Public Health Law: A Tool to Address Emerging Health Concerns

>>Thank you for
joining us today, no matter when or
how you’re tuning. I’m Dr. John Iskander, it’s
my pleasure to welcome you to CDC Public Health Grand
Rounds for December, 2016. Public Health Grand Rounds has
continuing education credits available for physicians,
nurses, pharmacists, veterinarians, health
educators, and others. Please see the Public
Health Grand Rounds website for more details. Some of today’s presenters
are lawyers, but they are not your lawyers, nor are they the
agency’s lawyers. If you need legal
advice or counsel on anything presented today,
please seek the advice of an attorney licensed
in your jurisdiction, but please watch
the session first. Grand Rounds is available
on all your favorite web and social media sites. We are also live tweeting today,
use #CDCGrandRounds. We have a featured
video segment on YouTube and our website called,
Beyond the Data, which is posted shortly
after the session. This month’s segments
feature my interviews with both Dr. Karen DeSalvo
and Mr. Matthew Penn. We’ve also partnered
with the CDC Library to feature scientific articles
relevant to this session, available at the
CDC Library website. Here’s a preview of upcoming
Grand Round sessions. Please join us live or on
the web, at your convenience. In addition to our outstanding
featured speakers today, I’d also like to acknowledge
the important contributions of the individuals listed here. Thank you! We’ll now hear some
taped remarks from the CDC director,
Dr. Thomas Frieden.>>Law is one of the many
important tools we can use to protect the public’s
health and safety. Law touches every aspect
of our day-to-day lives. From the seatbelt you
used on your way to work, to the clean air your breathe, to the water you use
to make your food. Laws are in place to protect
your health and safety when suggestions or
education aren’t enough. In the early 2000’s, some of the most effective
public health laws related to restricting tobacco use were
scaled up in New York City. When the public health community
saw how well these laws worked, to decrease smoking and improve
health, they became templates for public health action
around the country, and throughout the world. Some of the great public health
success stories of history’s, child immunization, safer
workplaces, clean water, wouldn’t have been possible without changes in
laws and policies. In fact, federal,
state, tribal, local, and territorial jurisdictions
routinely use law to make individual’s
default decisions healthier and to protect us from threats that we can’t individually
control. Examples of laws currently
in place, or being adopted to create healthier context,
include prohibiting the sale of alcohol to minors,
ensuring fluoridated water to protect oral health,
increasing prices of unhealthy products,
such as tobacco, alcohol, and sugar-sweetened beverages,
and protecting the health of children by banning the
use of lead-based paint. This year, as the
Zika epidemic grew, CDC’s Public Health lawyers
helped Puerto Rico’s legislators create a vector-control unit. We advised them on
what makes an effective and efficient control unit,
from a legal standpoint, based on the best practices
from around the United States. Law and public health
are inextricably linked, because law is a key function
to leverage better, faster, and longer-lasting
public health outcomes. Legal interventions aren’t
usually our first choice, but they can be very powerful,
especially in combination with more traditional
public health action. Because of our mission to
protect our nation by rapidly and effectively responding
to health threats, CDC has a unique perspective
on public health law. We use it to research
new approaches and inform public
health practice around the country
and the world. Public health law
research must be carried out with the same
scientific rigor and precision as other areas of epidemiologic
research and evaluation. This is important to
understand its impact as a tool and improve public
health outcomes. CDC’s Public Health Law Program,
in partnership with other parts of CDC, and organizations
from many different sectors, studies the relationship
between law and health, and promotes best practices in the application
of law and policies. Today’s speakers will
describe the role of law in affecting the social
determinants of health. To protect people and
improve health outcomes. Thank you!>>Our first speaker today
is Montrece McNeill Ransom.>>Thank you, John,
for that warm welcome, and thank you all
for joining us today. I’m very pleased to be
here, to talk with you about a topic that’s
near and dear to my heart, public health law. I’m going to start first
by providing a little bit of a historical context
and provide a framework for the presentations by Matthew and Dr. DeSalvo that
will follow. I’m going to begin by giving
you a little bit of an overview of CDC’s Public Health
Law Program. Last year, our program marked 15
years for public health service. PHLP was founded in
2000 by Dr. Jeff Koplan, former CDC director,
and Gene Matthews, former CDC general council,
who saw a need for a program that would help state,
tribal, local, and territorial health
departments, and their partners, better understand
the role of law and advancing their
public health goals. Shortly after our
founding, the September 11th, 2001 terrorist attacks, and the
subsequent Anthrax attacks took place, and there was a
recognition of a broader need for public health emergency
preparedness, including the need for a better understanding
of public health law. During this time, and for
almost a decade to follow, much of our work in the public
health law program focused on helping state, tribal, local, and territorial public health
practitioners better understand the role of law and
preparing for and responding to public health emergencies. We worked with partners to
create tools to help states in their planning for
public health emergencies, including an initiative called, The Community Public Health
Legal Preparedness Initiative, which was the first of it’s
kind partnership between CDC and the American
Bar Association. We also began convening the
first national conferences in public health law in 2002. So, why public health law? From my perspective, there is no
public health without the law. From the establishment of a
health department, which is done by statute, to passing a
clean indoor air ordinance, it really is the law that
creates the framework for healthy choices
to become the norm. And our legal history
is rife with examples of government’s action to
protect the public’s health. So our legal history
reveals both the power and the limitations of
government’s authority to protect the public’s
health, and I’m going to provide you with
a few examples. One of the more
widely-recognized foundational moments in the history
of public health comes from the 19th century
neighborhood of Soho in London. As you might recognize, this
is the Broad Street pump. After several outbreaks
of cholera in London, a major outbreak struck
the neighborhood of Soho. John Snow, who many
of us recognize as the British physician who
eventually linked the outbreak to contaminated water,
later called it, the most terrible
outbreak of cholera which ever occurred
in this kingdom. In fact, the outbreak killed 616
people and caused three-fourths of Soho residents to flee. And this is often
where the story ends. But it’s not where
the story ends. John Snow took his findings to
a local council, a legal body, who then decided to
remove the handle from the Broad Street pump. This is one of the very
first examples we see of a legal intervention
that’s based on epidemiological findings. Since that time, epi and the
law working together have really been the foundations for
modern public health practice in this country. So let’s look at an example
from the United States. If you take a look here, this is
Varick Street in New York City, prior to New York City’s
sanitary reforms of the 1890’s. Street cleaning and regular
trash pickup were only available to those who could pay
for it, to the affluent. I mean, as you can see here,
garbage and filth were allowed to accumulate on the city
streets and in the alleyways, and then the rest of the
city’s neighborhoods is shown in this photo. So focus, if you will, on the
lamppost in the foreground. I usually have a little
light that I can shine there, but focus on that lamppost. This is the same corner of
Varick Street, two years and a massive cleanup later. It wasn’t until the late
19th, early 20th century that public health reformers
and public health lawyers began to see a common thread
in their work. A shared understanding
of the causes of disease, and the ambitious sweeping
action that would be required in order to protect
the public’s health. Along with laws and
policies, sanitation laws in New York City resulted in not
only improved living conditions, but a decreasing burden of infectious diseases
for city residents. So, I’ve given you an example of
a legal intervention in the name of public health on
the neighborhood level, on the city level,
let’s now turn to what we call the
most important case in public health law,
certainly a foundational case, and it comes from the
early 20th century, Jacobsen v. Massachusetts. Jacobsen was a landmark
Supreme Court case on the constitutionality of mandatory public
health control measures. In 1902, there was
a smallpox outbreak in Cambridge, Massachusetts. The defendant, Reverend
Henning Jacobsen, refused to be vaccinated as
the law required at that time. He was fined 5 dollars,
which would be roughly about 130 dollars today,
and he refused to pay it. And he challenged
the constitutionality of the law in court. This case made it all the
way up to the Supreme Court, where the Supreme court affirmed
the state’s use of police powers to require mandatory
vaccinations for smallpox, and the judges in that case,
or the justices in that case, noted, that there are
manifold restraints to which every person
is necessarily subject for the common good. Now this case is
over 100-years-old, but it is still very important
to public health practice today. It represented the
beginning of an application of modern constitution –
constitutional analysis to disease control law and
to public health actions. And there were at least
four key holdings that – that are important today. The first is the
use of police power for public health concerns. It affirmed the state’s ability to use police powers
for public health. It also affirmed the
ability for states to delegate certain
authorities to health agencies, or lower-level government
subdivisions. It also provided
support for actions that may limit individual
liberty for well-established
public health interventions. And it also provided
constitutional support for a spectrum of
contemporary public health laws that both Matthew and
Dr. DeSalvo will expand on in just a few moments. So this has held
true ever since. This table lists four of the ten
great public health achievements of the 20th century,
originally described by CDC in the Morbidity and Mortality
Weekly Report in 1999. As you can see here, none of
these would have been possible without law and legal tools. So what does this mean for you? To apply law and policy to your
important work in public health, it’s really important that you
understand the constitutional framework for public health
practice in this country. The U.S. Constitution
distributes power between the federal,
state, and local government. We call this, federalism. And it also provides a
framework for the balancing of public health –
balancing of public health and individual interests. The federal government’s
powers come from Article 1, Section 8 of the
U.S. Constitution. There’s a set of
enumerated powers for the federal government,
and they include things like, the power to tax and
spend, the authority to regulate interstate
commerce, but in the realm of public health, those are
really limited authorities. What you’ll notice is that
while we have the authority on the federal level to
quarantine at state lines and along our borders,
the majority of core public health activities
lie in the hands of the states. This power is known as the
police power, and it’s expressed in the 10th Amendment
to the Constitution, which grants all powers that
are not explicitly given to the federal governments
to the states. This concept of police power
is particularly important for our work in public health. It’s important to note that
courts generally allow state and local governments to
exercise their police power, as long as the action
is reasonable and is for the purpose of
promoting the general health and well-being of the community. And states can delegate
this power or share it with their local governments. So, some states give local
governments extensive police powers. For example, Florida and
Illinois, and California, as you see on the slide here. And others greatly limit the
ability of local governments to exercise their police powers. Arkansas and Nebraska
are examples of states that limit local police power. This excerpt is from the
California State Constitution, which, as you can see, gives their local governments
broad police powers. So what about Native
American tribes? Well, tribes have a special
status, with their own set of powers and their
ability to govern themselves with significant extent. We call this tribal sovereignty. On tribal lands, which is
known as Indian Country, tribes have the power
to do what’s necessary to control their
internal affairs and preserve their
self-government. Including the ability
to create their own laws and health regulations that
protect the health, safety, and welfare of tribal
communities. What you see here is
the Navajo Reservation, which is the outer boundary, and the Hopi Tribe
Reservation within it. So how can we, as public
health practitioners use law as the public health tool? Well, on the federal level, the federal government
can use its powers to shape public health by
incentivizing local action. You see this most commonly
done through funding or through the establishment
of a federal program that might have a
trickle-down effect. The national minimum
drinking age in the United States
is an example of this. In 1984, Congress passed the
National Minimum Drinking Age Act, which withheld 10 percent
of federal highway funding from states that didn’t maintain
a minimum drinking age of 21. This law was challenged,
interestingly, by the state of South Carolina in 1987, but
upheld by the Supreme Court who has said that Congress
validly exercised its taxing and spending power,
and, therefore, did not infringe
on state’s rights. Higher level of governments can
also impact public health laws and policies through a
concept we call, preemption, or by prohibiting action at
lower levels of government. Here it’s important to note that preemption can
actually be frustrating to public health activities,
particularly on the local level, as we’ve seen with
state preemption of local smoke-free laws. But otherwise, state and local
governments really have a great deal of public health authority. And I’d like to close by
offering you a few examples. One of the best-known
examples is the power of local health officials to
investigate disease outbreaks, and to invoke isolation and
quarantine orders in order to prevent the spread
of infectious disease. Another example here
is while a state or local government may not
generally regulate smoking in an individual’s home
or in single-unit housing, because of the privacy
interest there, it can certainly regulate
smoking inside multi-unit housing, and the goal there
is to protect the health of other residents
from secondhand smoke. In fact, just in November
of this year, a new rule, federal rule, was announced
which prohibits smoking in public housing
developments nationwide. The final rule prohibits lit
tobacco products in the housing, in the common areas, and
also in the outdoor areas, within 25 feet of housing
or administrative offices. Now you won’t see this ban
implemented immediately. The rule does give
public housing agencies, across the country, 18
months to implement the ban. Local governments also have
considerable discretion when using zoning regulations,
or land-use classifications. We’ve seen communities
use their zoning laws to create farmers markets, which
we know can increase access to fresh fruits and vegetables, and further chronic
disease prevention efforts. And police powers also allow
us to protect the safety of children by requiring
them to wear bicycle helmets. Interestingly, most of
these laws are passed and enforced on the local level. As you can see on this slide
here, there are 22 states with statewide laws, but 201
local ordinances requiring children to wear
bicycle helmets. State policies can
also save lives by monitoring prescription
information, and also increasing
access to naloxone. Naloxone is the opioid
medication often used to reverse the effects
of narcotic drugs, pictured here in this slide. State and local laws can
permit naloxone to be used by paramedics, other
personnel, and even bystanders without a prescription. And finally, laws and policies
equip our state, tribal, local, and territorial partners
with the tools and processes necessary
to effectively and appropriately
prepare for and respond to public health emergencies. And a really good current
example of this is the use of emergency declarations to
respond to the Zika outbreak. So, before I pass the mic to
Matthew and then onto Karen, I’d like to close by saying, there really is no public
health without the law. And, as you’ll hear,
in both Matthew and in Karen’s presentation,
it really is the law and legal frameworks
that help us to advance our public health
goals in this country, and help us to ensure that
healthy choices are the norm. And, with that, I will
pass the mic to Matthew, Matthew Penn, our next speaker. [ Applause ]>>Thank you, Montrece. So the question is,
where do we go from here? When you can go three
miles in a major American city and see a 13-year difference
in the average life expectancy. One place that we must go is to
social determinants of health. We made incredible
advances in public health across the 20th century,
and if we expect to make the same advances in
the 21st century, we will have to address the social
determinants of health. So where does law
fit in with this? Laws stand as the
foundations of the systems that create social
determinants of health, many of them, like
healthy housing. Whether it’s zoning,
housing codes, improving indoor air quality,
or reducing exposure to lead, law plays a critical role
in maintaining healthy and affordable housing. Laws affect our transportation
system, with the potential to make our communities more
walkable, increasing access to alternative transit,
like bicycles, reducing air pollution,
increasing physical activity, and reducing the burden of
chronic diseases, generally. And education. Our education system is
structured and financed through the use of law. Now these types of law
are not important simply because they establish the
systems of social determinants of health, they are
important also because we create
them consciously. Laws don’t happen by accident. And if they can be created,
they can also be studied and changed to be better. So how do we do that? Well the first step
is to recognize that law is a social
determinant of health. In fact, it’s one of the most
significant social determinants of health. And we can study it, just
like we study other issues that affect our health. We do this through
transdisciplinary model of public health law, where
scientists and lawyers and epidemiologists work on
legal epidemiology projects. Researching law as a factor
in the cause, distribution, and prevention of disease
and injury in populations. Public health law is
not just about the law. It’s about science
and epidemiology and the law working together
to improve the public’s health. We use legal epidemiology to
assess the legal environment around a public health issue. Such as radiation contamination,
as shown on the slide here. So that we can understand
trends and study impact. Legal epidemiology is the
scientific study of law as a factor, and the cause,
distribution, and preventions of disease and injury. And legal epidemiology allows us to descriptively
answer questions about what laws say
and how laws work. And the practice of public
health law, as I said, is transdisciplinary,
involving both science and law. So what does legal
epi look like? Well, whether it’s legal
mapping or legal evaluations, the goal is to understand
what the law says, how the law changes over
time, how the law relates to health data, and what
the impact it’s having on our health. So let’s look at some examples
of legal mapping and get a sense of the types of questions
it can answer. So here we see an analysis
of vaccine exemption laws, organized by states
and by regions, showing the different attributes
of the laws that we assessed. So these results were
pretty surprising. I think one of the things
that stood out for me, when we first started
collecting the laws, was just the sheer number, this
is clearly an area very active for state legislators. We found over 6,000 laws
related to immunization and vaccines in the states. And when we started to
drill down into the data, we really found that this
– there’s a wide variety in how states address
vaccine exemptions, with really centering on
how to obtain exemptions and the administrative
requirements sort of built around those that
people have to follow. Moving onto another tool of legal epidemiology,
policy surveillance. Legal epi can show how
laws change over time. Note the deliberate similarity
between the definition of public health surveillance
and this description of policy surveillance. Here, in this slide, we
see an example of health in all policies provisions and state laws targeting those
social determinants of health, with, of course, the goal
being health equity in the end. We also studied state
ebola movement and monitoring policies, and
compared them to CDC guidance on the issue during
the outbreak. The light blue represents
states with policies equivalent to the CDC guidance, and the
dark representing policies that were more restrictive. And, importantly, we studied
how they changed over time. And we noted a shift toward
states clarifying their policies to be equivalent
to CDC guidance. Legal evaluations
are another type of legal epidemiology study. These assessments of health-related laws often
times come from real-world, front-line public
health responses. For example, during the 2012
fungal meningitis outbreak, public health departments
needed to identify patients in hospitals and other
facilities with clinical signs of the disease, figure out
the cause of the disease, and then find people who
may have been exposed to the contaminated steroids. One of the problems during the
outbreak was getting timely and useful access to electronic
health record systems. And it appeared that a variety of legal provisions both
facilitated and hindered access to patient health data at a
variety of these facilities. So, as a result, CDC and
the Association of State and Territorial Health Officials
conducted an evaluation of how well state
laws, and, importantly, implementing those laws. Allowed facilities to
provide access to patient data in health departments through
electronic health records. And what we found was that
there were many perceived legal barriers to accessing
electronic health records. That what many facilities
thought were legal prohibitions to accessing the records, were,
in fact, not true barriers. Through interviews with
the health departments, we identified solutions that the
health departments had developed to get around these
perceived barriers. Both technological solutions, such as dedicated health
department user ID’s, and also legal solutions, such
as new laws or memorandums of agreement, worked
out before an outbreak. And we rolled these findings
into a toolkit with ASTHO so that others can
improve access to electronic health records, hopefully before the
next outbreak occurs. So, why legal epidemiology? Why study law as a social
determinant of health? I think one reason is, in New
Orleans, you can go five miles and see a 25-year difference
in average life expectancy. This is the social determinants
of health in action. This is legal systems affecting
where we live, work, and play. And we must understand the
impact that these laws have on our health if we want
to change those numbers. And, with that, I’ll turn
it over to Dr. DeSalvo. Thank you! [ Applause ]>>Thank you very much, Matthew,
and thank you to the CDC and others for having
me join here today. I’m happy to get the
chance to share a story about the legal framework
in action for public health on the frontlines and how we’re
seeing that expand nationwide in something that we
call, Public Health 3.0. Matthew is correct. In a community like New
Orleans, we have a gap in life expectancy, had a gap
in life expectancy of 25 years, based upon the neighborhood
in which somebody lived. Which, by any of our
measures, would be inexcusable, but had been the
case for generations. And when Hurricane
Katrina struck New Orleans and the entire Gulf
Coast in August of 2005, she did not bring with
her the health challenges that we all began to talk about,
but she brought them to light. It gave us an opportunity
to understand that we had been
ignoring, in many ways, what were not only low means,
but wide gaps in health outcomes for the people in
our communities. The devastation from
Hurricane Katrina was that the entire healthcare
system, including the public health
system, from 911 all the way to academic health centers and public health
laboratories, was destroyed. But in that tragedy of
buildings and the death of some 1,800 people, we
also had an opportunity to rethink our approach to
health in our community, and to begin to rebuild, as we
put our system back together. Like many in the U.S., we turned
our attention, very immediately, to health, knowing that the
healthcare system itself was the frontline, and we had not been
sufficiently attending to some of the most important components
of primary care and prevention. And so as we looked to change
the infrastructure that we had in place, we began to
consider how we would move away from a system that
was very burdened by emergency room visits
and hospitalizations, that most of the care for people
in the community of New Orleans and the surrounding area
was received in long lines, in the waiting rooms of
places like Charity Hospital, pictured here in this slide, a
place that many of us trained and generations of people
had sought out care, that was good care when you got
in the system, but not available in neighborhoods and
not moving upstream, certainly to primary
care and prevention. The closure of Charity and many
of the healthcare facilities in our community caused us to
literally go on the streets and begin to meet people where
they were and provide services, some urgent, such as the giving
IV fluids to first responders, but, over time, taking over
facilities and buildings in neighborhoods so that we
could provide more comprehensive primary care and mental
health services to those in our communities as
they began to return. Really, our approach,
was to think about how we could
get a delivery system, a healthcare system, reformed so that we could better
meet the needs of the health of our population to raise the
mean and eliminate the gap. We built a system
that was grounded in a community health
infrastructure, great primary care,
mental health services, offered in these dots all in the
map, all across the community, serving some 20 percent
of the population. We built up a system that was
focused on improving the quality of care, the experience of care. We worked to digitize
that system so that we would have individual
care, not only that was better, but also be able
to use that data to advance population health,
and we focused on paying for value and on really
expanding coverage to include everybody in
the healthcare system. But as far as we took all of
this healthcare improvement, better care is necessary, but
not sufficient to reduce a gap, like you saw on the map
in Matthew’s presentation and in mine, we knew, indeed,
that what we would need to do to address this kind of a
health challenge would take more than healthcare. It was going to take attention
to the broader determinants of health, in particular the
social determinants of health. Using Don [inaudible] model,
this would move us away from buckets one and two, where
healthcare was more engaged to really moving
towards bucket three, where we would bring together
all the potential levers at our disposal to
really advance health, including the public
health legal framework. It’s worth, just underscoring, that sometime we take the
social determinants of health for granted, but in a community
devastated by any disaster, in our community of New Orleans, it was obvious how important
the social determinants were. People who were coming into the
healthcare system spent more time talking about
their lack of housing or educational opportunities
for their kids, or jobs, these were the important,
relevant factors in their health and on their minds everyday,
and so the healthcare system, but more importantly, the public
health system, very rapidly, began to embrace and understand
that we needed to work together to address, not only
the medical, but all of the social
determinants of health, as well. We embraced this
notion of public health, what we could do together as a
society to ensure the conditions in which everyone
could be healthy. That caused many of us, me
included, to begin to look for partners in our
society, our local community, and at the center of much of this was our local
public health agency, buffeted intensely by Hurricane
Katrina, as well as years of underfunding, but
really at the cornerstone of what would be necessary
to bring everyone together to improve all of the
determinants of health, and I took the opportunity, when asked to become the
Health Commissioner in the city of New Orleans, some 6 years after Hurricane Katrina
had struck and when we had a new
mayor who was interested in rebuilding health in our community using
the broad determinants. Like many other public health
departments around the country, at that time, we were
buffeted by many pressures, including the great recession
and significant underfunding and a loss of staffing
related to that, but we also saw opportunity. You heard about John Snow
earlier, there’s his map on the left, and the work
that he did with epidemiology, probably on paper, I’m guessing, but now we have renewed
opportunities in this era, from data – for example, from
electronic health records, this image on the right, used
in Flint to identify lead – elevated blood lead levels in
that children in that community. This source of data,
electronic health records, plus many other kinds of
big data is giving lots of public health departments,
including ours in New Orleans, a chance at seeing the health of our communities
in more real-time. The first piece of
advice that I got when I became a local health
officer, from Bobby Pestronk, who was running the
National Association for City and County Health Officials,
was that I needed to look at my legal underpinning and really understand what
the infrastructure was that had built our
health department, understand our statutory
roles and responsibilities, look at where we might have
gaps in our legislative or statutory authorities
that might impact health, and the CDC OSTLTS team and the
public health law group were right there to help us dig into where we might have
opportunities or challenges, and how we might
build a framework for moving forward the
health of our community, not only using more
traditional tools, but really using what may
be the most traditional tool of public health law. I say, often, that the
framework taught me that we have to understand what we must do,
what’s required, that, perhaps, we weren’t even doing
what was allowed, but we hadn’t leveraged,
and what was not allowed, but that we wanted
to be able to do. We found, in our digging, for
example, that the health officer of New Orleans was allowed
to regulate pigs and fowl in the French Quarter, which,
at first, made us giggle, but then we began to realize that that could be a pretty
important tool in the effort – in the event of something
like swine flu or bird flu, if we wanted to act
quickly in our community. But we also knew
that what we wanted to do was advance our
policies around tobacco, since cardiovascular disease
was such a major cause of death in our community. And we found, for example, that we were not
actually leveraging what – what was expected by the state’s
rules and so we had more room to grow without even
changing legislation, but we knew we also wanted to
and needed to do more over time. What we were doing
in New Orleans, of thinking about
rebuilding a health department that could address the social
determinants that could use data in more innovative ways,
that could bring partners to the table from
various sectors to take in a multisectoral
approach was not unique. What’s been happening in
local and state public health across this country is something
that we call Public Health 3.0, it is a transformed way of
more broadly addressing the public’s health. It’s what we might say
is a significant upgrade in public health practice that’s
part of a more modern vision, emphasizing this cross-sectoral
environmental policy and systems-level actions that can also address
the social determinants. Not to say that the work of,
the eras of Public Health 1.0 and 2.0 aren’t critical
and important, and, indeed, the goal is to build upon these
prior eras of public health. You heard already about the
importance in the early years of public health, not
only of using data to understand communicable
disease, but actually using policy
around housing and other tools to address those
social determinants, to tackle the communicable
disease that was the prominent
epidemiology of the time, but advancing into the
era of Public Health 2.0, noncommunicable disease, chronic
diseases, became more important and public health became more
of a healthcare provider, particularly for
marginalized populations. But this new era is a
new opportunity for us to build upon those
successes, and, again, work in a more multisectoral
fashion, and have public health at the center of
bringing people together to address the social
determinants of health. When I came to Washington,
I took the opportunity of being there to learn
from other communities, to see if what we had been doing
in New Orleans, and what I knew of happening in other
communities, was a movement across
the country. I wanted to understand if Public
Health 3.0 could be defined and have a framework,
and what we could learn from successful models
around the country. We laid out a framework
with key components that include leadership
and workforce developments, secondly, essential
infrastructure, particularly accreditation
and accountability. Third, strategic
partnerships, particularly those that may be not considered
so mainstream or normal, relationships with the business
community as an example. Fourth, it seemed
that data, analytics, and metrics were a
really critical part of this new transformed public
health infrastructure, and, finally, flexible and
sustainable funding that wasn’t so categorical, but allowed
for blending and braiding and really more broad
approaches to health. We visited five communities, not
because they’re the only ones, but because they met
a set of criteria that we felt would be exemplary
to help us understand what was – whether this framework made
sense, and what we could do to help them stay successful and let more communities
become successful. What we learned we produced
in a report this past October, which is available online
at We have five high-level
recommendations that I’ll walk through very quickly that
relate back to that five – five area framework, about
what we saw as successful in these communities, to help
them be able to transform and address the social
determinants of health so that they had
a broader impact. We found that they were working
as chief health strategists in their communities, and this
wasn’t always necessarily only the public health officer, but sometimes a local business
leader who was stepping up to the forefront to make sure that all the right
players were at the table. Secondly, we saw, recurrently, that there were very structured
cross-sector partnerships that allowed them to do collective action
on the frontlines. Third, we say that
they were accredited, but these health departments
took seriously their accountability responsibilities
and wanted to be able to not say themselves that
they were good and strong, but that they had an external
entity that was coming in and telling them, and the
taxpayers, and their partners, that they were accountable
and that they were able to be strong partners, not only
today, but into the future. Fourth, they were using
data, and are using data, in really interesting ways,
it’s very actionable information that tends to be more
timely and granular. They’re using tools
like mapping, but they’re also thinking about community-level indicators
beyond individual level health indicators, such that
they really are measuring and monitoring the social
determinants of health. And, finally, they’re finding
ways to expand the pie. So they’re – they’re
funding is enhanced by creating umbrella
organizations that can share funds,
and that allows them to be more flexible and,
frankly, to begin to work in spaces like public
health law, where they haven’t
traditionally had a set of categorical funding, but
they understand the power and importance of
broadening their reach. In fact, I’m going to show
you just one statistic from New Orleans in a minute,
but I will tell you that none of what we ought to do, not
only as an intellectual exercise as a public health commissioner,
but certainly actions that we were able to take
to advance the health of our community wouldn’t
have been possible without public health law. It is such a critical,
nonmedical determinant of health, but also can
affect the healthcare system. Certainly, nationally, the Affordable Care Act has
had a major impact in seeing that people have
access, not only to care, but to primary care
and prevention. The HITECH Act, which was
part of the Stimulus Act, gave all communities
in this country, not just the healthcare system,
but has touched public health as well, a chance to have
availability of more real-time, granular data to
understand, not only the care that people are receiving,
but the population and the public’s health. And we took that even further
in our community in New Orleans, looking at how we could tackle
the leading causes of morbidity and mortality, particularly
cardiovascular disease in our community, and
through our umbrella efforts of our social determinants
of health and Public Health 3.0
were called Fit NOLA. We – we advanced policies
through our city council, like Complete Streets,
to increase opportunities for physical activity, and,
eventually, the community of New Orleans went beyond
what was on the books, as smoking policy, and went
for a citywide smoking ban. And what you’re saying is
the same thing that U.S. News and World Report said, really? New Orleans? We – we were — as the communications people
will tell you, get the headline and the picture, and we did,
we were so proud as a community to be recognized for our culture
of health and our roadmap that we – we had laid out
forward, it’s a community that, historically, may not have been
known for health, but we began, we understood, very quickly,
that only by working together and including the broadest tools
and levers at our disposal, would we be able to advance
the health of our community, and though we don’t have gap
data quite yet, this information from county health rankings
is one of many indicators, that you are welcome to look at, about how we have been
progressing in health in the community of New Orleans, and certainly premature
death is down, as our many health care
indicators and, increasingly, some broader public
health indicators, like – like physical activity. New Orleans is an example of
one community that has learned to build upon the strong
foundations of public health and the eras of 1.0
and 2.0 and began to address broader
social determinants. The work that we have done
to advance in that community, just as we have seen
in communities all across the country, that
our Public Health 3.0 style communities, is grounded in the
importance of public health law, not only how they’re statutorily
created, but how they use that as a tool to advance
the public’s health. Thank you all, very much! [ Applause ]>>Thank you! Thank you, Matthew
and Dr. DeSalvo. It’s now time for Q&A. A couple of quick notes. You’ll need to ask your
questions via the microphones that are in the middle
of the room back there. And, also, it’s very important that we keep the questions
brief, we want to try to fit in as many as we can in the
remaining time that we have. I think I should start
first with Susan. Do we have any questions
from our online participants?>>We do. Thank you! Can the power to regulate
interstate commerce be used to regulate food industries
for maximum health outcomes, for example, sugar tax?>>So I will turn
that one to Matthew. The question, for those who
weren’t able to hear that, was, can the federal government
regulate food products, like sugar-sweetened beverages,
using the interstate commerce?>>Federal law is currently
used to regulate food products. So I think the answer
to that would be, yes. It remains to be seen
whether or not anyone at the federal level would move to regulate sugar-sweetened
beverages, but clearly the authority
is there to regulate food as it crosses state lines
and is a national industry.>>Thank you, Matthew. I think we can go ahead and
take questions from the room! If you’ve got a question for our
panelists, please step the mics in the middle of the
room there, please. Having seen no one move, Susan?>>Would you ask the presenters
in today’s Grand Rounds, to address how public health
is affected by housing laws?>>It’s a good question. I think we touched on that
some during our presentations, but I will open the
mic for Karen to answer that question first,
and the question is, how do public health
law’s impact housing laws?>>It’s a great and important
question, because it’s worth – it’s worth noting
something that Montrece spoke about in her presentation,
which is the foundations of public health actually really
date – date back to a time when the public health
infrastructure leveraged the built-in environment,
including housing policy, to tackle a whole
host of scourges, including infectious
diseases, like tuberculosis, and some of the most effective
tools that we have had that have reduced the
transmission of tuberculosis, as an example, have
been housing spacing and housing policy,
up through today. When we are increasingly
understanding that secondhand smoke has a
significant negative impact on the health of
children and others, and so in this space the housing and urban development
made a movement to – to prohibit exposure to
secondhand smoke in housing, and there’s really one other
component that’s worth saying, which is, we often think
about, you know, sort of health as the – as the – as
the outcome, and it is, but if you just think about
the most important overall determinants of health
and wellbeing, housing is the most
important, so quality housing, in and of itself, has a dramatic
impact on people’s health, much less the policy that we
apply in the housing setting.>>Matthew, would you
like to add to that?>>You know, I think,
you know, a good context to put this answer in is sort
of listening back to something that Dr. Frieden
said in, you know, law really affects
everything that surrounds us, including the houses that we
live in and the apartments that we live in and
the places we rent, and even the commercial
buildings that we go into. So it really has to
do with, you know, where your house is located in
relationship to other things that may be detrimental
to your health. When you walk into a house, that
house was built with a permit, and that permit was approved
under building codes. And the purpose of
those building codes is to keep people safe, and to
protect the public’s health. Even the things in your
home, that surround you, your appliances, your fixtures,
all those things are regulated with an eye towards
keeping people safe. The paint that we use,
the products that come into our homes, all of these are
regulated with safety in mind, and the idea is to reduce
morbidity and mortality in the places that we live, and
the places that we go and shop, if you talk about
commercial buildings as well.>>Just a follow-on to that,
which is one of the differences, in more recent years, is that
the notion of the impact of – of, say housing on
health, health is a bit of an afterthought at the
table, and isn’t – isn’t in — always present in the
conceptualization phase, so we might call this health
on all policies approach, where in a community, it would
be expected that public health, leadership would be at the
table to help think about the – the intended or unintended
consequences, whether that’s in housing policy or
transportation policy, and these Public
Health 3.0 communities, one of the movements we’re
seeing is that public health is at the table and sometimes
leading at the table, such that they are more involved
earlier and not trying to then, subsequently, change policy
after it’s happened, and, again, mirroring some of the earlier
years of public health, when public health was such a
strong leader in communities and was at the table
helping to shape policy, like transportation housing, I think it’s increasingly
important that we do this so that we’re weeding
it into the fabric of all the policy decisions
that we’re making at the local and the state and federal level.>>Thank you! Thank you both! Do we have additional questions
from online participants, Susan?>>We do, and I would encourage
our – our online audiences to pose their questions
at Twitter, Facebook, or to [email protected] This next question has
some multiple parts. How can CDC do the
greatest amount of good for our nation’s health with
regards to chronic disease? And I’ll kind of break
it into – into parts.>>So, the question is, how can
CDC have the greatest impact in the area of chronic disease? And I’m assuming, and the law. Matthew, thoughts? Karen? Who wants to go first?>>Alright, Matthew. [Laughter]>>Is there another
part of CDC that wants to answer that question? You know, I think – I think,
you know, what CDC is doing, we’re active in this space. I mean, I think the thing
– the thing we try to do in public health is identify
interventions that work, and I think public health law
and policy come in where we want to have those, where
interventions are proven to be effective, and there’s
a desire, both socially and politically, to have
those interventions applied to broader populations, and I think CDC is
active in this space. If you look at something like
the Winnable Battles Initiative, started under Dr. Frieden,
clearly there’s an emphasis on chronic disease,
noncommunicable diseases, are the biggest killer
in the United States, and CDC has been very
active in addressing those over this past administration.>>But I’ll answer for
HHS, which is Health and Human Services, which
is simply to remind people that there is a pretty broad
umbrella of opportunity, not only to HHS, but federally,
to address the public’s health and where, again, remembering
these things, increasingly. So whether that’s in housing
or transportation as examples, but even closer to home,
the federal, the Food and Drug Administration,
which, in recent years, has banned trans
fats, and if you think about cardiovascular disease as
a – as a leading cause of death, the impact that has,
not only on an individual, but at a population level,
and we’re certainly trying to use every tool in our toolbox to advance the health
of the public.>>Thank you! It looks like we have a question
from someone in the audience? We’ll start over here. Judy?>>Hi, I’m Judy
from OSTLTS. Thanks for a really
great presentation. I think it’s really important
and great to hear this presented at the CDC from all of you. I wonder if you could speak
to some terminology issues. Because a lot of – a lot
of the social determinants of health work is also talking
about structural determinants of health, and things
like civil rights issues, civil rights laws,
discrimination laws, antidiscrimination laws,
how would you see those as interplaying in this world
that you’re talking about, social determinants of health,
would you call them structural? Are there – are there these
kinds of issues being discussed in the Public Health
3.0 communities?>>Karen, do you
want to take that on?>>Well, I love this question! Do we have about four hours
that we could [laughter] – that we could dig into it? It’s quite relevant for
a number of reasons. One is the language
social determinants, I think begs to be improved. Because it doesn’t, as you say, quite capture either the
broadest umbrella of all of the many determinants
of health, and it can be so nebulous that it’s hard
for people to know how to act. I would want to commend
the CDC specifically in that second area, and their
work on this, the high-five, the high impact in five
years, which are sort of specific toolkits
that can be used to address the social
determinants, and those social
determinants are defined through the federal space
by healthy people 2020. There is actually a
structure definition that we’ve all agreed on. But when you step out of the
bounds of what we do here in government, and begin
speaking to leaders in business or local elected officials,
I think that language gets to be a little more confusing. So there is work to
be done to clarify it. I also want to just step on
something you said, I haven’t – I haven’t used this language,
structure determinant, structural determinant
of health. We did talk a lot about
institutional racism in New Orleans, it
was a major part of the public health
conversation that we had there, and that would be sort of a structural determinant
of health. I think where – where we made
a lot of progress in health, generally, in the last 8
years of this administration, is in civil rights progress,
globally and I think that stands to help advance health
more broadly. We don’t often think of civil
rights as a social determinant, more broadly – more broadly,
so I’m glad you raised it, because we shouldn’t lose sight
of that, and what we should – but here’s what we should do. We should find a way that public
health isn’t talking to itself, and that we’re expanding
this conversation, because I can tell you that
payers and business leaders and elected officials
and civic leaders in communities are hungry to really understand what
this other question are asked, which is, how can we
make the most difference on what’s killing people in
our country and killing – killing them at a rate that
is increasingly alarming, because we’re losing the
battle for the public’s health. And so we shouldn’t – but we
shouldn’t let the language get in the way of at least
us beginning to have that broader conversation.>>Yeah, it’s a great question. I think about it in kind
of two different ways. I think on the one hand,
clearly, structural racism, systemic racism in the United
States is a social determinant of health, clearly. I think the – the exercising of civil rights is also a
social determinant of health. I kind of put civil
rights laws in a little bit of a different category, because
I think they stand as a tool that we can use to
address the exercising of civil rights and
systemic racism. So I think they kind of
counterbalance each other, and certainly something
that we study within the public health
program, quite in depth, and the development of
new civil rights laws. For instance, under the
Affordable Care Act, in Sections 15, 57, is a
way to move the ball forward on civil rights and
start to address some of the health disparities
and racial disparities that we see in the country. So it’s an emerging
area of – of study, I think across the country,
including here at CDC.>>And I’ll just say, in my
studies, in earning an NPH and studying the social
determinants of health, that language, structural
determinants, was used. For me, the work that
we’re doing really unpacks that a little bit. How are the structures
developed? What legal processes and tools
are we consistently using in this country to sort of
establishing those structures, and are those structures
barriers or impediments to health, or where they can
actually be levers toward improving public health? So, to me, it’s more about
unpacking of that term and making sure that all of
the people at the table that – all the people that have a
role in that are at the table for those discussions.>>I think we had a
question over here. There was a – a man sitting
down with his hand up. Yes, sir, that’s you [laughter].>>Yeah, I just was wondering if you could address the
Affordable Care Act a little bit more and it’s role in public
health and what aspects of it do you feel are most
needed, given what we anticipate as the repeal of that law? Usually you don’t hear about that law being a public
health law, you usually hear about it as, you know, how
we pay for medical care and how that’s organized, but
you’re talking about it in terms of the Public Health 3.0, and that aspect probably has
not been addressed as well.>>I think that was
for you, Karen.>>Yeah, so, to begin,
I would just share that the Affordable Care Act
was a law that had many – had broad reach, beyond
just paying for care, and as some people may know, it
touched on civil rights issues, it – it created a
prevention fund, it created some infrastructures that are directly
public health related, to support better thinking
and better advancement of public health goals. It helps to advance the
availability of data and information, not
as directly as HITECH, but has some touches on it. I think where it had more impact on the public health
infrastructure was in reducing the number
of uninsured, I must say, by 20 million more
people being insured and having the lowest rate of
uninsurance this country, ever, since we’ve been measuring it. Below 9 percent now. And what that felt like for
public health departments was that people who had
been receiving care in public health clinics
who were uninsured, I was one of them as a
child, have now a way to pay for their care, and can go
anywhere, and that has meant that for public health, they’ve
been able, in some cases, to get out of the business
of delivering direct services and anyone who’s run direct
service delivery knows it can be very time consuming,
you really focus on an individual rather
than on a population. So it’s created some bandwidth
for – for policy thinking that has brought public health
forward, but also, I think, to some roots and that movement
has not been without tension and without struggle, but many
public health departments have embraced it. We certainly did in New
Orleans, and others have, and it’s given them
the opportunity to be a mutual convener. So they’re not a healthcare
provider in the community, and they can bring others
– others to the table. It’s meant a loss of revenue,
so there’s been some downside, I don’t want to minimize it. Whether the Affordable Care
Act then, if there’s going to be a change, we haven’t
seen legislation, but if, let’s say coverage
were to go away for those 20 million people, then that would probably change
the role of public health in communities again, and I –
and I, amongst the many reasons that I wouldn’t want to
see people lose access to quality care is that I
think public health is – public health is accountable
to everyone who lives, learns, works, and plays in
your community everyday, like there’s nobody
else like that. You don’t have anybody
else who’s making sure that you’re alive today, because
that’s what’s required in law, and having them focus on
other books of business, because there’s no one to
backfill that, the safe water, all the things that we all know
and believe and talk about, I believe is going to step us
back as a country in our health. So, good, specific things,
but I think more broadly, it’s been to help them move
back in the stronger space of broad public health.>>Okay, we are coming
up on time. Susan…?>>One more question.>>One more question.>>We have several, but all of them will be answered
via email later. Are laws being brought
to Congress that would increase
federal jurisdiction, in case of a healthcare
disaster or outbreak?>>What was the first part? Are laws…?>>Are laws being
contemplated that would further, on the federal level, that
would further protect us in a public health emergency?>>I am not aware, currently,
of any laws being introduced to Congress right now that
we’ve had some preparedness laws passed over the years,
certainly at the federal level. Some of them updated,
reauthorized, but nothing currently on the
– on the slate, as it were.>>Before – before we get the
hook, I have to do a commercial for Matthew and his team, and I
want to publically say thank you to him and to his
team for helping, not only the New Orleans
health department, but health departments
all across the country, and not that I want to lend
you out, but I think what you – what you’ve been doing here, in
the last few years especially, is reshaping our thinking
about the power and importance of public health law
and creating a field of public health
epidemiology that’s going to lead to some measurement. It’s going to allow us to have
a much better feedback loop as we begin to assess the
social determinants of health. So I thank you and I thank
you the CDC for bringing this to the forefront
in public health.>>Thank you. [ Applause ]>>Well I’d like
to, again, thank – thank all of our presenters. Again, there will be additional
content, videos posted online so that we can all
continue the conversation and continue our learning. Please join us next month for
CDC Public Health Grand Rounds. Thank you!

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