader in efforts to
re-vision how diverse stakeholders can work together to build
healthier communities, stronger hospitals and public
health systems, and importantly, more strategic investments
in community health. Welcome, Mary. We look forward to hearing your comments. DR. MARY PITTMAN: Thank you so much, John,
and thank you to Kaiser Permanente for hosting this really
important conversation today, as announced that it's very timely.
I also wanna thank my fellow
panelists, Anand and Lauren, for the comments that they're
going to share with us as well. When I think about what we need for the public health system of the future, I think about what we've learned
from past public health crises. For example, yesterday was World AIDS Day. We learned a lot from that, but we've learned so much more
during the COVID-19 pandemic. During the first months of the pandemic, the Public Health Institute
was able to swiftly pivot our infrastructure
to partner with local health departments in the Pacific
Northwest and to develop a new model of contact tracing that emphasized
trusted community voices, those who had lived experience
and the necessary language and cultural skills to be able to effectively
service contact tracers.
The success of this model and our ability to rapidly respond to outbreaks, including at food packing plants
and other business venues, led to our work with Kaiser Permanente to implement a similar model in California. And we built off of the clinical expertise of Kaiser Permanente and their engagement, as well as connecting
with the local health departments and community clinics. Tracing Health had 240 contact
tracers in California and 155 in Oregon and Washington. and they effectively
supported county health departments and clinical systems.
It was somewhat a unique
model in that connectivity. The combination of working with
governmental, public health, the state and local health departments, Kaiser Permanente and community clinics, as well as community-based organizations, gave us a unique vantage
point to understand what was happening in the COVID pandemic and really where
the leverage points existed to intervene. It also helped me really crystallize
what we need moving forward to make our public health system and our
overall health system stronger. Community-based organizations have played a critical role in this pandemic. They strengthened equity and justice, and they're extending
the reach and capacity and effectiveness of every
part of our COVID-19 prevention and vaccination efforts.
Many have referred to
community- based organizations as partners in this work, but community-based organizations
are more than partners. They are an integral part of
the public health ecosystem, and we need to think about how
do we shift resources, power, decision making
and different ways of thinking about community based organizations and our next steps of
building that important link between health
care and public health. SPEAKER: During one of
the conversations on Tuesday, the panel highlighted
the need to build trust with communities and most
particularly among communities that have experienced systemic racism. I want to say that
the community based organizations are those trusted messengers,
and they're key.
We've worked with over 2,400
CBOs around the country now, and they know how to address
the barriers that exist for individuals. They're working in more than 50 languages, and they know how to reach
difficult populations that are difficult to reach
through normal channels normal meaning our governmental systems. We often talk about
the three-legged stool, but there are really four pillars that can effectively support
public health infrastructure, health care systems, governmental public health organizations, community-based organizations
and the glue which we have seen, which are the nonprofits. Organizations like PHI and many others who can serve its critical connectors. SPEAKER: We all have a role to
play in public health, and we work best when we work together.
That's why my first recommendation is that we ensure dedicated funding streams and direct support for CBOs as part
of our public health infrastructure. In California, we are championing
Health Equity and Racial Justice Fund that has been
promised to begin in 2022. It would provide $200 million every year to local health jurisdictions across the state and another
$100 million that would support community-based organizations. Second, we need to start
building the workforce of the future of public health
and clinical workforce that looks like speaks
the languages and understands the needs of the communities it serves. This interrupts the medical
racism that exists, and it means better care, and ultimately it means better
outcomes and lower costs. SPEAKER: We do that by lowering barriers
to entry into the field. For example, we don't always
have to have a college degree to be effective in some of
the public health jobs. We have certainly learned that
through our contact tracing program. So if it's not necessary,
I'll put it as a barrier. And for those who are seeking a degree, make sure that you're counting their
lived experience as an important part of consideration
and make sure that we are also providing the wraparound
services that are needed.
Particularly for people who may not
have had some of the advantages, economic advantages in particular. The Department of Health
and Human Services has promised $240 million for
a new program focused on education and on-the-job
training to build a pipeline of public health workers. And I think that that is
something that's very exciting and community-based
organizations, health centers
and faith-based organizations need to be part of that pipeline. We need more of this kind of
programming to make sure that we're getting qualified public
health leaders for the future. Without a renewed commitment to building and expanding the public health workforce. We will not achieve our
healthy people 2030 goals, and we won't be ready for the next phase of COVID-19 or the next pandemic. SPEAKER: Third, as Greg Adams mentioned in
his remarks earlier this week, we must make upstream investments in
the social determinants of health. Clinicians have to address
the social determinants of health. They have to understand the housing, food security and safety
issues of their patients. And then they also have to
be able to connect them to the community assets
that are available. One promising model of this is common spirits-connected community networks.
The networks, including Kaiser Permanente, rely on trusted community conveners and a shared technology
platform to connect community partners who help
individuals with their housing, their mental health,
nutrition and other needs. This is why the Public Health Institute
has joined others in calling for a comprehensive federal
Health Equity for All Act. This is modeled after the Ryan White
Act that we know is effective. It would drive cross-cutting government
investments at the national, state and local level to address
racial and health equity. They includes funding Health
in All Policies program, which we have had in California,
and it has worked effectively. We now need to scale it
on the national level. SPEAKER: And finally, I won't go into
any depth because I think Anand covered it well is
that we need better data, better data systems and more
connected data systems, including telehealth.
So what I'd like to just end on is saying that the lessons that we have learned, whether it's from
community-based organizations, local health departments
or from the health care system is that we all have
the assets to bring to the table. So ,when we look at the future
of public health conversations like the ones that are being
hosted are absolutely critical. And then we need to put the workgroups together to make sure we implement. Thank you, Jim. SPEAKER: Well, thank you, Mary,
and thanks for offering those concrete
and specific recommendations, and I think when we get
into the discussion, we'll have a chance to
dive into the different topics that you'd mentioned. I think those really resonate
well with the report that Anand was releasing today as well. So, a lot for us to get into. But we're looking forward to
our final panellists now, and that is Dr Lawrence Smith. Dr Smith is the Chief
Health Equity and strategy officer for the CDC Foundation.
And in this role, she partners
with the CDC Foundation's other senior leaders to develop and drive strategic efforts to embed
health equity across the foundation's COVID-19
response activities, with an explicit focus on addressing
systemic racism and its impact on the resiliency of vulnerable
populations that admits the pandemic. And previously, Lauren
was the co-CEO of FSG, a social impact consulting firm, and she served as the medical
director and interim commissioner for public health at the Massachusetts
Department of Public Health. So, Lauren, it's great to have you. We look forward to hearing you. SPEAKER: Thank you so much, and I again, I want to echo my colleagues
in really recognizing and applauding Kaiser Permanente
for convening this conversation. And I think that the focus
of being in a place where we can have conversation
and thinking about these issues. But also how we pivot to action and how we pivot to doing something differently, I think is really important.
And I'm excited to be part
of that conversation. I would just want to add
or offer a few reflections on where I think we are now. What are some of the issues that we're going to have to confront in order to move out of this kind of situation
that we're in right of way. The first, I would say,
is I've begun to think about this situation as a crucible moment. And by that, I mean, I know crucible
moment is one of intense challenge or strain in which elements go
into the fire in the crucible, and then they emerge fundamentally
change into something new. And I think Mary and Anand pointed
out very well that the experience of COVID-19 has really indicated that
hat we had before wasn't working, and we knew that it wasn't
working, and we could predict how a pandemic would play out, and it did.
SPEAKER: So what we have to do is to develop
a different way of going forward, not just to recreate or to get back
to what we had before or since. Unfortunately, that wasn't
working for so many. I wanted to just respond also to one of the themes that I think have came up in the prior conversation was about the need for equitable response and recovery that acknowledges the persistent
structural challenges and various community
health and wellbeing, and I know we're going to dive into that.
But that that idea of
the acknowledgment and the reckoning with what we in public health
as well in health care. I'm also a clinician, so I consider
myself part of that field as well. What has been the situation that has led us to be in this persistent place, knowing that so many of us have been working to address this for so long. SPEAKER: The second issue I wanted
to sort of reflect on was just how much
people have stretched, and I think again, both Mary
and Anand have mentioned this over the past 20 or 21 months. People have really stretched
they've expanded their thinking. They've begun to do that
reckoning and acknowledgement in places that maybe
hadn't done so before. But now I think we're
beginning to see a bit of equity a bit of weariness
with some of that, not just weariness
and burnt out and exhaustion from being on the frontlines
of public health. But from having to sort of confront these challenging conclusions about our systems that are deeply uncomfortable to
recognize, and so there's a tendency, I think in our field and in our
society more generally to want to snap back to what was
comfortable and familiar before.
And so we need to be very aware of
this phenomenon and be intentional in terms of how we counteract that in
ways that will allow us to build the kind of resilient
and vibrant communities that we want to do by continuing to challenge and doing
the uncomfortable work that we have done. We've come too far in the past
20 months to sort of backslide and allow ourselves tosort of
snap back into those other, perhaps more comfortable
but not effective situations. SPEAKER: I wanted to pull on a thread that
Mary mentioned about expanding our definition about what
counts as public health and what skills and capacities
are needed in order to practice public health
effectively in the future.
And I think you're mentioning
the connections with community-based organizations and the ability to develop authentic and bi-directional
mutually agreeable and productive relationships
is an example of that. But there's a whole host of other things that really our public health officials, some have but others will need
support in order to grow them, such as the ability and
the experience in applying equity principles across all stages
of the data lifecycle. Both Mary and Anand mentioned
data and the idea of how we decide what questions
to ask where to go, how to involve a community in a meaningful way throughout the whole process, not just in the data extraction
process for many communities. That's what it feels like
it's an extractive process. We go, we take information and we
don't, they don't see us again. So how do we do that in
a really very different way that contributes to the next
topic I want to mention, which was galvanizing public
support shifting the narrative, developing different
narratives for public health. SPEAKER: We need to be even more
sophisticated in how we discuss and convey the essential
role of public health.
So much of what we found out
during the COVID pandemic is that people don't have
an idea or don't have an accurate and credible
idea of what public health is and our role and why
we're so important. I think the analogy is no
community would wait until houses are on fire to build and staff
and train a fire department. It sounds absurd to even say
that, but in a lot of ways, because of the decades of
underfunding of public health. We've decimated it to
the point that that's sort of what we expected to do
during a crisis or pandemic. So we need to work on that. And why is essential to
build that public support. So I'm hopeful that in our conversations that we're just about to have it, we'll be able to dig in
to these pieces around how we can be sure that we don't snap back to a process or
an approach that wasn't serving many of our communities well.
And how can we go forward
and building that kind of deep support for public health to be able to do the kinds of
investments that we know are necessary and need to be sustained? SPEAKER: Well, thank you, Lauren for
raising such important questions and thoughtful questions. And I think those issues
will come up now as we get a little bit deeper
into the discussion. It's clear from
the discussion that took place on Monday and also what the panelists have just highlighted already that
there is both a lot of challenges, a lot of opportunities and just
a lot of issues for us to dive into. And so I want to start out by diving into an issue that maybe it's the hot topic now and that has to do with
infrastructure and what we mean by public health infrastructure.
There's has been said,
we never used to talk about public health infrastructure, and now that is getting
a lot of attention, including from members of Congress. And so I guess I'd like
to ask each of you, what are we talking about when we're talking about the need for a strong, durable, resilient public
health infrastructure? So we're ready for future pandemics. When you hear that term, what do you
think of and what do you think is the most important part
of an infrastructure for us to pay attention to? And by the way, this is going to be
a discussion among the three of you. So I'm not going to direct
a question to one person, but I really hope you will
all dive in to the extent that you have some thoughts about this. So, any one of you please
feel free to start. SPEAKER: I'll start, and I'm sure
my colleagues will add on, we've heard many, many times data. And certainly, most local
health departments and I would say the connectivity between state and local health
departments are antiquated. Our data systems can't
talk to each other well.
We saw that just in the exchange
of data with contact tracing, we couldn't always get a quick turnaround so that the tracing could happen. But it's beyond that. In some places we have data and we don't have people trained to utilize the data. And so we need the professional
workforce to be able to analyze the data to use
predictive analytics. And I would say we also have
to make sure that that data is transparent
and accessible to the community. I talked a lot about
community-based organizations. Sometimes our data is delayed,
and by the time you get that data, if you go out and talk to
people in the community, you find that the whole premise that
you're operating from has changed. So you have to be able to collect
the right data, has to be granular, has to include the social
determinants of health, and it has to be cognizant
of race, ethnicity, language needs of the communities and then making sure we have both the right workforce and
the relationships to understand what that data is telling us.
SPEAKER: That's a great start. So data definitely is a topic we're
going to want to talk about, maybe before we move to other aspects of infrastructure other thoughts about the importance of data and particularly where you see opportunities for us to do something differently now that
will strengthen the data systems. SPEAKER: I think that you know,
totally agree with Mary, with what you were just saying, and I think that's what part of what
I was alluding to as an example in terms of applying robust equity
principles across the entire data lifecycle and not making I think,
what is a common sort of step, which is to comment at the end
and then to involve community or two at that point when you've already
really narrowed what you're going to be able to find out based on
the questions you asked, how you asked, what you were even emphasizing
in terms of a priority.
And certainly the piece around
sort of meaning-making. That is what is the data, what
is the data actually show, and then what do we do with
it and how do we apply it? Yeah, it's a whole separate set of
issues, so I totally concur there. I think the other thing about
data and interoperability, Mary, you mentioned, I think it makes sense to is how
do communities know what data is available and what do we understand
to be rules around who owns the data and who can control how
it's used and how it's described. And how are we doing in terms of
ensuring that there's not a deficit approach to the way data is
talked about and that there's an element there of having an asset
based approach and recognizing that their communities have
strengths and not only deficits.
SPEAKER: And I'll just add to it, Mary and Lauren, ANAND PAREKH: Or say, I think data is
a great example when we talk about Public
Health Infrastructure. And I think, we've seen on
the data front the dearth of data on race and ethnicity when it
comes to COVID-19 testing, as well as vaccines during this pandemic. As has been talked about, I think we need a bidirectional flow of data from local, the state, and Federal Public Health. And then, we need that bidirectional flow between health care and public health. And I think often, from a policy
perspective, what is it that we need? And I think what we need is
we first need to define what is a core public health
dataset that we can agree on. ANAND PAREKH: Then, we need standards for that data set. And then, we need some
funding and accountability, to ensure that public health at
all levels is able to collect, extract, and share that kind of data.
And on the health care front, we also
need incentives and requirements to ensure there's reporting of
the important demographic data. We need to reduce health
disparities and inequities that that electronic case
reporting is occurring. So, the delivery system is getting
information on public health. And so, I think it takes
a number of things. I think it takes policy,
I think it takes some funding. But that's just a great
example, I think John, of data, one aspect of public
health infrastructure. ANAND PAREKH: And maybe this leads
to your next question. But essentially, again,
anything that is critical to tackle any public health challenge, whether it's COVID-19, whether it's
the opioid crisis and mental health, whether it's diabetes and obesity, what are those critical
capabilities like data that are necessary irrespective
of the public health challenge or threat in front of us? That's what it means
to me when I think of, sort of public health infrastructure.
MARY A PITTMAN: I want to build on that last
statement because you really talk to the fact that we don't need
just siloed data systems, you know, that deal with
COVID or deal with the, you know, drug overdose. What we need are much more
integrated data systems, which is part of the barrier
that I think we have now. We were fortunate in California, we
had the Public Health Institute, Southern California
Public Health Alliance, which is built from the health directors. They identified this health
gap years ago and developed a tool called the Healthy Places Index, that served as the basis for
a statewide equity metric so that when we were
dealing with the pandemic. MARY A PITTMAN: That was used by every county to
determine how resources were allocated, and when they moved from
one tier to another, looking at the most disadvantaged quartile of people living in that community. That was really a hands-on implementation, and everybody knew what it meant.
The business leaders knew
because it had relevance. And so, I think we also have to
learn, how do we come up with data that we explained to the general
public that has relevance? People know what the S&P 500 Metrics are, but they don't know what
the Healthy People 2030 Metrics are. So, I think we have some
education to do as well. LAUREN A SMITH: And Mary, I was just gonna jump in. Totally agree about avoiding
the Siloization of data.
And also, the need to connect data that comes from really different sources. So, the clinical data, which is,
you know, at the individual level, we need a repository or a place
where we can connect that and look for patterns with data on housing
conditions that come from HUD, or data on, you know,
educational attainment that might come from
the Department of Education. We need a way to pull in those data sets in an effective way across those silos because we know all of those things
interact at the community level. JOHN AUERBACH: So, let me just ask one follow-up question before we move on with the data.
If you're, you know, we're being
hosted by Kaiser Permanente, who, let's face it, does the most innovative work
in terms of thinking about the connection between clinical
care and community health. Looking at a Kaiser
Permanente, or other health care organization that is interested in working with the public health
sector and thinking about data, well, what are your recommendations
for the health care system in terms of its relationship to public
health when it comes to data? ANAND PAREKH: Well, I think, you know, one of the things that comes to mind is trying to understand what the gaps are right now or
the deficiencies in the current system. So, you know, is the delivery system
able to transmit, for example, data to local or state
public health departments? Is the delivery system able to
ensure that important demographic information gets to local
and public health? You know, what are the barriers there? Do states and the states
legislatures need to get involved and pass laws to allow that
type of information exchange? Are there other kinds of
technological issues? Are there privacy-related issues? ANAND PAREKH: And so, I think, maybe the first
thing would be to understand, what are the barriers preventing that
type of exchange of information.
I think health care and public health, now it's important to
transmit information. But there are certainly barriers, and identifying those barriers
might be the first step. JOHN AUERBACH: Thanks. Well, let me move to a different
topic that I think is often included when we're talking
about infrastructure. And that is having
a highly skilled workforce, doesn't necessarily mean Mary, that they've gone to medical
school, or nursing school, highly skilled can be knowing
their community very well, but highly skilled in terms
of the tasks at hand.
We do have an opportunity. Now, as I was saying, there's
the new funding that's coming from the federal government
to pay for workforce. We have a workforce that's been
hard hit, by the pandemic, both in terms of just the magnitude of the work and in terms
of the public response. JOHN AUERBACH: In many communities, has been
harsh against Public Health. Where do we need to go in
terms of the workforce? Where do you see some of
the key places that you would say, let's pay particular attention
to this aspect of building a highly-skilled public health workforce? LAUREN A SMITH: Well, I'll jump in. And I think, Mary already touched on
one, which is facility where data, all aspects of, you know,
across the whole lifecycle.
I think another area I would bring up is, in public health has generally
been used to doing this. But I think we have to sort of challenge ourselves to do it in a different way, or an evolving way, which
is around community partnership and engagement. And to do that in a way
that's truly authentic, not just informing community, but being attentive to the power
dynamics that come from working in a government agency and going to
communities who have had, you know, different kinds of experiences
with government agencies. LAUREN A SMITH: So, how do you do that? How do you encourage that in your staff? How do you encourage that
in your funding mechanisms, your funding approaches? All those different ways of how
you show up in the community, and how you can engage with
the community in different ways, is, you know, another example
of different skills. MARY A PITTMAN: I think it's really critical that we
focus on new communication skills, public health sometimes
uses the moral high road and the science as their lead
to their communications.
And we have to realize that there are competing values and value systems, and we have to understand
how to communicate so that we can bridge different audiences, different value systems, and that
doesn't undermine the science. But if we do a better job of educating people what public health is about and building up a collective community
public health understanding, then I think it'll be
a lot easier for us to have regular conversations
with business leaders, with elected officials,
with the local community. MARY A PITTMAN: I think too often public health stays
inside their box, if you will, and they need to be out communicating
with people on a regular basis, not wait until there's a crisis. Crisis communication is one thing, but you have to have those
relationships and the facility to be able to communicate
with people about what you're doing day in and day out. And, you know, the other thing
is, in the political process, all you need is a 51% majority. When it comes to a pandemic,
51% is not enough.
So, you can't just pick and choose a few parts of the community to talk to. You really need to talk to all sectors. ANAND PAREKH: I wholeheartedly agree
with Mary and Laura, and, you know, couldn't agree more. You know, the first assistant
secretary of health that I worked for over 15 years ago now, sort of reminded me about
something at the time, I thought it was very elementary. But I've always sort of kept
it in the back of my head. He often used to remind
me that public health is made up of two words, alright? And that it's the second word, health, that we spent a lot of time on,
the science, the evidence, understanding from a policy perspective,
from a service perspective, what works, how to improve health. ANAND PAREKH: But public health also has
that first word of the public, and how imperative it is for
us in public health to ensure that the very public that
we're trying to serve, that we understand their
aspirations, their perceptions, meeting them where they are,
understanding where they are. And I think to Mary and Lauren's point, this is a time not only
to educate the public and other partners about
what public health is and what public health does.
It's also an opportunity to partner
and build trust with the public. And we do that by remembering
that we really need to go out and better understand
the public we're trying to serve. Ultimately, that will help us
optimize health in this country. MARY A PITTMAN: It also calls for those
trusted community messengers to be our partners in doing that. JOHN AUERBACH: I'm thinking back to
the discussion that took place on Monday when the topic
of workforce came up.
And one of the real concerns
that was raised then was, how we support both public
health and for that matter, health care and its workforce, given what they've been
through in this pandemic. We have, you know,
a significant amount of burnout, demoralization within the workforce. And I guess, I wonder,
your thoughts about that. How do we help the workforce recover
where there's some concern, we're gonna lose people from
the public health sector and maybe from the community
public health organizations, if they feel like this is
such a difficult profession? JOHN AUERBACH: Clearly, that's the case, I think, in the health care
delivery system as well. So, as we're thinking about workforce, what are your thoughts about that? How do we how do we recover? How do we build a more resilient
and supported workforce? MARY A PITTMAN: First of all, I think,
recognition that it has been a very tough time for frontline
health care providers, for people in public health,
people in every sector. And so, I think first, we have to
have a little bit of gratitude for what they've done
and show that gratitude.
I think we have to have a bit
of space for people to recover. And if that means extending
some additional time, you can't expect people
to continue to work at the pace they have,
and not hit burnout. We also have to protect
people who have had the general public lashing out at them. We have to realize that while
they're trained professionals, for some people, their lives
are being threatened. MARY A PITTMAN: And that's not acceptable. And that adds a whole
other level of stress.
So, we have to protect them. We have to give them
some space to take time. We have to compensate people adequately. If you take a look at the salary levels for some people in public health, they're well below what they might
be able to earn in other areas. So, their dedication to
the field can get tough to maintain when they have
all these other forces. I also would say, I went to school
on a public health traineeship. I have to say that, the new
graduates that I'm talking to are excited about going
into public health. So, I think we also have to be
nurturing that next generation, and help them pay for their education. LAUREN A SMITH: Yeah, I think that pipeline issue
is really important, Mary. You know, the data that
suggests that applications to public health school
enrollment, you know, have gone up, you know,
as people have seen, this is a really exciting career.
So, that's really important. And that's one of
the reasons I also mentioned about sort of galvanizing public support. It's sort of the opposite of, you
know, picketing people's lawns and, you know, following their children
to school, that kind of thing. But I think it's
the acknowledgment and recognition. LAUREN A SMITH: But it's part of the explanation
of an advance of a crisis, what is public health doing, and why it is important because
so much of what public health does is, when it works well, it's invisible
to the rest of the community. And so, they're not aware that it's there. So, it's hard to get excited
about what you don't know about. But what you don't know, it's protected.
ANAND PAREKH: Yeah, couldn't agree more. You know, I think we use sort
of the term public health, we're all in public health, we
work in public health a lot. But for the, you know, the average
person, if you go, you know, in America and you and you
use the term public health, they may not know what
you're talking about. But if you say, you know, clean
water or you say clean air, or you say infection control, or you say smoking cessation,
or you say injury prevention, and you go down the list,
I think they have a much better idea of the role of public
health, how important it is. ANAND PAREKH: And again, I agree with Lauren that,
that just helps the understanding with the public helps galvanize
them to ensure that, that public health doesn't get demonized and public health doesn't get politicized.
JOHN AUERBACH: Let me shift gears to
another important aspect, I think of the work in
public health of the future, and that is strengthening partnerships. We've had one of the listeners to
this webinar ask the question about, why is it so important that
we should be encouraging strong and lasting partnerships
between public health and other sectors, including
the health care sector? Is that central to building
the public health system of the future? And which sectors are the most important? MARY A PITTMAN: I think it's foundational, that
we have these community-based organizations and other
sectors working together. We found that the Faith Community was
in some places the most effective spokespeople to get recognition
of the value of vaccines.
And we've seen that in many different
cases over the years that the, you know, faith community can be
strong partners in public health. You know, community leaders are
experts in lived experience and understanding what the problems are, so they can both help us
understand what the solutions are. And sometimes they can help us prioritize. MARY A PITTMAN: Our priorities are not always
what the communities are. And if you don't address their priorities, if they're hungry and they
don't have a place to live, expecting them to pay
attention to our public health priorities may not resonate.
So, I think that's important. We also haven't lifted up
the issues in rural areas. And so often, the rural public health folks are wearing two or three hats, as are the community members. So, I think we really need
to provide additional support resources to build
those relationships, and where people are stretched thin
to augment what's already there. JOHN AUERBACH: So, Mary, you really were talking
about a lot of it as grassroots work, really getting to work with the community and the community organizations.
Do other sectors come to mind, as key to building the strength
of the public health system? ANAND PAREKH: I can add a few, you know,
certainly, I think housing, nutrition, and transportation
to me are central. And then, other partners, Mary
mentioned the faith-based community, I think business and health care. Of course, I wanted to spend
a minute on business, and then primary care specifically. But, you know, we've done
a lot of work at the Bipartisan Policy Center as others have as well, looking at the value
proposition between businesses and public health to
improve community health. And there's a lot of alignment
here, a lot of opportunity there, where those two sectors can work together, and really conquer issues related
to trust and resources, et cetera. So, I think that's one
particular one to highlight ANAND PAREKH: Within health care.
I can't think of any more
important relationship that needs to be strengthened, and we've recently written about this then between public health and primary care. Talk about two of probably
the most important sectors out of the $4 trillion we spend on
health in the United States, public health gets roughly
about two percent, and that's that's generous. Primary care only gets about
six to seven percent. These are the two most important
sectors to improve health that focus on prevention,
focus on population health, the synergies there we
recently talked about it with with respect to COVID 19 vaccination, but there's so many areas there
to to leverage partnerships between public health and primary care. And so I think that there
are a lot of opportunities. I think partnerships with sectors and with specific stakeholders are really ripe. JOHN AUERBACH: And let me just ask you a little
bit of a follow up question there. In terms of that partnership
you were mentioning of a health care and public health.
Are there incentives
that can be created that that make that more likely to occur? Or is there is are there policies that can be adopted that can get those parts to, the two sectors to work more closely
than they have historically? ANAND PAREKH: I think that's a great question,
and I do I do think that there are opportunities there
that that are untapped. You know, we usually don't point
our public health departments in in the direction of community
health centers or primary care. We usually don't reimburse
our primary care providers or in point them in
the direction of public health.
But those are (UNKNOWN)
to two sectors that. And there have been a lot
of great connectivity and advances over the years. But but but I think there's much
more that can be done there, John. MARY PITTMAN: Well certainly a primary
care and public health both have prevention at
the center of what they do. And I think that there's a lot of synergy there and I think that there are places where there are really well-developed relationships around specific issues, whether it's dealing with
undernutrition and food deserts or. And and also in positive things
like enhancing maternal outcomes. We've seen a lot of examples
of health care systems, particularly primary
care and public health, working together towards common goals. What we have seen,
I think in COVID is a real gap in a place where we should be focused.
Focusing some energy is in
the long term care and home care area where I think we really need
to be investing in workforce. We need to be investing in technology. And there's an opportunity
for public health and health care to work together. I think health care also really adopted some technologies quickly during COVID. You saw an incredible rise
in the use of telehealth, and we could apply that in
so many places in public health. So I think that there's places
where technology and lessons can be shared and training
could exist as well. JOHN AUERBACH: You know, in our last few minutes,
I want to try to address to two remaining questions about
public policy and its role.
But I want to start by returning
to the the comments that you were making about
the importance of equity and the importance of centering
efforts to overcome racism and discrimination at the core
of the work that we're doing. And so, you know, I guess I'd ask you, what are the concrete ways that we can? Emphasized that work embed that work within the work of the public health sector and and other sectors it's
working with, including health care. What does it really mean to make
equity at its core, at our core? LAUREN SMITH: That is a good question,
John, and I think that there's probably many ways to answer it, but it's one that I would just
sort of throw out first is that. Organize as organizations. We have to identify
and communicate very clearly our equity principles and then
begin to hold ourselves accountable for how those
are getting built into every aspect of the work that we're doing.
And it's not a one and done
kind of phenomenon, you know, like take class or do an all day workshop. You know, those are
important ways of educating and exposing ourselves
and expanding our understanding. But it's really in the work. How do we do our procurement? How do we do our hiring? How do we do our contracting? How do how do we think about
who's eligible and who's not for just the kind
of grant opportunities? What, what, what's included in the grant, the applications, what are required. So to Mary's point about what's required for a role is a college education, a college degree rather required or both. We have to really interrogate
or reflect on assumptions that we've made around how or what, what are the ways we have to work.
And some of the ways we
have to work our habits, but they're not necessarily requirements. And so having that stance of inquiry and sort of that openness to saying, we're going to really
examine the different aspects and then having
a set of principles that you can apply
so that everyone understands what you're doing is not arbitrary, but it's like we're we're using
these principles to apply. MARY PITTMAN: And John, I would say, you know, there's a lesson that I learned
a long time ago is follow the money and build into some of our
programs requirements so that people are not just
doing the right thing, but they're also getting compensated
for doing the right thing. And that's why I mentioned
the federal health equity for all Act, and that's modeled after Ryan
White, which is greatly successful, and it's going to be
putting investments at all levels of government for programs, embedding health equity goals. And so I think you'll start
to see a demonstration of that with programs like that.
We certainly have seen
it through our health in all policies worked here in California, cutting across every different department, including transportation and housing. ANAND PAREKH: Yeah, I agree, I think you have to be
really intentional about embedding health equity in all of
the areas that we've talked about. Data comes to mind as one of
the most important unless we have data with respect to
disparities and inequities. Unless we can collect them,
we're not going to be able to to address some
of these challenges. The Robert Wood Johnson
Foundation has recently been doing great work in that area. So I think being intentional about
this and really embedding it, whether it's workforce or whether
it's financing related issues, as Mary is saying, whether it's data, whether it's with their partnership related activities, ensuring equity is is front
center in all these areas, I think is critical.
JOHN AUERBACH: Well, you know, we've got only about a minute and a half and the three of you have so much to say
and and are so thoughtful rather than ask a question. I think I'm just going to
ask if you have each of you has maybe 30 seconds
of comments issues that may not have been raised
if you want to put on the table for future
conversations, perhaps. So any closing thoughts? MARY PITTMAN: I have one, and that is the expansion
of Medicaid is so critically important to be able to address
health equity in this country, to be able to deal with chronic disease, as well as acute pandemic issues. And so I would say we
have to pay attention to making sure that we see Medicaid expansion and that we prioritize that
that includes comprehensive care.
We haven't spoken about mental health, but the pandemic showed
the critical nature of mental health. JOHN AUERBACH: Yeah, very true. Lauren Anand, your thoughts? LAUREN SMITH: I guess I was just going
to go back to this piece around excellence in strategic and communications
and being able to describe the work to be able to address concerns. I think in some ways sometimes
we've been caught a little bit back on our heels for some of
this and not being as forward. And I think that, for
example, the work that the Public Health
Communications Collaborative, that the CDC Foundation
Trust for America's Health, others are involved in this
sample of really supporting that.
So I think that getting
getting ahead of things with really powerful
strategic communications, I think is important. JOHN AUERBACH: I'm so glad you raised communications. Thanks so much. And Anand ANAND PAREKH: (INAUDIBLE) you know. I think I'll just stand it back
to your initial question, John, about public health infrastructure and the need for sustained
long term investments. And you know, its data, its surveillance, its laboratory capacity and its I.T. There's so many aspects to that. But without a long term commitment,
it's very difficult for the public health system to address or to help
and try to address any challenge. There is some legislation right now and in the Build Back Better Act that would provide a down payment to support our public health infrastructure.
You know, it's not everything that's
required, but it'll be interesting. You know, I've been over the last
six months in Washington, D.C. I've been waiting for public
health and infrastructure to be used in the same sentence. We were talking about everything else with respect to infrastructure, you know? But, you know, public health, we take
it for granted every single day. It's absolutely a part of our
nation's infrastructure and people should be talking about that when
we talk about infrastructure. So I hope that there will be
some more federal support for our nation's public
health infrastructure.
MARY PITTMAN: Maybe everybody in public health
has to raise their voices and proclaim that we're
being heard at the table. JOHN AUERBACH: Public health and health
care and our other partners. Indeed. Well, I want to thank the three of you. You know, this has both been
a wonderful conversation because you all are
so smart and insightful and really are using your
your vast experience to think about where we need to go. It's also been one of
the most frustrating because it's really difficult to
have such a an important conversation within
the constraints of what we always have to do when we we have limited time. So hopefully we've piqued the interest of those who are listening and they'll be following up in terms of many of
the issues that have been raised. And so again, thanks to
the three of you and Cecilia I am turning things back over to you.
CECILIA OREGON: Thank you, John. That was an incredible conversation. I want to thank you for
moderating the discussion, and I want to also thank the panelists for sharing their time and insight with us. And I want to thank our
audience members for tuning in. Will be emailing a link to
the recording and we'll also be posting the recording of the event on our
website in the coming weeks.
But before we go, I'm going to turn
it over to our final speaker, Dr. David Grossman, who will be
offering his own reflections on the conversation that spanned
over two events this week. Dr. Grossman is a pediatrician
and interim senior vice president of social and community
health at Kaiser Permanente. He leads Kaiser Permanente Social
Health Strategy in partnership with Permanente Medical with
the Permanente medical groups, and he leads the organization's public health advocacy and COVID 19 response. Dr. Grossman. Sorry, Dr. Grossman leaves the organization
efforts to advance our social practice that connects members
with social services, programs and resources to
alleviate food insecurity, socialize isolation and other
social needs, as well as to achieve equitable health outcomes for
the communities we serve. So thank you for being with us today, Dr. Grossman, and I'll hand it over
to you for your final word. DAVID GROSSMAN: Thank you very much, Ceci.
First, on behalf of Kaiser Permanente, I wanted to add my thanks
to and deep appreciation to the speakers and also
the moderators of this panel as well as our
previous one this week. You guys are it's been terrific. We've heard from a really
deeply experienced and insightful set of leaders, and I've heard some, I think very
robust ideas and themes expressed. Many, if not most, of these ideas,
I think, are truly actionable. So we all know that this is a critical
policy conversation that needs a lot more attention and focus
by our nation's policymakers, state policymakers to and also
the public and the conversation's timely given the bipartisan policies. Bipartisan Policy Center new
report as outlined by Dr. Perak. And we and we also know
that more is yet to come. So we convene this panel because
keepy Kaiser Permanente does deeply care about
the future of public health. We believe that health care needs to be at the side of public
health as a key partner, supporting its critical work
in so many different ways.
And I just wanted to really highlight a few of the number of key points that I've come across over the last
several days in these conversations. First, the pandemic has revealed the need for a much enhanced infrastructure. We've heard a lot about that. We have a workforce that's
undervalued, overworked, and it's all a result of
many years of underfunding by state and local authorities, something that clearly needs
addressing very fast and fortunately is being addressed with some
of the recent legislation. We also need a public health
structure that can flex up rapidly in times
that are emergent need, and we need actionable data systems and interoperability so that data and and also analytics can flow in real time across systems using common measures. We also heard about the need to address
the complexity of the oversight, finance and also the operations of
our nation's public health system. And then in addition to
that, we also heard about the importance of
relationships and partners partnerships with key
community institutions, businesses and most importantly, as we just heard today
from the public that for the public health to operate effectively, we need really long standing,
trusting relationships.
Public health needs to
refocus on its key customer, the public and as the public's
trust with public health builds, so will trust with policymakers
and relationships with health care, as we've heard about, are
especially important. And we heard from one of
our speakers on Monday about how that mattered so much for her in her local health jurisdiction in Seattle as the COVID pandemic unfolded. Communications is at the foundation
of trust and relationships, and we heard about
the importance of honing, messaging and curating
the messengers when it comes to talking with the public
and with policymakers. We heard that we need to
be facile storytellers and training our workforce to be more adept at communicating
with the public on every channel. We also heard a lot about
the criticality of using a lens of health equity in all public health work
and the need for public health to assert itself with policymakers
and the public in prioritizing and focusing on vulnerable
and lesser advantaged communities.
Stronger community relationships
matter here too so much. And the public health
credibility with communities of color needs significant strengthening. Addressing as we just heard from our
speakers just a few minutes ago, addressing the underlying
social determinants of health like housing
and food insecurity, and also digital equity
is thankfully getting more attention by health care, but needs much more focus by everyone,
including our policymakers. We heard about the fact that
public health has throughout this pandemic been fighting
a multi-front war, that COVID has been front
and center efforts by public health. Many people are not really
aware that there are other major epidemics that are
co-occurring, like violence, like harm from drugs like
mental health conditions that underlie many of these deaths. And so public health must be
outfitted and prepared to fight disease and injury on multiple
fronts simultaneously.
But before we start the rebuild,
let's acknowledge that our public health troops are hurting very
badly and they're under attack, as we heard, and leaving
the workforce in unprecedented numbers, especially our public health leaders. So that means we must work
to bring some healing and trust back to these
incredibly valuable workers who have saved
literally millions of lives through the work that they've done. The community needs to really rally behind public health and health and health care, along with other communities
and stakeholders must have their back. We must be speaking up
for them and with them. So we at Kaiser Permanente look
forward to being a part of this emerging dialogue and also
the problem-solving ahead. We've all learned some very hard
lessons and are now are ready to lock arms and rebuild our
nation's public health system.
Thank you all for joining us here today and for being part of this conversation. We are really looking forward
to your participation in rebuilding public
health across our nation. Thank you again and goodbye..
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