Building Healthy and Resilient Communities Across America

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode, we unveiled the challenge ASTHO's new president has for health officials in the state and territories.

DR. NICOLE ALEXANDER-SCOTT:
We want to uplift communities and support them in leading the changes that they need. And we want to help the engagement with the business community and policy makers, and direct them to invest in those communities.

VADM JEROME ADAMS:
I say to state health officers, and local health officers, and public health practitioners that working together may be easier than you think.

KEVIN SUMNER:
Everything is public health—we just have to explain how it's related to public health.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we discuss the most pressing public health issues facing our states and territories and explore what health departments are doing to improve the condition of our country's most vulnerable populations.

Today, a look at the year ahead for ASTHO and its members with the focus on a unique challenge to all states and territories from the association's president, Dr. Nicole Alexander-Scott, director of the Rhode Island Department of Health. Later, we'll hear from other national leaders supporting the initiative—the U.S. Surgeon General Vice Admiral Jerome Adams, and then Kevin Sumner, president of the National Association of County and City Health Officials.

First up, the announcement of the challenge from Dr. Alexander-Scott.

ALEXANDER-SCOTT:
I'm very excited to say that the ASTHO President's Challenge is Building Healthy and Resilient Communities. This challenge will be led with the National Association of County and City Health Officials' president as well, and will align with the U.S. Surgeon General's priority that focuses on community health and economic prosperity.

So, together we will call on state, territorial, local, and tribal health officials to build healthier, more resilient communities by supporting investments in community-led, place-based approaches.

JOHNSON:
Can you tell us what action on this challenge looks like to you?

ALEXANDER-SCOTT:
The action for this challenge is really encompassed within the two overarching goals that we have. ASTHO, NACCHO, and the Surgeon General will help health officials with taking steps towards these two overarching goals.

The first is we want to equip health officials to mobilize community-led, place-based approaches. And so, that means helping health officials lead public health to engage with community in such a way that allows the community to lead the charge in the improvements that need to be made. We want to do this by focusing on measurable outcomes; and so, we get to support our surrounding communities with the usual public health principles that we use.

We bring data, we support robust needs assessments. We encourage developing measurable outcomes, implementing them, and evaluating them to make sure that that they are working. And by implementing those public health principles with the community leading and governmental public health supporting, we can help build stronger community.

JOHNSON:
When you say community leading, does that mean someone in the city, town, county needs to step up and take charge? Or is that going to be the role of NACCHO, in this case?

ALEXANDER-SCOTT:
Well, ASTHO, NACCHO, and the community each can serve in certain roles. By community leading, it emphasizes that, across the board, communities have various resources and assets that they can turn to.

We oftentimes, in public health or in government or in academia, feel like—especially disadvantaged—communities, "We have the answer, they don't know it. We have to give it to them. We have to tell them what they need to do to fix all of their problems." And it's really shifting that paradigm and that understanding to a more strength-based approach: what does the community already have? How can we support the community in activating their own voice in organizing, in setting shared goals, and establishing measurable outcomes that they can strive towards together with our support?

That's what I mean by community leading. And so, helping them mobilize to do that allows communities to pull together municipal leadership, as you mentioned, but also their local law enforcement partners, local businesses, certainly the residents of the communities, local education systems, housing development organizations, other community-based organizations—that list can go on.

There are often times those resources and partners that are already present in communities. Sometimes they are already working together, and it's just a matter of supporting that effort to be even more effective and stronger. Sometimes, governmental public health can just help convene those groups and guide them in establishing shared goals that they can work towards together to build stronger communities.

JOHNSON:
I would think there is a big opportunity here—a real appetite for this kind of approach, you know, on the part of folks in the cities and towns.

ALEXANDER-SCOTT:
Absolutely. You know—and it's about, you know, mobilizing them, engaging them in what's possible. Oftentimes, certain communities may feel beat down or misunderstood or not heard, and we want to be a part of helping to change that so that the conditions in the community can be more positively impacted. And sometimes, just having a voice and an organized approach can get to that point.

JOHNSON:
And that goes for whatever the public health challenge might be?

ALEXANDER-SCOTT:
Correct. It's across the board. You can focus on improving housing or making low-income housing more available, or making the education system better quality.

One of the keys is recognizing that whatever the challenge is, you can pretty much guarantee the community who is dealing with those challenges know and have the ability to determine what needs to be focused on, how to prioritize it, and develop shared goals towards fixing it once they have the support to organize in that way. And this is an opportunity for health officials to lead public health in supporting communities to organize. That's the essence of goal number one.

Goal number two looks at the opportunity that health officials and public health has, as the chief health strategists, to engage more deliberately with the business community and with policy makers. Sometimes those partners already want to invest in community, and either they don't know how or they have their own siloed approach to doing it. And who better than public health to bring them to the table and say, "Yes, we love that you want to invest in community. Let's connect you to these community-led approaches that we know are coming together and that we know can have a significant impact, and help you direct your investments to something that is going to move the needle and is going to make a difference."

It's really serving as that convener that brings together people that want to invest—or that don't know they should, and they could—and help them understand the benefits of investing in these community-led approaches. And that's what's so exciting about having the U.S. Surgeon General aligned with us, because he has a priority that is focusing on community health and economic prosperity.

I've appreciated hearing him say that part of his focus has been engaging with the business community—with corporations—and helping them understand that it does impact their bottom line to invest in the community that surrounds them. There is tremendous benefit in doing that, there's return on investment. So, the more that we can convince of that importance, the more that we can direct to the community-led approaches that need to be sustained in order to have the impact that we want it to have.

JOHNSON:
Do these connections usually occur, or are they something that you think has been missing from the equation for too long?

ALEXANDER-SCOTT:
I think it's something that people are starting to build momentum with now. And one of the things we want to do with this challenge is just highlight it and say, "This is the direction we want for public health to be able to go in." Many jurisdictions, many communities are already starting to have conversations with business leaders and with policy makers. And it's just about connecting those dots.

That's what we want to be able to do here. We want to uplift community and support them in leading the changes that they need, and we want to help the engagement with the business community and policy makers and direct them to invest in those communities in the changes that are needed because it is a benefit all the way around—including the bottom line for those businesses, because sometimes that's what's most important. And as the chief health strategist, we wanted to be able to speak the language to say, "You can take what's important to you and still be able to have a positive impact on public health and what's needed."

JOHNSON:
Your goal uses the word "invest." I wanted you to tell me how that plays out under this challenge.

ALEXANDER-SCOTT:
Invest can be a number of things. It certainly involves funding and money.

There also is an expanded descriptions of the word "resources." There our resources that exist in our society, in the business community; resources that policy makers have access to; resources that other leaders have access to. And it's a matter of getting those resources directed towards the communities that now have a model for leading change and making a difference. And we want to connect those two dots.

JOHNSON:
It sounds like you've done this before.

ALEXANDER-SCOTT:
We are learning as we go, and it's such a necessary direction to go in. In Rhode Island, we've activated the health equity zones, and it's our way to achieve goal number one—to mobilize community-led, place-based approach. And with the health equity zones, we as governmental public health serve as that convener for the community: issued an RFP—a request for proposal; allowed communities to apply; required them to organize themselves, form a collaborative; do a needs assessment; and develop an action plan that had shared goals that they could work towards. And with seed investment from us, we supported them in implementing those goals and now evaluating it and sustaining it for the long term.

And so, in the sustainability phase for this first cohort, we're implementing goal number two, which is engaging with business leaders, with foundations, with policy makers, corporations who want to invest in community, and telling them the health equity zones are ready-made infrastructures that the community has to invest in, and you can get return on your investment because of all of the partners that are already engaged that we are seeing the benefits from.

JOHNSON:
What kind of help do you expect to deliver inside those zones?

ALEXANDER-SCOTT:
We are supporting the health equity zones' collaboratives that involve leaders from across the gamut. So, each health equity zone includes law enforcement, municipal leadership, legislators, education systems, health systems, business community, city planners, and so many others.

And so, with those resources and taking a strength-based approach, we want to, as public health, support them in implementing and fulfilling the goals that they have laid out through their collective action report. And so, we are seeing a variety of positive impacts of that.

We're seeing complete and green street ordinances that are getting passed. We're seeing community gardens that are getting created, walking school buses that weren't in place before. One of our health equity zones, which has LIST as a backbone organization, partnered with their community development corporation to take one of the dilapidated buildings in the middle of the city, renovate it, and use the levels above the first floor to create low-income housing and use the first floor to create locally-grown foods for a supermarket that was also supported by a jobs training program to become a chef for youth who were incarcerated.

So, that was something that the community decided and initiated and implemented. And all we did was provide the support and the public health principles that we know work—here's what the data shows, here's what an action plan looks like and the shared goals that you can work towards, and here's how to evaluate it. And the community has really led the changes, and we want to see more and more of that and give the community the voice to start talking to their legislators and changing the policies that they know are needed.

Those are some of the examples of the outcomes, and there are examples like that all over the country; and it's really continuing to mobilize those types of community-led, place-based approaches.

JOHNSON:
This is called a challenge; but hearing you talk about, it sounds more like a movement.

ALEXANDER-SCOTT:
We'll take that, too. We can challenge each other to, you know, have this transformative movement and change. We know it's needed. The first time that our country has had a lower life expectancy in a year-over-year change. And one of the reasons we know that's happened is because too much money is focused on healthcare, in the acute healthcare settings, and that's where only 10% of what makes us healthy actually occurs.

It's really outside of the healthcare setting and a doctor's office that we know the way, the reason people are healthy occurs. It's in our homes and our schools, in our jobs and in our communities. And if we really want to have an impact, we have to be able to shift our focus to those communities and help them lead the changes that we know are needed.

JOHNSON:
The U.S. Surgeon General, Vice Admiral Jerome Adams, has been on the job for the past year. Before that, he was Indiana state health commissioner. He believes in the fundamental goals of the challenge because he too is worried about America's declining life expectancy.

ADAMS:
Life expectancy in the United States is lower than in many other high-income countries and, unfortunately, it's actually declining for at least two years in a row—and once we get the final data for this year, we're expecting that to become three years in a row that life expectancy on decline.

We know that poor healthcare is not the sole reason for this. Arguably, we have the best healthcare in the world and we pay a premium for it—we pay more for healthcare than does any other country in the world, and a lot more than the next highest spender does when you look at the data.

Yet, we continue to have plenty of health problems. Six of 10 Americans have at least one chronic health condition; one of 10 American adults have limitation of activities of daily living due to a chronic condition; and, as everyone is aware, we're in the midst of an opioid epidemic that is killing people at unprecedented rates and limiting the productivity of those who are living with an addiction.

So, the question that I ask is why aren't people that are healthy as they could be? Well, Americans aren't optimizing our greatest asset, in my opinion, and that's community. We can prevent most chronic diseases by changing the community environment to make sure that healthy behaviors are easy behaviors for folks to engage in and that they are available for more people.

Equity is a big part of this. We want to make sure that they're available not just for rich people or not just for certain people, but for everyone in the community. And we know that this is a major issue for state and health officials because they know their communities much than any federal employee in Washington, D.C. does.

JOHNSON:
So, how do you characterize a resilient community?

ADAMS:
That is a great question. And when I think about resiliency in a community, I think a lot of community that prevents the problems that can reasonably be prevented, and that anticipates and mitigates the problems that can be prevented. I also think of a resilient community as using the best available scientific evidence. And I think that the state health officers, local health officers in my office are in a great position to help community to understand what it means to be resilient and to achieve that outcome.

JOHNSON:
You've been in the position about a year now, and I understand that you've gotten quite a few frequent flyer miles. You're visiting as many states as you can—more than half so far.

ADAMS:
Absolutely. We've made it to 28 states so far, and I hope to make it to all of the states at least every two years.

JOHNSON:
Only 22 left—you can do that before the end of the year, right?

ADAMS:
Well, as some of the ones that we haven't made it to are a little bit farther away, but we're going to make sure that we get to everyone, if I have a say in it.

JOHNSON:
What have you seen so far? What sorts of initiatives along the lines of the president's challenge have you witnessed, and what do you think about those?

ADAMS:
The good news is there's a lot that is already going on out there.

For instance, I recently was in Fort Worth, Texas and visited Mayor Betsy Price, who instituted the Blue Zones concept there. Their city is working together to make the restaurant menus healthier, to connect streets for walkability, and to improve housing quality to support better health—interestingly, all three areas that many towns and communities that are focused on across the country, but that they don't necessarily associate with public health. We need to make sure that health officers are at the table and involved in the sorts of initiatives.

Last year, I visited purpose-built communities in East Lake, Georgia, where they built mixed income housing, quality schools, and a public-private partnership to bring a full service grocery store to what was previously a food desert. They've connected transportation and jobs. And again, this started around housing and schools, but ultimately was a health initiative.

And just recently, I met with an employer in rural Indiana with Second Lady Pence. Belden, which is in Richmond, Indiana, produces and sells a comprehensive portfolio of connectivity and networking solutions. But more importantly, they are the largest employer—and one of the oldest employers—in their town. And this town has been hard hit by the opioid epidemic, and they've been working on innovative ways to help individuals with substance use disorders get into treatment.

What they actually do is test potential employees upfront and if they test positive, if they screen positive for substance us, they're offered treatment. And if they successfully complete treatment, then they're guaranteed a job at the company. This is in contrast to what was happening previously, where they were having individuals apply for jobs, go through screenings, go through multiple interviews, and then find out on the back end that they tested positive. And they would actually never tell them they tested positive, they just tell them, "You didn't get the job," and it was a lose-lose. Now, we've got a win-win: folks are getting treatment, and they've got some of their best employees through this program.

JOHNSON:
Those are not exactly examples of your father's or your mother's public health practice.

ADAMS:
There are a great example of how we can attack and overcome stigma, which I've often said as surgeon general is truly our biggest killer. The more we can have the anchors in the communities, the Beldens in the community, the mayors, the non-traditional partners out there—from a public health point of view—out there talking about addiction as a chronic disease, talking about obesity and smoking as a community-wide issue, the more success we're going to have tackling these problems.

JOHNSON:
The challenge talks about seeking investment from partners, and you just mentioned some that I think maybe 15 or 20 years ago we might not have encountered or engaged on public health issues. This is a critical piece of this challenge and I think it sounds like, anyway, something that you think is very important, too.

ADAMS:
Exactly. My motto as surgeon general is better health through better partnerships. And I feel, as a public health professional, we need to do a much better job communicating our priorities with non-traditional partners like the private sector. There's a mutually reinforcing cycle—a virtuous cycle—where businesses investing in communities improving community and individual health, and then healthy workers can reduce healthcare costs and are more productive on the job.

We know that leads to greater opportunities for healthy communities. We know that it improves the health of consumers, which then gives them more money to actually spend in the community, increasing tax revenue that we know that creates healthier businesses and a stronger economy across the board.

So again, what we've seen across America is this unfortunate downward spiral where poor health leads to poor productivity and these communities are suffering. But we've seen also across America a virtuous upward cycle.

We know what works; but unfortunately, from a public health point of view, we haven't been that great at explaining it. So, we need to do a better job at communicating our priorities to help individuals understand how we can all partner to achieve our collective goals.

JOHNSON:
In closing, give us the pep talk: what do we need to hear as we launch on this endeavor to go out and try to really reframe the way public health operates, the way it serves the communities?

ADAMS:
Well, that's a great question. And throughout my travels, one thing I've learned is that there are best practices, but there is no one-size-fits-all approach to building healthy and resilient communities. And there are things big and small that all communities can do that will have an impact. And we want them to understand what the evidence says—and that's why we're working to collect that evidence for the Surgeon General's report—but then to customize it based on the obstacles that exist in their community, but also the assets.

That's why the Office of the Surgeon General is working with the CDC to put together the report I mentioned on community health and economic prosperity, or CHEP. We're hoping to put together a menu of best practices and exemplars that public health professionals, business owners, politicians, and state health officials can select from and implement into their communities.

But that said, and as we've talked about, it takes an open mind and a willingness to collaborate with partners, both traditional and non-traditional. We can't do it alone, and leaders across the state and in communities need to be the conveners. There may be educators or police officers, for instance, leading innovative public health interventions without us even knowing about it. With the opioid epidemic, I've seen examples of law enforcement officers spearheading naloxone trainings and transporting individuals to the care that they need.

And again, we don't necessarily need to recreate the wheel, we just need to bring all of the folks together to build a vehicle that will take us to our shared destination. I say to state health officers, and local health officers, and public health practitioners that working together may be easier than you think.

Ah, the last thing I'd say is I urge all health officials to use the tragedy of the opioid epidemic as an opportunity to galvanize and convene community leaders. And the reality is, Robert, we've been trying for years, for decades, for many of us our entire careers, to get people to pay attention not just to addiction, but to mental health, to ACEs—or adverse childhood experiences, and to the social determinants that exist in all communities.

What's amazing now is that folks want to talk about these things they want to hear and learn more about these issues, and they actually want to figure out how we can tackle them, and that's where we can lean into this. Out of this tragedy that's the national opioid epidemic, I 100% feel that it's a tremendous opportunity for us to achieve better health through better partnerships and to make sure funding and programs are applied in an equitable manner.

And if we can do this then 10, 15 years down the road, maybe we won't remember this time as the opioid epidemic and one where life expectancy went down; but perhaps we'll remember it more of the time when we really change the way we think about health, the way we think about partnership, a time when we really invested across the board in overall health and wellness and our communities. In 10–15 years, maybe we'll say, you know, "That was a tragedy, but ultimately we turned it into an overall positive for the country.

JOHNSON:
Kevin Sumner is the president of the National Association of County and City Health Officials. His group has joined with ASTHO to support this year's challenge. We asked him how community-led, place-based approaches look to his members on the local level.

SUMNER:
Historically in New Jersey, public health has meant environmental health; and what I think people expected—and to some degree is still expect—in New Jersey is local health departments to do food inspections and complaint-based inspections. And they didn't, as a general rule, didn't really recognize the other activities and potential impact that local health departments can have on communities.

And today, we see a shift in those areas where local health departments are partnering with individuals, organizations, businesses, groups within communities that historically they've never played in the sandbox with, if you will. And those individuals, organizations, et cetera, are community-based often and have the ability to have—in conjunction with the local health departments—a connection to the community and its residents that maybe the local health department on its own hasn't been able to.

And so, the local health department can help facilitate conversations and partnerships and drive initiatives at the very local community-based level that it may not have the resources, the personnel, or even the expertise in that, with partnerships, we can now drive at that local level.

JOHNSON:
So, these truly are additional resources, then?

SUMNER:
Well, it's a combination. I do think that that partnership provides greater personnel resources—local health departments tend to be fairly strapped with the limits of personnel, as well as financial resources. And so, by partnering with others in the community, we can help explain what their activities, the impact their activities can have on the community's health, and guide them to support activities that will improve the health of those communities. And that may mean using their resources or leveraging their resources and human resources to get activities done that weren't done in the past.

JOHNSON:
This challenge has a couple of very specific goals. The first one is to equip health officials to mobilize community-led, place-based collectives focused on measurable outcomes.

How do you envision that goal playing out?

SUMNER:
Well, that's kind of what we were just talking about, right? That's the local health department facilitating conversations and partnerships with a traditional and non-traditional partners in the community who may be taking actions that support public health, community health activities within that community. And they may be taking actions that they don't even recognize as public health initiatives.

One of the things I preach is that everything is public health. We just have to explain how it's related to public health, and often that means seeking out those partners within the community to explain how what they're doing really is a public health initiative. We want to support that, we want to make sure that it happens, and that it gets spread throughout that community, and that that community takes it on as their own initiative.

JOHNSON:
The second goal seeks to make connections between public health officials and business and policy leaders. There's even a mention of economic development in that goal; you just touched on it, so it warrants follow-up.

What does that goal say about the changing definition of public health?

SUMNER:
I think, as I alluded to before, we've expanded the definition of public health and are now recognizing more than ever before the impact that non-traditional public health entities and activities have on the community's health—so, for example, transportation.

Transportation in and of itself, I know for sure from my experience with my local boards of health, they think of transportation as the public health issue because of concerns around air pollution. But they don't necessarily think about transportation as the public health issue with regard to the ability of community residents to access healthcare or access well-paying jobs so that they have the individual resources to get healthy foods or entertainment, exercise, whatever those needs that they have are. And so, transportation goes just beyond contributing to air pollution, but it is a benefit if a community residents have a good transportation system to access those resources that they need.

JOHNSON:
From a practical perspective as it relates to this partnership on the challenge, how do you see your members engaging on this issue between now and this time next year?

SUMNER:
I think it will vary a lot. One of my initiatives—separate and apart, but very much linked with ASTHO's president's challenge—is to consider and address small= and medium-sized local health departments as we look at the spectrum of different health departments across the country. And I think, in some ways, we can learn from the small- and medium-sized local health departments because, by necessity, they have had to take some of these initiatives we're talking about with regard to partnerships in order to survive and be able to provide for their communities the way that they do.

And so, I think that we can provide the means for communication of those practices amongst all of our members so that our large health departments are learning from our small health departments on what works in the communities and vice versa. And through that network of communication amongst our members, I think we can promote the activities that lead to healthier communities.

JOHNSON:
As we wrap up this conversation, the word is out—when people hear this podcast, they will know about the challenge, it will be on the street.

How might a city or county implement the change that this challenge seeks? How does that work?

SUMNER:
I think depending upon the community and where they currently are in this process, it will vary. I think for some, it may take some time. And as I expressed to my members back in July, you know, a one-year term as president is not a long enough time in my eyes to see an initiative start and end. And so, I would anticipate that this challenge, the NACCHO support of this challenge, will go on for a fairly long time, and that we'll see a gradual but steady progress over that time period.

I think one of the challenges is that as we try to explain the depth and breadth of public health, particularly to policy makers and how they should be considering the impact of their policy decisions on the health of their communities. Those are fairly new thought ideas that will take some time to educate folks about and convince them that public health should be a consideration in everything they do.

But I think we have a good place to make that argument, and I think we will make that argument and we'll see change over time.

JOHNSON:
For more information about ASTHO president Dr. Nicole Alexander-Scott's challenge, visit the ASTHO website—www.ASTHO.org. A link to the president's challenge page is also in the show notes for this episode.

Thanks for listening to Public Health Review.

If you like the show, please share it with your colleagues.

And if you have comments or questions, we'd like to hear from you. Email us pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.