Celebrating 80 Years of ASTHO

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

On this episode: ASTHO is 80 years old. Its leaders and members consider the organization's legacy and the way forward.

ANNE ZINK:
I think what I took the most from ASTHO during the pandemic is its incredibly rapid ability to respond and to collaborate.

NIRAV SHAH:
What ASTHO has done throughout its history, and most recently during COVID, is be the voice and the view for Americans into what their state health department does.

MICHAEL FRASER:
I don't think we can put the genie back in the bottle, that reporters want to talk about what happens in states and territories.

ELKE SHAW-TULLOCH:
During the last 80 years, ASTHO's become a well-respected and established advocate for us in public health, and their overarching values and charge of the organization have remained consistent.

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

Today, a celebration with four people familiar to most everyone listening: ASTHO leaders here to discuss the organization's history, impact, and future. We are joined by ASTHO President Dr. Anne Zink from Alaska, ASTHO immediate past president Dr. Nirav Shah from Maine, ASTHO CEO Mike Fraser, and Idaho public health administrator Elke Shaw-Tulloch.

We begin with ASTHO President Dr. Anne Zink. She tells us what comes to mind when thinking about ASTHO's 80th birthday.

ZINK:
I think the immediate thing that comes to mind is just joy and gratitude. And I think the reason is because public policy and public health are always fraught with politics and people and challenges; and to see an organization thrive through wars and pandemics, and cultural revolutions and divides, and continue to stay together and united towards the wellbeing and the health of the people we serve is a great inspiration.

So, I find a lot of comfort in and a lot of joy from the fact that ASTHO has been together for 80 years and has been representing this incredibly diverse country. I mean, from the territories to the states, to my home in Alaska, to my colleagues in Florida, and Texas, Hawaii, New York, South Dakota—we have so many different challenges, different public health experiences. And to have an organization be able to facilitate conversation, facilitate collaboration, and learn from each other, support each other, all for the common goal of the health and well-being of the people we serve—I think it's amazing.

JOHNSON:
Thinking about it, ASTHO is actually older than Alaska. So, given that, what do you think is the value of belonging to an organization with a history that goes so far back into the record books?

Yeah, you're exactly right. Alaska was not a state when ASTHO was formed, which is a great perspective, just to think about how much has changed during that time.

Again, I think that public health comes from this immense well in history of trying to improve the world that we live in and how we respond. And to have an organization do that with structure, with intention, with collaboration, I think reflects a lot on the history of public health and the importance of what we do moving forward.

I was just at an interesting conference, and it was like disaster management people. And we were talking about no one remembers what happened during Ebola, and how can we make sure that longevity is continued. And I reflected on how people didn't remember what happened during the 1918 pandemic, and how the oral history of Alaska Native people and what they had shared with how they have responded to diseases in the past directly influenced our response. And so, I think we've have so many lessons from the past to take into the present and the future on how to respond to diseases. And layering that and blending that with new tools is incredibly exciting.

And so, to have that historical memory and organizational strength of ASTHO being 80 years old I think just lends structure to that history, and structure, and lessons learned throughout decades of promoting the public's health. And I think that that provides a real richness and a real depth of knowledge and expertise that you don't just get from being involved with it for a short period of time or a newer organization or responding to the most current, rapid challenge.

You know, there's always that saying, "Those who don't know the past are doomed to repeat it." And we have so many lessons from the past that I think that's actually one of the greatest challenges in public health right now. There's been so many successes—with clean water and sewer and vaccinations and antibiotics—that people have forgotten the past of what the world can look like when we don't have those public health measures.

And, unfortunately, we're starting to see that. I saw the worst case of chickenpox I've ever seen in my life. And I honestly have not seen a case of chickenpox clinically, except for one in residency, because it's essentially been eliminated from most of the everyday work that we do in the emergency department. And it was just a stark reminder on how if we're not vigilant against these diseases, if we're not vigilant towards our health and wellbeing as well as those in our community, our states, our territories, our country, we're doomed to continue to succumb to them or to be plagued by them.

JOHNSON:
You were ASTHO's president elect during most of the pandemic, and of course doing your job there in Alaska. How do you think ASTHO fared during this very trying moment in public health history?

ZINK:
Yeah, I got the pleasure of being an extended president elect, a little bit of extra training wheel time—which was really useful and great—and I really learned what ASTHO was during the pandemic. So, it's actually been fun for me to see some of the non-pandemic work during this kind of—I wouldn't say quieter time, but during just this different time that we're in now than we were during the middle of the pandemic.

I think what I took the most from ASTHO during the pandemic is its incredibly rapid ability to respond and to collaborate. Part of the reason we have this federation of states is that you get to try all these different things. But we were all learning so fast and having to respond so quickly that ASTHO provided this just critical crucible for sharing of information and knowledge and expertise so that we could all learn from each other as quickly as possible, as well as partner with each other. And then, also be a grounding board and a place of support and concern, an aide during really tough times.

So, I just I have so much gratitude for my other SHOs [state health officials] during that time, as well as the incredible staff at ASTHO who were nimble and compassionate and responsive. And I think that ASTHO did not act like an 80-year-old organization during the pandemic. ASTHO was fast, nimble, and responsive, yet brought with it the structure and history of the years of service before it. And that combination was fundamental and paramount to my ability to respond to the state and, I think as a country, our ability to respond to this pandemic,

JOHNSON:
Thinking about ASTHO now, as president of the organization, what are you hoping for in the new year?

ZINK:
Yeah, first and foremost, I hope that we continue to find common ground and collaboration. We have so much more strength when we work together, when we listen to each other, and work with each other. So, I'm really hopeful that even in times of turmoil and stress, we're able to continue to work across all states and territories moving forward.

I also really hope that we're able to build together public health and healthcare more closely. I think, since the development of Medicaid and Medicare and the payment structures, and honestly the complexity within the healthcare system in the United States, the worlds of public health and healthcare have completely, almost completely, continue to diverge from each other. But they are one and the same, and we have to continue to work hard to bring those two together. So, I'm really hopeful that ASTHO, that each SHO, that our country as a whole, that HHS as a whole, can help to bring together the many different parts and pieces of health delivery—be it prevention, promotion, or delivery of care—to better that individual, to better that person as well as their community. I sometimes feel like we are asked to treat different diseases or different parts of a person instead of the whole person. And to be able to really do whole person and person-centered care, we've got to braid together public health as well as healthcare.

And then the third thing I really hope that we come away from this is not just the structural organization, that standardization, but also the personnel and payment to create the fundamental building blocks of data information sharing so that we can continue to make and improve on our ability to have data-informed decisions, both in an emergent response as well as long term. And so, to have that kind of rotten foundation of a lack of data infrastructure, we all saw how it hampered us and inhibited our ability to do our work. And so, we really owe it to our colleagues of the future, to our constituents, and our future selves to rebuild that foundation of data and data infrastructure.

JOHNSON:
Dr. Nirav Shah of Maine was ASTHO's president through most of the pandemic. We asked what this 80th anniversary means to him.

SHAH:
What I think is important about that sort of longevity and legacy is a lot of folks in the United States don't have a clear vision or role or view for what their state health department does. I think a lot of Americans know that their state health department exists and pre-COVID maybe had some inkling that the health department was involved with TB and some other stuff.

What ASTHO has done throughout its history, and most recently during COVID, is be the voice and the view for Americans into what their state health department does. They have been that voice consistently. In some areas, it is with our colleagues in the media to talk about what state health departments do, and some it's with our colleagues in DC, in the capital, in the executive branch. But in many respects, what ASTHO does is to communicate with people across the country about the important work that their state health department does. ASTHO has done that consistently for 80 years, and it speaks to the importance of that sort of longevity.

JOHNSON:
What is the value, in your view, of belonging to an organization that has that sort of history?

SHAH:
From an individual perspective, ASTHO has been instrumental in my development as a state health official. Jobs of this nature are difficult, and they are challenging, and really the only thing that can prepare you to be a state health official is being a state health official. And that's why it's really critical on day one to have friends in the form of your colleagues in other states who know exactly what it is you're going through and always have a sense of what the right next steps may be.

So, just on a personal professional level, being a part of ASTHO is instrumental in helping any new state health official find their footing. But on a more sort of advocacy-based level, being active in ASTHO is critical because state health departments need help. We need funding, we need the buy-in of the public, and being active in the organization that represents those interests is critical.

JOHNSON:
You mentioned the pandemic and your service as president during this historic public health moment. How do you think ASTHO held up during all of it?

SHAH:
My view is that ASTHO saw the challenge and rose to that challenge and exceeded all expectations in the manner in which, as an organization, we advocated for and represented the interests of state health departments and, while doing so, raised the profile of state health departments.

One of the goals that I set forth during my time as ASTHO president was to do just that—was to raise the profile of state health departments. I wanted to make sure that any time the media or anyone in the general public had a question about public health—invariably the first place that they would go for comment would be the U.S. CDC, understandably so. I wanted their second call to be to ASTHO for reflection and comment from the state health department perspective.

Our view is that public health is done at the state level. Of course, the U.S. CDC is the North Star that sets the direction and the bearing and the heading, but the work of public health fundamentally is done at the state and local level. And that's what I wanted folks out there to appreciate, particularly during COVID. I am proud of the way in which ASTHO spoke on behalf of and represented the work of state health departments.

JOHNSON:
Looking ahead into the new year, what would you like to see ASTHO accomplish in 2023 and beyond?

SHAH:
Well, I'll first comment that ASTHO remains in very good hands under the leadership of not just Mike Fraser and the outstanding team at ASTHO, but now under the leadership of Dr. Anne Zink as president. So right off the bat, ASTHO is on a very strong footing to continue the good work.

I think there are really important questions as we think about a world in which COVID is not what it was before. What did we learn from COVID that will help us prevent the next pandemic? How can we improve on some of the systematic failures that were observed during COVID? For example, a lack of data sharing and things of that nature. ASTHO has a critical role to play in charting that course for the nation's public health system, and I have no doubt that we as an organization will continue to do so.

JOHNSON:
Elke Shaw-Tulloch is Idaho's public health administrator. As ASTHO's longest serving state health official, she knows the value of belonging to an organization with so much experience.

SHAW-TULLOCH:
Well, first off, gratitude. I'm grateful that there is an organization that's supporting state and territorial public health. During the last 80 years, ASTHO's become a well-respected and established advocate for us in public health, and the overarching values and charge of the organization have remained consistent, which is really important because it's instilled trust as a valued partner.

And so, ASTHO is very unique in that there's no other national association that represents and convenes the leadership of state and territorial public health. ASTHO's also concerned with the wide variety of issues and policies that directly impact us in the states and territories. What we do is very broad in scope, and ASTHO has an organization that really supports all of that.

Something else I really value is that ASTHO's core mission is future-focused and dynamic. They've worked to transform public health within the states to accomplish our missions in the states and the territories. It supports us as leaders, and provides professional development to state and territorial health officials and their executive teams. It advocates for our work, and it also collaborates with funding partners and public health stakeholders to help build the capacity of state and territorial health agencies. And as the state health officer, I know I can always count on ASTHO for sure. And we all know that with ASTHO's support, we're not out here all kind of going it alone.

JOHNSON:
You know, having a history like that is impressive, but what's the value of that to you as a state health official?

SHAW-TULLOCH:
Oh, gosh, no, I think the value is tremendous that they've been around this long. I mean, they've been part of some significant accomplishments in public health over time. But I think the biggest thing, as I mentioned previously, is that they've helped us elevate what we do in the states. They've supported and helped us survive and grow over time. They've helped support public policy to improve public health. And they advocate for important funding and important needs of states and territories regardless of their size and politics, which I think is incredibly important.

Their capacity building work that they have been doing has led to the development of a substantial body of technical assistance and training support for states and territories from the many programmatic and operational areas of our agency performance. And they've also supported and enhanced the link between science and the development of interventions and organizations to public authorities to employ those interventions and increase the public's understanding of and social commitment to enhance health.

JOHNSON:
We've asked everyone on this podcast the very same question: thinking about where we are today—hopefully, with the worst of the pandemic behind us—how do you think ASTHO held up? How did it fare in this moment in public health history?

SHAW-TULLOCH:
I would say, you know, they've fared very well. Of course, they are a proven and steadfast organization. They care about our futures in the state and territories and the health departments. They've supported us through the pandemic to date, and we so appreciate their continued advocacy for funding to support our public health infrastructure and our recovery from the pandemic.

We've learned the hard way that, you know, some of the proven medical and non-medical interventions that we were trying to employ during COVID to help control pandemic weren't necessarily met with I guess a lot of applause in some cases, and some communities were reluctant to follow some of the science. And, you know, one of ASTHO's great roles that they serve, and the value that they bring, is helping to kind of elevate that work, because I've mentioned, to make sure that we're out there in the forefront, and that they're helping to support the credibility of what we're doing in public health.

JOHNSON:
Let's look ahead now: tell us what you would like to see out of ASTHO in the new year.

SHAW-TULLOCH:
I think just kind of like what we're trying to do as well, is to really continue to prop up public health. They have incredible staff and incredible leadership and my hope is that they continue to thrive and provide the amazing work that they've been doing, and that they continue to provide the great services to us that they have then.

I'm grateful that they are seen as a leader and they're also getting public health funding through CDC and other organizations like the states are so they have kind of shared experiences and shared values. My hope for them is just continued success.

JOHNSON:
ASTHO CEO Mike Fraser has said he prefers to look ahead, but here he's willing to make an exception for an exceptional milestone.

FRASER:
I love this theme. I love this connection that, regardless of how the world changes, regardless of what's happening in public health, regardless of the way government works or doesn't, that ASTHO's always been around for that, and survived and thrived and been a touch point for state and territorial public health leaders and always will be.

So, I just love that continuity, that look back that informs our future. I mean, there's these funny conversations we have about, "Didn't we try that before?" We can go back and look and say, "Yeah, actually, we did it a little bit differently, you know, beginning of the AIDS epidemic." But ASTHO had a role, just like they did in COVID, in that time of, you know, emerging global pandemic. So, more things changed, maybe the more they stay the same? I don't know.

JOHNSON:
And isn't there value in having all of that experience and continuity?

FRASER:
Absolutely. And, you know, I think it's definitely important, it's definitely a value. But the thing that we also need to do is not get stale, not rest on those laurels, not do it the way we always do it. And I think that's why we've managed to grow and be so successful as an organization and be nimble, be flexible while honoring the past, you know.

And certainly the engagement of our alumni members. I mean, we've got so many former health officers doing great things across the country and around the world, both in health plans and in government and in philanthropy and academia. There's just so many connections that we make with our health officers and our alumni. That's fun to watch, too. And that's certainly grown over time, that alumni group, and we keep in touch with all of our former state health officers.

JOHNSON:
We heard from Dr. Zink and Dr. Shah on this question. I'd like to pose it to you: how do you think ASTHO fared during the pandemic?

FRASER:
Yeah, COVID was like—I mean, we all knew it was coming, right. And we had been talking about the under-resourced public health system for years prior. And it was just another example of, well, what we could have done with probably more resources and a well-functioning public health system.

But it's another example of the resilience of the public health system and of ASTHO being able to play that role in convening and filling the gaps between state and federal government, between locals and states—we did that in H1N1, we've done that with HIV, we've done it with several other very pressing public health threats, not just infectious disease.

So COVID, obviously, was nothing anybody could have anticipated in terms of the politics of this, the extent of this, the rapid development of vaccine. But the way we responded and sort of the expectations of ASTHO, while very, I'd say on steroids or scaled, you know, to the extreme, the core principles of that—connecting members sharing our points of view, getting consensus of all the states, linking to the best science, getting that out to our state and territorial health official partners—those are all the same, we do that every day.

JOHNSON:
Thinking about the impact of COVID on everything, how much do you think ASTHO grew or was impacted by the pandemic over the last few years?

FRASER:
We grew in lots of ways during COVID. We added a tremendous number of great and talented staff. We certainly grew in terms of our media outreach and getting state and territorial health officials in the media to tell the story of what COVID meant in their state. We grew tremendously fiscally because we were able to more nimbly pass through resources to states that needed them that could quickly procure. And we saw lots of organizations, our partners, grew too—CDC Foundation, National Association of County and City Health Officials, many others.

But the growth wasn't just COVID. It wasn't just response. It was also COVID-related issues like vaccine disparity or addressing vaccine equity and hesitancy. So, all the issues COVID raised—the underfunding of the public health system, the equity issues, the ability of different communities to fairly or equitably access public health services—those all came up during COVID. And addressing those things allowed us to grow as well. So, it wasn't just like COVID response—it was these other issues associated with the pandemic that allowed us to grow in both our media capacity as well as the technical assistance and training activities that we do with state health officers.

JOHNSON:
Public health is now a household name. How do you maintain that? How do you continue the level of engagement with audiences like the White House, Congress, the media, and others? How do you leverage that so that public health can get stronger and do more, more good, for communities all over?

FRASER:
You know, it's a good strategic question for us. I mean, we don't want to be in the limelight just because there's a pandemic, but there's plenty other public health issues. Certainly we saw Mpox, we saw Ebola—you know, on the infectious disease side, there's no shortage of "opportunities," if you will, in air quotes. They're not always, you know, positive.

We have a lot of sick people in this nation and bringing attention to chronic disease, chronic disease prevention, the work of states and moving upstream to help people lead healthier lives across the life course—that's, like, never ending, honestly.

And so, the trick now is how do we get attention to those issues, similar to what COVID brought to state health departments. And we've made a lot of new partners. I don't think we can put the genie back in the bottle, that reporters want to talk about what happens in states and in territories—sometimes good, sometimes bad, but they want to cover it. Our health officials in many places are celebrities and their successors will be as well just, you know, based on folks now knowing what public health does.

So, you know, looking forward, there's lots to manage in terms of expectations, but certainly I think ASTHO will continue to play a leading role, along with our partners.

JOHNSON:
It's almost the new year and everyone is thinking about it. Some are making resolutions, making new plans.

What do you have on ASTHO's agenda for 2023?

FRASER:
Well, I hope we can learn from the lessons of COVID, integrate some of the improvements that have been made in our data systems and the ways that states were able to surge and respond and kind of institutionalize those, while we ratchet down some of the response so that folks actually get a break, you know, in the year ahead.

We'll be seeing a lot of new folks joining health departments, hopefully, with the new resource that they have terms of recruiting, as well as addressing some of the retention issues. So, that'll be really positive.

You know, we're a little bit—I guess we're anticipating and being proactive about strategy when it comes to oversight, with the House flipping to the Republicans. We know there's a lot of criticism of CDC in particular. It's an agency we work with a lot, and so we're anticipating that states will get dragged into some of that conversation and health officials will be asked to testify. So, you know, that's something we're anticipating, see how that goes.

And then, of course, as I mentioned, you know, just this first year rollout of the public health infrastructure program, as an opportunity to transform agencies I think is really exciting.

So, it's gonna be a great year. I'd love to have us pivot to some non-infectious disease work there. We still have an overdose epidemic, we still have an epidemic of obesity, chronic disease—all of which are preventable with, again, more attention. And then, you know, the wildcard is what happens overseas with Ebola. You know, we've had some success with Mpox. When that emergency goes away, are we going to see a resurgence?

Yeah, so there's lots open questions for the future. That's why we need a long, nice long holiday break.

JOHNSON:
Thanks for listening to Public Health Review.

If you liked the show, please share it with your colleagues on social media. And if you have comments or questions, we'd like to hear from you. Email us at pr@astho.org—that's P-R at A-S-T-H-O dot org. You can also follow us using the Follow button on your favorite podcast player.

This show is a production of the Association of State and Territorial Health Officials. For Public Health Review, I'm Robert Johnson. Be well.