Disconnect and Discord

One of the studies out of the 2014 Public Health Workforce Interests and Needs Survey (PH WINS) examined the level of awareness among local and state public health employees about eight emerging public health trends (1). The authors, Shah and Madamala, said it was important for the public health community to be aware of these trends to make public health practice consistent with them. They found, however, that many of the respondents had not heard of these developments.  A brief summary of each is presented below followed by a discussion about the challenge of moving these developments forward given the disconnect and discord between local, state, and federal public health agencies.

The trends

  1. Cross-jurisdictional sharing of resources – The National Association of County and City Health Officials (NACCHO) refers to this trend as the “wide variety of means by which jurisdictions can collaborate around the provision of public health services” to deliver those services in a more efficient and effective manner (2). An environmental health specialist who works across more than one county is an example of resource sharing.
  2. Fostering a culture of quality improvement – NACCHO describes quality improvement in public health as “a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community” (3). In 2012, the three most common approaches used by state agencies was Plan-Do-Check-Act or Plan-Do-Study-Act (88%), Lean (43%), and Six Sigma (20%) (4).
  3. Leveraging electronic health information – Shah and Madamala (1) refer to this topic as the “systematic use of information technology to improve public health administrative practices and services.” An immunization information system (IIS) is one example of an important public health information technology capability.
  4. Public health and primary care integration – The Institute of Medicine (IOM) defined this integration as “the linkage of programs and activities to promote overall efficiency and effectiveness and achieve gains in population health” (5). The IOM committee envisioned integration on a continuum ranging from isolation to merger with the concepts of mutual awareness, cooperation, collaboration, and partnership as steps along the continuum leading toward greater integration (see Fig. S-1,page 4, of the IOM report).
  5. Evidence-based public health practice (EBPH) – EBPH has been described “as an integration of science-based interventions with community preferences for improving population health” (6). Its aim is to increase the effectiveness of public health practice much like evidence-based medicine has influenced the practice of medicine (1). Brownson and colleagues (7) suggest the key attributes for EBPH are:
  • Making decisions using the best available peer-reviewed evidence (both quantitative and qualitative research)
  • Using data and information systems systematically
  • Applying program-planning frameworks (that often have a foundation in behavioral science theory)
  • Engaging the community in assessment and decision-making
  • Conducting sound evaluation
  • Disseminating what is learned to key stakeholders and decision makers
  1. Health in All Policies (HiAP) – HiAP is a strategy that the Association of State and Territorial Health Officials (ASTHO) defines as “a collaborative approach that integrates and articulates health considerations into policy making and programming across sectors, and at all levels, to improve the health of all communities and people” (8). This strategy is based on the recognition that health is determined by social and economic factors, not just health sector activities (1).
  2. Public Health Systems and Services Research – PH WINS respondents were least likely to have heard about this trend, which Shah and Madamala define as research that “aims to increase the scientific knowledge about how to best organize, finance, and deliver the right combinations of prevention and public health strategies” (1).
  3. Implementation of the Affordable Care Act – The Patient Protection and Affordable Care Act (ACA) was passed and signed into law by President Barack Obama in 2010, and it put into place health insurance reforms to expand coverage, lower costs, and enhance the quality of care (9).

The inter-agency disconnect

Local, state, and federal public health agencies form the backbone of the public health system. They are supposed to be partners in their common mission of ensuring the health and safety of communities. Instead, many within these agencies have grown to distrust each other. One does not understand the needs of the other, and the resulting divide has contributed to the disintegration of the public health system.

A colleague and I were talking about this disconnect the other day and its impact on local health departments, which sit in the heart of the communities the system professes to protect. We talked about how local practitioners just want help in getting their jobs done. Instead of looking for ways to support their work, however, partner agencies weigh them down with, for example, siloed, pet projects that have limited relevance to their communities, excessive grant requirements, and inflexible funding.

Local health jurisdictions have long experienced difficult financial conditions, but the Great Recession brought many agencies to their knees. In an August 2015 Op-Ed piece, LeMar Hasbrouck, NACCHO’s director, noted that local health departments have cut 51,700 jobs since 2008 (10). He rightly wondered if Americans would have tolerated losing that many positions within another local protective force, namely firefighters. I left my first position with a state health department in 2009 and returned to work with that agency on a statewide project as a consultant in 2012. In 2009, individuals I had known as communicable disease nurses were, by 2012, also the local health department’s administrator or preparedness coordinator. Plus, they were seeing patients in their clinics. Where is the sanity in that? For that same project, I was asked by local coordinators if project funds could be used for non-project operational and capital purchases—basic items like a simple exterior sign identifying the department. The answer was no; CDC grants do not cover those expenses, and apparently, neither did their county commissioners. And too often, I visited local health departments that were housed in small and run-down buildings that sat across the street from large and gleaming hospitals.

How much better off might local health departments be now if their state and federal partners had worked to support them? For example, counties that employ epidemiologists can produce county health profiles that examine their jurisdiction’s progress toward benchmarks on multiple topics. The resulting analyses can be used to: inform the county’s progress toward those benchmarks; determine the best use of a county’s limited resources; and demonstrate the health department’s value to decision-makers. What are counties to do if they cannot afford epidemiologists? Turning to the state health department for assistance may not be much of an option. In Oregon, only a handful of epidemiologists are employed in the thirty-one local health departments outside of the highly-populated three-county, Portland-metropolitan region. I was told that state-level epidemiologists cannot work on comprehensive and cross-cutting local or regional health profiles because of grant constraints under which their positions are funded and that the work they do on behalf of local jurisdictions could be considered pro bono.  Those statements ring hollow, however, when one sees barriers pushed aside to support moneyed and political interests. I witnessed a rather rapid and concerted effort to give coordinated care organizations the data they needed to assess their progress toward health benchmarks. (Look at how the data are presented in reference 12 as an example of whose interests prevail).  Local data do exist, but not in a single comprehensive format that includes helpful interpretations and recommendations.

The intra-agency disconnect

Implicit in many of the trends noted by Shah and Madamala (1) is the burgeoning requirement for professionals with data and information technology skills within health departments. Public health leadership, however, seems reluctant to understand and prioritize this business need.

For example, an IIS is a local, regional or statewide registry that collects and stores immunization records for its jurisdiction. IIS’s are clinical decision making tools used daily by public and private health care providers to look up their patients’ immunization histories and determine which shots are needed.  Also, IIS data are invaluable for monitoring vaccination uptake rates for counties, states, and large metropolitan areas. As a former manager of IIS research personnel, I watched the understaffed operations side of the IIS team struggle to maintain this critical system. The CDC provided limited funds for IIS operations, and I saw IIS positions put on hold indefinitely during hiring pauses while positions were filled for the top-heavy and questionably-effective executive and administration teams.

Standing together

Somewhere over the years, public health agencies lost sight of how to support each other in pursuing their common goal, and local health departments have borne the brunt of that disconnect.  Some corrective actions are being taken. For example, through Oregon’s public health modernization activities (12), county commissioners and state legislators might eventually grasp the importance of public health practice and better fund local and state agencies.  At present, however, cynicism, resentment, and burn-out pervade those agencies because people are tired of being overworked, underappreciated, and dismissed by their partners.

Many of the trends examined in Shah and Madamala’s paper, if advanced, have the potential of transforming public health practice into an efficient and cost-effective discipline that can quantify and communicate its value to decision-makers.  This will only happen, however, when local, state, and federal agencies demonstrate their commitment to each other through sincere actions and deeds.

Your turn

Comments about this posting are welcome and can be entered below. I am looking into whether email addresses can be eliminated as a required field. If you would like to be a guest blogger, please contact me through the Contact tab on this website.

Please also take a moment during this holiday season to remember our public health brothers and sisters who were slain or injured last week in San Bernardino, California.

All the best!  Kathy


1) Shah GH, Madamala K. Knowing where public health is going: levels and determinants of workforce awareness of national public health trends. J Public Health Management Practice, 2015, 21(6 Suppl), S102-S110. Available at: http://journals.lww.com/jphmp/toc/2015/11001. Accessed Nov. 28, 2015.

2) National Association of County and City Health Officials.  Cross jurisdictional sharing of services. Available at:  http://www.naccho.org/topics/infrastructure/cjss.cfm.  Accessed Nov. 28, 2015.

3) National Association of County and City Health Officials. Quality improvement. Available at: http://www.naccho.org/topics/infrastructure/accreditation/quality.cfm.  Accessed Nov. 28, 2015.

4) Association of State and Territorial Health Officials. ASTHO profile of state public health: volume three. June 2014. Available at: http://www.astho.org/profile/. Accessed Nov. 28, 2015.

5) Institute of Medicine. 2012. Primary care and public health: exploring integration to improve population health. Washington, DC: The National Academies Press.

6) Jacobs JA, Jones E, Gabella BA, Spring B, Brownson RC. Tools for implementing an evidence-based approach in public health practice. Prev Chronic Dis 2012;9:110324. Available at: http://www.cdc.gov/pcd/issues/2012/11_0324.htm.  Accessed Nov. 29, 2015.

7) Brownson, RC, Fielding, JE, Maylahn, CM. Evidence-based public health: a fundamental concept for public health practice. Annu. Rev. Public Health 2009. 30:175–201. Available at:  http://www.astho.org/Programs/Evidence-Based-Public-Health/Evidence-Based-Public-Health–A-Fundamental-Concept-for-Public-Health-Practice/.  Accesssed Nov. 28, 2015.

 8) Association of State and Territorial Health Officials. Health in all policies. Available at: http://www.astho.org/Programs/HiAP/.  Accessed Nov. 28, 2015.

9) Medicaid.gov. Affordable Care Act. Available at:  http://www.medicaid.gov/affordablecareact/affordable-care-act.html.  Accessed Nov. 28, 2015.

10) Hasbrouck, L. Americans endangered by cuts to local health departments. The Hill. August 4, 2015. Available at:  http://thehill.com/blogs/congress-blog/healthcare/250099-americans-endangered-by-cuts-to-local-health-departments. Accessed Nov. 29, 2015.

11) National Association of County and City Health Officials.  2013 national profile of local health departments. January 2014. Available at:  http://www.naccho.org/topics/infrastructure/profile/upload/2013-National-Profile-of-Local-Health-Departments-report.pdf.  Accessed Nov. 30, 2015.

12) Oregon Health Authority, Public Health Division. Oregon Health Profile. Available at: https://public.health.oregon.gov/About/Pages/HealthStatusIndicators.aspx. Accessed Nov. 30, 2015.

13) Oregon Health Authority, Public Health Division. Public health modernization. Available at: https://public.health.oregon.gov/About/TaskForce/Pages/index.aspx. Accessed Dec. 7, 2015.

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