INSIGHT & INSPIRATION FROM APHA’S 2012 MIDYEAR MEETING

Survive All In This Friends Prevention, Strategies 

& Thrive Together For Health Opportunity & Equity For Health 

INSIGHT & INSPIRATION FROM APHA’S 2012 MIDYEAR MEETING

“Earlier today, the Supreme Court upheld the constitutionality 

of the Affordable Care Act — the name of the health care reform 

we passed two years ago. In doing so, they’ve reaffirmed a 

fundamental principle that here in America — in the wealthiest 

nation on Earth — no illness or accident should lead to any 

family’s financial ruin. 

I know there will be a lot of discussion today about the politics 

of all this, about who won and who lost. That’s how these things 

tend to be viewed here in Washington. But that discussion 

completely misses the point. Whatever the politics, today’s 

decision was a victory for people all over this country whose 

lives will be more secure because of this law and the Supreme 

Court’s decision to uphold it.” 

— President Barack Obama, June 28, 2012, 

in reaction to the U.S. Supreme Court upholding most of the 

Patient Protection and Affordable Care Act

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& Thrive Together For Health Opportunity & Equity for Health 

Letter from Dr. Benjamin 

Dear fellow public health practitioners, researchers, educators and supporters, 

On Saturday, Nov. 7, 2009 — the first day of APHA’s 137th Annual Meeting in Philadelphia — 

the U.S. House of Representatives passed its version of a bill that would eventually lead to the 

historic passage of real health reform. It was a pretty good day for public health. Fast forward 

to June 28, 2012 — the closing day of APHA’s Midyear Meeting in Charlotte, N.C. — when the 

Supreme Court upheld nearly every provision of the Patient Protection and Affordable Care Act. 

That was a very good day for public health. 

Hearing the long-awaited news surrounded by hundreds of fellow public health workers — 

the very people who are bearing witness to the law’s real impact on people’s health and wellbeing 

— was incredible. But in typical public health fashion, after a few minutes filled with 

celebratory cheers, ecstatic hugs and audible sighs of relief, the conference room quickly 

filled with that determined energy to make a difference. It was time to get back to work. 

The Supreme Court’s decision was good news, but the Affordable Care Act and its landmark 

investments in public health and prevention are hardly on sturdy ground. Attempts to repeal the 

law or strip the law of funds to implement it will likely continue. This comes on top of serious 

cuts to federal, state and local public health budgets. At the same time in our communities, 

people are still becoming sick and disabled, and are dying from preventable disease and injury. 

Significant health disparities persist, shining a glaring light on our moral obligation as a nation 

to eliminate health inequity. The need for public health is clear, but — as was heard again and 

again in Charlotte — our resources and capacity are truly in peril.

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It’s time to adapt, something public health has always excelled at doing. It was certainly the 

call to action that threaded its way throughout June’s Midyear Meeting. Whether the topic 

was building coalitions, adopting new technologies or developing the workforce, the need to 

maximize efficiency and quality — to adapt to a quickly changing health landscape — was everpresent. 

As Lydia Ogden, director of the Centers for Disease Control and Prevention’s Health 

Reform Strategy, Policy and Coordination Office, said during the Midyear Meeting’s closing 

session: “Let’s evolve and let’s do it together.” 

We hope this report from the Charlotte proceedings will help you on that journey. In the 

following pages, we’ve tried to capture the valuable insights and lessons learned that emerged 

during three days of public health presentations and conversations. Sharing our success stories 

— as well as our not-so-successful stories — is essential to empowering all communities with 

the opportunities for good health and well-being. 

Because as public health practitioners can attest to, we’re all in this together. 

With best and healthy wishes, 

Georges C. Benjamin, MD 

Executive Director 

American Public Health Association

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Executive Summary 

Hundreds of public health practitioners from across the nation 

gathered at the Westin Hotel in downtown Charlotte, N.C., for 

APHA’s 2012 Midyear Meeting, which took place June 26–28. 

With a theme of “The New Public Health: Rewiring for the Future,” 

the meeting zeroed in on equipping public health workers 

with the tools, knowledge and insights needed to thrive — 

and survive — in a challenging environment. Presenters also 

brought with them encouraging stories from the frontlines of 

community prevention, most notably the positive outcomes 

already unfolding thanks to support from the Communities 

Putting Prevention to Work and Community Transformation 

Grants programs funded through the Patient Protection and 

Affordable Care Act. 

As the theme language hints, meeting sessions did indeed 

cover rewiring in a very literal sense, such as North Carolina’s 

impressive success implementing health information exchange 

technology. It also covered rewiring in a more metaphorical 

sense, such as the efforts of Nebraska’s Douglas 

County Health Department to transform how communities can 

work together to improve population health and create the 

conditions that afford good health to all. 

Presenters also brought to the table helpful tips for advocating 

on public health’s behalf, engaging with nontraditional public 

health partners and elevating an evidence-based, healthin-all-policies 

approach. The topic of communicating public 

health’s good works received attention as well, with speakers 

calling on attendees to gather the data and craft the stories 

that illustrate the role of public health in people’s lives and the 

critical part that a robust public health system plays in improving 

health and curbing health care spending. 

The Charlotte Midyear Meeting welcomed session presenters 

from state and local health departments, federal public health 

agencies, schools of public health, private sector public health 

partners as well as research, policy and advocacy organizations. 

Topics ran the gamut, from community prevention and 

health disparities to partnering with the clinical sector and 

ensuring quality public health services. Of course, throughout 

the nearly three-day meeting, fingers were crossed about the 

most popular topic of the day, the soon-to-be announced Supreme 

Court decision on the constitutionality of the ACA. The 

caveat “if the law is upheld” could be heard on more than one 

occasion in the days before the ruling came down. 

For public health, the June 28 ACA ruling was not only a victory 

for the millions of Americans without access to affordable, 

quality health care; it was also a victory for the millions of 

Americans who will benefit from landmark community health 

investments via the ACA’s Prevention and Public Health Fund. 

In fact, many meeting presenters discussed the new opportunities 

to promote prevention that are unfolding thanks to 

health reform.

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Unfortunately, they also discussed the challenges of tightening 

budgets, shuttered programs and lost staff. The meeting’s 

host, North Carolina, was the perfect example of the ups and 

downs of public health work. During the meeting’s opening 

session, North Carolina State Health Director Laura Gerald 

praised the state’s public health quality improvement efforts, 

such as a new directive requiring local health departments to 

achieve accreditation. She also reported on the recent slashing 

of the state’s tobacco prevention funds — from $18 million to 

$2.7 million — and voiced concerns over the state’s continuing 

ability to sustain hard-fought declines in tobacco use. 

Attendees at APHA’s 

2012 Midyear Meeting 

react to the news that 

the Affordable Care Act is 

constitutional and will be 

upheld. 

This report, a collection of lessons learned from presentations 

during APHA’s 2012 Midyear Meeting, provides insights, tips 

and hopefully some inspiration as you navigate the new opportunities 

and challenges of today’s evolving public health practice. 

The report is divided into five topic chapters with input 

from various Midyear Meeting sessions. Each area is footnoted 

so readers know during which meeting session a presenter 

spoke. Every chapter is also followed by a list of active recommendations, 

titled Steps for Action. In between chapters is 

coverage from some of the meeting’s general sessions, and 

the report includes a list of helpful resources and a roundup of 

take-home action steps. 

“Public health is going through amazing changes,” said APHA 

Executive Director Georges Benjamin during the meeting’s 

opening session. “This is a time for public health to begin reenvisioning 

itself.”

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Public Health In Action: 

Key Recommendations 

From APHA’s 2012 Midyear Meeting 

ADAPT AND THRIVE: By no means does this mean public 

health practitioners should sit back in silence as life-saving, 

evidence-based programs land on the budgetary chopping 

block. But neither should we let the current fiscal environment 

— or future fiscal environments — be the driving force that 

shapes our work, our goals and the health of our communities. 

It’s time to adapt, innovate, step outside our comfort zones and 

even take some risks. It’s also time to ask the hard questions: 

Are we being efficient enough? Does this activity or service 

still provide good value and is it worth our limited resources? 

Adaptation has always been a strong suit of the public health 

practice and now is the perfect time to put it to use. 

CHAMPION HEALTH IN ALL POLICIES: Public health can’t do 

it alone, especially when it comes to changing and creating 

the conditions that afford good health for all. This idea isn’t 

new for public health practitioners, however it might be quite 

new for those outside the public health field. Take the time 

to reach out to transportation planners, land-use decisionmakers, 

school administrators, business owners, parks and 

recreation officials, housing authorities, etc., and engage them 

in improving community health and offer your expertise. Not 

only is this an effective public health strategy, it’s a smart way 

to leverage existing community resources and infrastructures 

for improving health. 

ENGAGE THE MEDICAL COMMUNITY: One of the many 

great aspects of the Affordable Care Act is that it views 

health in a holistic sense, acknowledging through policy and 

investment that good health happens both inside and outside 

of the doctor’s office. More and more, those in the medical 

community are realizing this too and are reaching out to public 

health practitioners for help. In fact, many physicians are 

realizing that precisely what’s missing from their toolbox is the 

public health approach. Reach out to the medical community 

and include them as partners in your efforts. As was heard 

multiple times at the Midyear Meeting, creating a new health 

system means integrating health care and public health. 

PICK A PARTNER: Behind nearly every success story told 

in Charlotte was the critical role of partnerships. Of course, 

building partnerships and coalitions isn’t new to public health; 

in fact, it’s one of our great strengths. But in a time of limited 

resources and competing priorities, building community-based 

partnerships that engage and empower stakeholders may be 

the surest path to sustainability. Plus, it’s a great way to teach

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more people about the power of public health and the need to 

speak up on its behalf. 

SHARE @PUBLICHEALTH: New technology and communication 

tools are already proving transformative for public health. 

From Twitter and mobile phone apps to information exchanges 

and electronic health records, we’ve only just begun to wield 

these new tools on behalf of public health. Learn about how 

these tools can help you reach the different communities you 

serve. Think about innovative ways to use new and growing 

amounts of data to create opportunities for better health 

outcomes and quality care. Technology is a powerful tool, but 

only if we know how to use it. 

E. Winters Mabry, director of health at 

Mecklenburg County Health Department 

in Charlotte, N.C., welcomes attendees to 

his hometown. 

DEMONSTRATE VALUE: Our communities will continue to 

look toward public health for help, guidance, oversight and 

care, but they will also be asking: Is this worth it? The answer, 

unequivocally, is yes. But, it’s up to us to make that argument. 

That means collecting the data and telling the stories that 

illustrate the value of public health in people’s lives. And 

not only the value in terms of better health and longer lives, 

but in terms of reducing medical spending and preventing 

unnecessary and costly hospital care. It is also important to 

define what “value” means. In other words, the value of public 

health work cannot — and should not — always be measured 

in dollars and cents. Surveys show that Americans believe in 

and support prevention; let’s capitalize on that momentum. 

EMPHASIZE EQUITY: Improving the nation’s health can’t come 

about without addressing the health inequities that persist in 

our communities. More than a matter of access, health equity 

is a matter of justice and fairness. Continue to fight for policies 

and resources that create the opportunities for all people to 

live healthy and prosper, and shine a light on the disparate 

social, economic and environmental conditions that propagate 

such inequities. Continue to be a voice for justice.



1SURVIVE & THRIVE: 

ADAPTING TO A 

CHANGING ENVIRONMENT 

“We need better care, better health and lower 

costs at the same time. Better care we can get 

done through the care system...But we need 

the public health community really mobilized 

around achieving better health. How to do that 

in an environment of decreasing resources 

when the customer of public health is a little 

more vague — that’s a very tough problem.” 

— Donald Berwick, former administrator of 

the Centers for Medicare & Medicaid Services

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A State’s Perspective 

“Decimated” is the word session presenter Frances Phillips used to describe her state’s public 

health budget during the last five years. The cuts have been terrible for local health departments 

and hundreds of jobs have been lost, reported Phillips, deputy secretary for public health 

at the Maryland Department of Health and Mental Hygiene. But instead of pulling back, Maryland’s 

public health community is quickly adapting to the new environment and making real 

progress toward improving health as well as health care — and it has “nothing to do with the 

budget,” Phillips said. 

“What is happening locally now is truly phenomenal,” she said. “And that’s really where people’s 

lives change and where health happens.” 

Phillips reported on three areas that are helping Maryland public health workers do “more 

with less.” The first is building collaborative relationships and embedding public health goals 

into momentum already happening at the community level. As of summer 2012, 17 local health 

improvement coalitions were working within a new framework created by Maryland’s recently 

launched State Health Improvement Process. The process marshals energy around 39 health 

objectives and sets short-term health improvement targets to be met by 2014. Phillips said 

that each goal must be backed up with locally available data, noting that it’s not good enough to 

reference state-level data “unless we can break it down locally where the health improvement 

action happens.” 

The state health department assists local coalitions by providing localized data, hosting a 

convening website and supporting the role of the local health officer in chairing the coalitions. 

Phillips emphasized that the state health department had zero funding to take on the coalitionbuilding 

endeavor. But the department capitalized on a “mutual understanding” with hospitals 

about the role that community prevention plays in helping hospitals come into compliance with 

ACA directives on quality care. It eventually led to the state hospital association providing about 

half a million dollars in start-up funds for local health improvement coalitions.

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The second area that’s helping Maryland do more with less also involves hospitals — specifically, 

leveraging new ACA-related financial incentives aimed at improving health care delivery 

to strengthen community-based care. For example, Phillips said, there’s a lot of pressure on 

hospitals to avoid preventable readmissions and better manage services for high-cost health 

care users. In turn, hospitals are looking toward community partners, such as public health 

departments, to help empower residents with the tools and services they need to stay healthy 

at home and they’re providing the financial support to help make it happen. Phillips noted that 

it’s a tremendous opportunity to illustrate public health’s critical role in curbing health care 

spending. 

Lastly, Phillips turned to technology, which she predicted would help “advance public health in 

ways we haven’t even imagined.” Maryland is home to a robust health information exchange, 

with all 46 acute care hospitals signed on and sending in data. And while the data flowing 

through the exchange is certainly a boon for the clinical treatment of patients, its potential to 

enhance public health surveillance and intervention is “huge — it’s almost unthinkable,” Phillips 

told attendees. So, with funding from a private foundation, the Maryland health department 

launched the Maryland Health Data Innovation Contest, calling on people to submit innovative 

ideas on using the exchange data to address public health challenges. The winner, who 

received a $5,000 prize and worked at the Maryland Poison Center, proposed marrying data 

from the medical examiner on overdose fatalities with poison control center data on overdose 

fatalities and near-misses. The combined data can help public health workers conduct needs 

assessments and better measure the impact of interventions. Maryland’s health department 

continues to host a website where people can continue the brainstorming process. 

“We see the role of public health at the state level as a convener of good ideas,” Phillips said. 

From session 2001/2006, All In This Together: Public Health Community Benefit, June 27

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Revitalizing the 

Public Health Workforce 

Will public health have the people, skills and training to excel and adapt in the new century? It’s 

an issue that the nation’s top public health agency is tackling head-on. 

Widening the pipeline into the public health profession, investing in emerging public health disciplines, 

and strengthening the linkages between public health and health care are top priorities 

at the Centers for Disease Control and Prevention. Session presenter Denise Koo, director 

of CDC’s Scientific Education and Professional Development Program Office, said the majority 

of the agency’s workforce development efforts falls into five categories: recruiting new talent; 

training workers in new disciplines; training the existing workforce; providing services and 

technical assistance; and developing a workforce strategy. Much of the attention is going toward 

recruiting new talent, Koo said, highlighting CDC’s service and learning fellowships. 

“In this day and age, we really feel that the deep experience that (students) get through fellowships 

is needed more than ever,” Koo told attendees. 

CDC has created a virtual one-stop shop for fellowships at cdc.gov/fellowships. Koo reported 

that nearly 300 fellows have been assigned to work in the field with local and state public 

health agencies. The fellowships are two- to three-year training programs that are similar to 

the medical residency model, but unique within the public health field. She noted that there 

are more than 8,000 residency opportunities for physicians, but really only a handful for public 

health practitioners. Today, about 75 percent of CDC fellows go on to secure a job in the public 

health field. 

North Carolina State Health Director 

Laura Gerald speaks at opening session.

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One of the challenges, Koo noted, is moving from a one-on-one to a population-based approach 

to workforce development. To help move this framework forward, the agency hosts the online 

CDC Learning Connection at cdc.gov/learning. The site hosts a wealth of learning and training 

opportunities, from those that offer continuing education credits to what CDC calls Quick Learn 

Lessons, which are lessons that take 20 minutes or less and that users can access via mobile 

devices. Koo said the agency is also developing core curriculums for the public health sciences, 

such as “public health 101” courses in epidemiology, informatics, surveillance and more. Unlike 

an academic setting, Koo said the CDC offerings are meant to be short courses that people 

can access when they have a few minutes to spare. 

CDC is also working to develop a long-term strategy regarding public health workforce development, 

with a big focus on how to more effectively bring together the public health and health 

care sectors. Through CDC’s Public Health Workforce Development Initiative, Koo said the 

agency has been engaging a variety of stakeholders to gather input on what CDC’s future workforce 

priorities and strategies should entail. During the meetings, stakeholders are discussing 

factors that are transforming the practice of public health, such as the massive amounts of 

data now coming into health departments via multiple sources and how public health workers 

can wield this data to improve health. CDC has also learned from stakeholders that the core 

competencies of the “new” public health are: convening and collaborating (not just doing); improved 

monitoring of community health status to aid community engagement; leveraging policy 

change; and employing clear communications, including the use of social networks.

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What are some of the emerging skills public health partners tell CDC they need? Practitioners 

with policy skills, systems thinkers with a broader definition of public health, liaisons to 

strengthen public health-health care partnerships, and workers skilled in informatics. (“Informatics 

skills, informatics skills, informatics skills. (It) keeps coming up over and over again. 

How do we leverage technology but still in an evidence-based way to support public health,” 

Koo asked meeting attendees.) 

In fact, for the first time, Koo reported that CDC placed nine fellows in the field to focus on informatics. 

Also, with Prevention and Public Health Fund dollars, Koo said CDC is keeping more 

graduates in epidemiology and placing them at the intersections of medicine and public health 

— “that is the future, we need people who can do that boundary spanning,” she said. CDC is 

also looking for opportunities to implement a systems-based approach to workforce 

development and garner more recognition for public health as a discipline. 

For example, the agency recently finished the first phase of a collaboration with 

the U.S. Department of Labor, which has designated CDC’s public health informatics 

fellowship as an official federally registered apprenticeship — it’s a first for 

a professional public health fellowship as well as a first step toward having public 

health informatician as a standard occupational code, Koo reported. 

“We don’t want a public health system and a health care system,” Koo said. 

“What we want is an integrated health system and public health is a critical piece.” 

From session 1001, Who Will Keep the Public Healthy?: Building the 21st Century 

Workforce for Public Health, June 26 

“We as a public health system need to adapt; we need to 

transform,” said Judith Monroe, director, CDC Office 

for State, Tribal, Local and Territorial Support

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New Times, New Partners 

Breaking down the barriers between the public health and clinical sectors received significant 

attention at the Midyear Meeting. In fact, over and over again, speakers noted that engaging 

medical partners and helping them meet new health care delivery directives under ACA will be 

critical to elevating — and sustaining — public health’s role in a time of health reform. It’s not 

just public health that must adapt to new times; the clinical sector must also adapt to a new 

framework of prevention and it needs public health’s help to do it. 

Janet Wright, executive director of the Million Hearts initiative, spoke on how bringing together 

public health and clinical players is key to reducing two of the nation’s top killers: heart disease 

and stroke. The Million Hearts initiative, which is led by CDC and the Centers for Medicare 

& Medicaid Services, launched in 2011 with a goal of preventing 1 million heart attacks and 

strokes by 2017. Wright began her Midyear Meeting presentation with what she called a confession: 

She is not a public health practitioner. 

As an interventional cardiologist, she said she struggled with trying to change patients’ health 

trajectory, while patients struggled with a culture that was driving them in the wrong direction 

— “toward disease as opposed to health.” She was frustrated with her ineffectiveness as 

a clinician to change people’s behavior. She would often ask patients who were successful in 

losing weight, stopping smoking or adhering to treatment: How did you do this? Oftentimes, 

the answer was that they got connected with a wider, community effort. She said she started 

to realize that she was missing a big chunk of training needed to turn around health outcomes, 

and that training was in public health. 

“I am becoming very slowly...a public healther,” Wright said. “I am enormously devoted to this 

initiative and to the successful marriage of clinical practice and public health around cardiovascular 

disease.”

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The goal of the Million Hearts initiative is an audacious one, she said, but it is achievable 

through the combined efforts of many diverse organizations. Wright said the architects of 

Million Hearts are very purposefully aiming to integrate clinical and community-based prevention 

to create an environment in which both are seen as critical to preventing heart attack and 

stroke. For example, among the key components of Million Hearts is getting the ABCS (aspirin, 

blood pressure, cholesterol and smoking cessation) embedded into clinical care mechanisms, 

while also changing environments to support heart healthy habits, such as instituting smokefree 

policies and reducing sodium in the food supply. (Interestingly, Wright noted that she met 

with food manufacturers about sodium content. Manufacturers told her that putting a lowsodium 

label on a product was the “kiss of death” for a product’s success. In other words, they 

would consider decreasing sodium content if they could still sell the product — they need more 

public demand. Wright called the situation a “public health puzzle.”) 

Today, Million Hearts boasts an impressive array of public and private health and public health 

partners. Wright noted that state health departments are signing on as partners and developing 

state-based plans bringing their clinical and public health sectors together — “all with data, all with 

targets and a will to change the current cardiovascular health of the nation one state at a time.” 

One of the “coolest” outcomes of organizations making a public commitment to the goals of Million 

Hearts is partners hooking up with partners, she told attendees. For example, WomenHeart, an organization 

of hundreds of “champions” who lead community efforts and educate women on cardiovascular 

disease, wanted to do more work on blood pressure, but they didn’t have the expertise. In 

turn, the Preventive Cardiovascular Nurses Association put together some educational materials on 

blood pressure that is now going out to communities around the nation via WomenHeart. 

“I need you...to be ambassadors for Million Hearts and to guide this initiative,” Wright told session 

attendees. 

From session 3000, Strange Bedfellows Make Powerful Champions: Emerging Partnerships in Public 

Health, June 28 

STEPS FOR ACTION: 

• DON’T let budget problems 

define your work. Find 

creative ways to adapt to 

new fiscal environments 

and leverage public health 

success stories and 

relationships to continue 

momentum toward healthier 

communities. 

• TAKE advantage of 

workforce training and 

development opportunities, 

especially those that will 

help your department thrive 

in a new era of efficiency and 

technology. 

• REACH out to clinical 

partners. Many are just 

as frustrated as you with 

rises in preventable health 

conditions and are looking 

for more comprehensive 

approaches to patient care.

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2012 Midyear Meeting Opening Session: 

‘The Biggest Risk Of American Health Care Today Is That It Will Fail The Moral Test’ 

Donald Berwick, former administrator of the Centers for Medicare & 

Medicaid Services, started his opening session keynote address with an 

admission: He wasn’t sure how to address the question of how public 

health can thrive in today’s changing health care world. The question, 

he told attendees, doesn’t have an easy answer. 

The Affordable Care Act, he said, does essentially two things: It attempts 

to make health care a right, and to make health care sustainable 

via improvements in quality and delivery. The question of how to define 

what improvement means — and what we should expect — in an era 

of health reform is what motivated Berwick as he worked to transform 

CMS to align with the goals of the now-famous “Triple Aim:” Better 

care, better health, reduced costs. However, the framework also stresses 

the importance of equity — an overriding goal of public health work. 

According to a 2008 Health Affairs article Berwick co-authored, the “Triple 

Aim is an exercise in balance and will be subject to specified policy 

constraints, such as decisions about how much to spend on health care 

or what coverage to provide and to whom. The most important of all 

such constraints, we believe, should be the promise of equity; the gain 

in health in one subpopulation ought not to be achieved at the expense 

of another subpopulation...A health system capable of continual improvement 

on all three aims, under whatever constraints policy creates, 

looks quite different from one designed for the first aim only.” 

“The biggest risk of American health care today,” he told opening session 

attendees, “is that it will fail the moral test.” 

Berwick said, in part, it didn’t matter how the Supreme Court ruled on 

the health reform law, as the “health care evolution agenda” had already 

left the station and is quickly moving toward improved care coordination, 

better transparency, patient-centered care and the adoption of 

health care technologies. And the opportunity to provide input as health 

care evolves doesn’t depend on your ties to Washington, D.C., he noted 

— it’s a community affair. 

But what does it all mean for public health? Berwick said he wasn’t 

entirely sure. Public health faces real challenges, he said, especially 

in communicating its value to the public and to policymakers. It’s that 

classic problem of how do you tell the story of a person who didn’t get 

sick or injured because of a successful public health intervention? How 

do we communicate the value of prevention, even if it doesn’t always 

save health care dollars? 

So, while Berwick began his keynote not sure about what advice he 

could offer, he did end with what he called a prescription for public 

health: When possible, reduce costs within public health; cooperate and 

don’t work in silos; reach out and partner with nontraditional organizations 

and systems; get involved in reducing health care costs and waste; 

and mobilize support for public health. 

“Public health needs mobilization too,” he said. “If there isn’t political 

force behind the public health endeavor, it will remain frail.”



2ALL IN THIS TOGETHER: 

LEVERAGING THE ACA TO 

PROMOTE PUBLIC HEALTH 

“The boundaries are blurring...everyone needs 

to improve the health of their populations.” 

— Lisa Simpson, president & CEO, 

AcademyHealth

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Community Collaboration 

Together again. That’s how Julie Trocchio described the emerging collaborations between 

health care and public health. The senior director of community benefit and continuing care for 

the Catholic Health Association of the United States, Trocchio began her presentation with a 

little history of Catholic health care in the United States. 

She told the story of six nuns who left France in the early 1700s and came to New Orleans. They 

began visiting the city’s sick and poor, supporting their work through begging and eventually 

receiving a house where they cared for residents. Trocchio said it was among the country’s first 

hospitals and maybe even the first group of public health nurses. About 100 years later, Henriette 

DeLille, a woman of color, began visiting slave quarters in New Orleans, caring for ill and 

aging slaves. Similar to her predecessors, she was eventually given a house where she took 

patients in — Trocchio said DeLille’s work may very well have been the country’s first nursing 

home and hospice. This is our history, she told session attendees. 

“Those stories tell us...that we share a common mission — not-for-profit hospitals and public 

health agencies — in that we were created to deal with the problems in our communities in 

the times when they were happening,” Trocchio said. “I have heard about collaboration since I 

walked into this hotel’s door, every session is talking about the importance of collaboration. We 

can’t do it without our friends. The last thing (these stories) tell us is there’s never been enough 

money to go around.” 

Every not-for-profit hospital was started to address a community need, and so conducting community 

health needs assessments is often already part of the mission. However, the ACA has 

formalized the process, creating a legal imperative. ACA now requires hospitals to do such assessments 

and develop implementation strategies to address the needs identified. The directive 

has been codified in an Internal Revenue Service notice, which also states that such an assessment 

must be done in collaboration with community partners, especially those with knowledge

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and expertise in public health. Trocchio said that in conducting an assessment, the community 

served is typically defined by geography, but that a hospital cannot gerrymander its definition in 

a way that excludes certain populations. 

Trocchio noted that the IRS leaves much of how an assessment is done to the hospital’s discretion; 

however, the agency is specific about gathering input from those who represent community 

interests — “this is to be a collaborative process,” she said. The same collaborative intention 

frames the implementation strategy hospitals must develop to address the needs identified 

during the assessment phase. 

“Increasingly, hospitals are realizing that the health and the cost problems that we have really 

do have community-based solutions,” Trocchio said. 

From session 2001/2006, All in This Together: Public Health Community Benefit, June 27 

Donald Berwick, former administrator of the 

Centers for Medicare & Medicaid Services, was the 

the keynote speaker at APHA’s Midyear Meeting.

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Community Transformation Grant: 

The North Carolina Experience 

In 2011, North Carolina received the nation’s fourth-highest Community Transformation Grant, 

or CTG, a federal program created by the ACA and focused on community-level interventions to 

reduce rates of chronic, preventable diseases. Today, the state’s public health practitioners are 

using the grant to truly leverage transformational change toward better health for all. 

North Carolina’s CTG work is targeted in four areas: limiting environmental tobacco smoke; improving 

active living by design; promoting healthy eating; and improving clinical preventive services, 

which is focused on reducing the risk factors for heart disease and stroke via the Million 

Hearts campaign. Just a few examples of the state’s goals are to: promote smoke-free regulations 

in affordable housing and on university campuses; increase the number of corner stores 

that sell healthy, affordable foods; and up the amount of community support for residents living 

with high blood pressure and high cholesterol, and those who use tobacco. 

“No pilots; we want to begin at scale,” said session presenter Jeffrey Engel, then a health policy 

advisor with the North Carolina Department of Health and Human Services. “When you know 

that this works, let’s just get beyond the pilot and move it to scale.” 

Engel said that the state’s CTG work will also build on efforts to eliminate the “health disparities 

that plague our state,” noting that the state Office of Minority Health and Health Disparities 

has been fully incorporated into the CTG community so that such inequities will be considered 

in all interventions. 

Successes to date include the proliferation of smoke-free policies and more fresh food at local

20 



convenience stores. However, the new resources are also allowing public health practitioners to 

pursue a health-in-all-policies approach — “finally, public health is getting a seat at the table 

with the broader policymakers. This is the beginning of the health-in-all-policies philosophy 

we’re trying to permeate through the state,” Engel told attendees. For example, in North Carolina’s 

Pitt County, community health has been officially identified as a goal in the county’s 2030 

land-use plan. CTG funds are also promoting linkages between community health resources 

and clinical preventive services “in a way that really puts boots on the ground,” Engel said. 

“This is real transformational change for public health in North Carolina, to be working closely 

with our clinical partners and doing the things we know work on a population basis, but in the 

clinic,” he said. 

The North Carolina health department is using a regional approach to its CTG work, leveraging 

existing regional infrastructures. For example, workers in existing Area Health Education 

Center regions are partnering with clinical practices to implement Million Hearts. Using such a 

regional approach means North Carolina’s CTG work can have the farthest reach possible. For 

instance, the state’s Mecklenburg and Wake counties were not funded during the first round 

of CTG grants. But because the state is taking a regional approach to CTG work, the two large 

communities still have a seat at the table and will be able to take advantage of new efforts even 

without direct funding. 

“Leveraging our existing infrastructure is really the only way we can go about this in such a 

large state,” Engel said. 

From sessions 2004/2009, Innovations in Community Prevention, June 27 


• HELP bring public health 

and medicine back together 

again. Health care systems 

are busy working to meet 

new ACA directives and are 

realizing that communitybased 

solutions will be key. 

• LEVERAGE existing public 

health structures and 

resources to make the most 

out of new ACA prevention 

and public health funds. 

Use new grant funding to 

build capacity outside of 

traditional public health 

services.



3FRIENDS FOR HEALTH: 

THE IMPORTANCE OF PUBLIC 

HEALTH PARTNERSHIPS 

“If you want to be understood, seek first 

to understand.” 

— Lydia Ogden, director, CDC’s Health 

Reform Strategy, Policy and Coordination 

Office

22 



Prevention & The Private Sector 

The flu. A preventable disease that, despite an effective vaccine, thousands of Americans die 

from and become ill with every year. But today, with the help of a well-known pharmacy chain, 

the nation’s top health agencies are beginning to make additional inroads. 

While overall adult flu vaccination rates aren’t as high as public health officials would like, 

certain populations bear a disproportionate burden of the virus’ effects, said session presenter 

Jamila Rashid, associate director for research and policy with the Office of Minority Health at 

the U.S. Department of Health and Human Services. According to the Office of Minority Health, 

not only are flu vaccination rates considerably lower among black and Hispanic adults, the 

populations also have higher rates of flu-related hospitalizations. Among the barriers to flu 

vaccination are a lack of insurance and access to care, misinformation about flu vaccine safety 

and complacency, Rashid said. 

To tackle the problem, HHS formed a number of workgroups to tackle low vaccine rates, 

among them a workgroup dedicated to closing the vaccine disparity gap by widening access 

to flu shot opportunities. The effort partnered with a wide variety of organizations, from 

churches to health care providers to fellow federal agencies. However, the work received an 

extra boost when a pharmacy chain familiar to many Americans agreed to join. That familiar 

storefront was Walgreens. 

J. Michael McGinnis, a senior scholar at the 

Institute of Medicine, discusses how public 

health and prevention can be better incorporated 

into clinical care settings.

23 



The partnership was new territory for federal health workers, Rashid said, so the 2010-2011 

flu season effort got off to a late start, kicking off around Christmas. That season, Walgreens 

donated 350,000 flu vouchers, which were distributed to state, local and regional health agencies. 

Unfortunately, not many people took them — the effort wasn’t working, Rashid said. But in 

typical public health fashion, organizers convinced federal leadership to give it another go. During 

the 2011-2012 flu season, organizers provided Walgreens with a list of potential community 

partners and encouraged the company to reach out. It was a success: Walgreens reached out 

to more than 700 community organizations and agencies to help plan and host flu shot clinics 

with the help of Walgreens’ pharmacists and trained vaccinators. By the end of that flu season, 

Walgreens had distributed 300,000 free flu vouchers to the uninsured and vaccinated more than 

51,000 uninsured or underinsured residents. Rashid said CDC is continuing to lead efforts to 

recruit more pharmacies to join. 

“What was most valuable and important was getting Walgreens to go out into communities, to 

work with local community partners and set up those clinics,” she said. “Now, we’re saying to 

other pharmacies, ‘Hey, look what happened with Walgreens — don’t you want to also participate 

in this process?” 

From session 3000, Strange Bedfellows Make Powerful Champions: Emerging Partnerships in Public 

Health, June 28

24 



Empowering Community Partners 

Building partnerships means more than gaining buy-in for a particular cause or action; it also 

means empowering community players with the tools and knowledge to make a difference and 

become leaders for change. In fact, empowerment may be the key to whether an effort lasts the 

test of time or slowly fades into the distance. 

Terrence Roche, senior director of organizational and community change at the YMCA of the 

USA, told session attendees about his organization’s experience in driving healthy change at 

the local level. The renewed efforts date back to 2002, Roche said, when people began asking: 

“Where is the Y?” It seemed people were noticing that the familiar organization was missing 

from national, and some local, discussions about serious health problems, such as obesity and 

diabetes. In response, YMCA developed a variety of efforts that shift the organization from working 

with people who are already proactive about their health to reaching out to those struggling 

with their well-being. The shift also meant getting out into communities — bringing healthy 

choices to the people, Roche said. 

Lauren Sogor, discusses the success of 

Text4baby, a free mobile information service 

designed to promote maternal and child health.

25 



“We’ve changed a lot over the years and have adapted to the needs of communities across our 

country as well as across the world,” he told meeting attendees. 

So, the YMCA began building and improving their capacity to not only make internal changes, but 

to work externally and empower community groups to become agents for healthy change. One 

example was the Y’s Healthier Communities Initiative, which works to build community partnerships 

that advocate for systems, policy and environmental changes that support healthy living for 

all. In communities that take part in the initiative, the YMCA plays the role of convener, bringing 

together a variety of stakeholders, such as schools, public health workers, insurers, elected officials, 

media and business leaders. Among the tools that community coalitions can use is YMCA’s 

Community Healthy Living Index, an easy-to-use assessment tool that anybody can use to 

measure how well their community supports healthy living. Roche said that even though YMCA 

isn’t able to provide the kind of funding support that federal agencies can, the focus on building 

community-wide partnerships puts local efforts on a good path toward sustainability. 

Roche reported that thanks to YMCA efforts, more than 200 communities have contributed to 

more than 26,000 policy, system or environmental changes that have impacted up to 46 million 

people. Just a few examples are: More than 100 new farmers markets, nearly 500 new community 

gardens, nearly 200 new walking trails and sidewalks, and more than 1,000 schools and 

workplaces with new food and vending policies that favor healthy choices. 

“A decade ago, it was sort of like ‘Where is the Y’ and we weren’t at the table,” Roche said. 

“But a decade later, we’ve actually set the table.” 

From sessions 2004/2009, Innovations in Community Prevention, June 27 

Larry Cohen, founder and executive director of the 

Prevention Institute, speaks during APHA’s Midyear Meeting.

26 



Bringing Health Care Into the Fold 

In 2000, an Institute of Medicine report stated: “It is unreasonable to expect that people will 

change their behavior easily when so many forces in the social, cultural and physical environment 

conspire against such change.” Larry Cohen, executive director of the Prevention Institute, 

couldn’t agree more. 

During his Midyear Meeting presentation, Cohen talked about an emerging approach to improving 

health known as community-centered health homes. The approach grows out of the fact 

that medical care alone cannot solve the nation’s health problems or close disparity gaps, nor 

is medical care the primary determinant of a person’s health. Public health practitioners must 

help health care providers recognize and address the broader contributors to poor health, injury 

and disease. 

“This is really the first time that we intentionally said ‘How do we bridge prevention and health 

services,’” Cohen said. “And we did it, frankly, from the perspective that health care has most of 

the resources, most of the credibility, most of the weight in our health system, and if we want to 

focus on health, not health care, it must be done as a very thorough partnership.” 

In 2011, the Prevention Institute published “Community-Centered Health Homes: Bridging 

the gap between health services and community prevention,” which outlines how community 

health centers can offer quality care while also addressing the roots of patients’ health problems. 

Cohen told attendees he was surprised at the level of enthusiasm the concept received 

from the health care community, noting that “we need medical participation to make things fair 

and that’s why the environment is a key opportunity for prevention.” In other words, changing 

people’s environments must be part of a physician’s role too.

27 



Cohen said that clinicians’ existing skills set — patient intake, diagnosis and treatment — can 

also be applied outside the clinic doors to community prevention, which requires inquiry, 

assessment and action. Clinicians already engage in inquiry (in medical terms, cataloguing 

symptoms and vital signs; in public health terms, gathering relevant data); assessment (in 

medical terms, diagnosis; in public health terms, measuring community conditions); and action 

(in medical terms, treatment; in public health terms, engaging in work to change community 

conditions and create opportunity.) 

Understanding the link between a person’s health and their environment means taking two 

steps back, Cohen said. For example, in addition to prescribing medicine for a patient with 

a stomach ailment, a community health center clinician should also take two steps back by 

inquiring about underlying behaviors and then what environmental factors contributed to that 

behavior. 

“We can speak up for community change,” Cohen said. 

From sessions 2002/2007, Best of Partners: Reconnecting Public Health and Clinical Care, June 27 

John Auerbach, 2010–2011 president of the 

Association of State and Territorial Health 

Officials 


• DON’T be wary of 

approaching the private 

sector. Their familiar brands, 

not to mention financial 

resources, can be a real 

boost for public health goals. 

• EMPOWER organizations 

and residents with the tools 

and data to take ownership 

of their communities’ health. 

This strategy will also 

increase the chance that 

efforts will sustain over the 

long term, despite the ups 

and downs of funding. 

• ADVOCATE for new models 

of clinical care that take 

into account a patient’s life 

outside the doctor’s office 

and utilize a populationbased 

approach to health 

and prevention.



4PREVENTION, OPPORTUNITY 

& EQUITY: STAYING TRUE TO 

PUBLIC HEALTH VALUES 

“We think we can make a difference in closing 

the gap by the medical model — and I think 

it’s important to recognize we don’t need to be 

an adversary to the medical model — but the 

medical model is not going to close the gap 

in excess death. It has to be one based upon 

social justice and the notion of human rights.” 

— Adewale Troutman, APHA President, 

2012-2013

29 



Keep the Focus on Inequities 

“Child health is rural wealth.” That’s what the banner reads in an old picture from 1923 of the 

country’s first rural health department, which actually began as a pilot project to see if it was 

possible to bring the urban protections of public health to a rural setting. The session speaker 

behind the picture was Michael Meit, co-director of the Walsh Center for Rural Health Analysis 

at the University of Chicago, who reminded attendees that rural communities continue to face 

barriers to good health. And on the flip side, public health workers continue to face barriers in 

reaching rural communities. 

“The challenge that we face in rural public health is how do we provide equitable public health 

services — basic public health services — to a population that is dispersed,” he asked. 

First, what is rural? There are more than 70 federal definitions of rural, Meit said, from small 

towns to frontier, which is defined as six or fewer people per square mile. About 20 percent of 

the U.S. population lives in rural areas, and most of the nation’s landscape is rural even though 

most people live in urban settings. Rural residents face a number of social determinants that 

impact their health, from lack of access to health care and public health services to isolation 

and poor local economies. Meit noted that per capita income is about $10,000 less in rural 

areas than in urban areas; about 31 percent of food assistance recipients live in rural communities; 

and 48 of the 50 U.S. counties with the highest child poverty rates are rural. 

Meit said that disparities worsen even more when taking into account the racial and ethnic 

make-up of rural regions. Hispanics are the nation’s fastest growing rural population; the 

American South is home to large rural black communities; and the Plains and southwestern 

states are home to large American Indian communities. All such groups suffer from documented 

disparities in access and disease rates. 

“A lot of the health disparities we see are an interplay between geography and race and ethnicity,” 

he said.

30 



But bringing effective public health interventions to rural residents is no easy task. For one, 

data gathering is a serious challenge, Meit said. He noted that in 2001, CDC’s annual “Health, 

United States” report focused on rural populations for the first and, so far, only time. And data 

collection is so difficult in rural areas that health workers are still using the old CDC data when 

creating grant proposals today. Also, many rural communities simply have no public health 

infrastructure and strengthening what infrastructures do exist is a big challenge, both in terms 

of financial resources as well as in recruiting and retaining workers. 

“This is critical because we think that public health is everywhere and it’s not,” he said. 

Complicating matters is the perception in many rural areas that public health is simply a waste 

of taxes and a form of government intrusion, Meit said. So, how do we tip the scales, he asked 

meeting attendees. We must build grassroots support for public health and develop messaging 

that communicates the benefits of strong public health services in a way that resonates with 

rural residents. Meit said that “public health does itself a disservice by not engaging rural communities 

because rural people and rural organizations are the best advocacy groups there are.” 

“If we all want to have food and fuel and timber and a lot of the resources that are provided by 

rural communities, we need to figure out how to care for rural residents,” he said. 

From session 1003, Achieving Health Equity: Solutions from the Field, June 26

31 



The Value of Public Health 

The question of public health’s value may seem like a no-brainer to the practitioners who get 

to witness the discipline’s outcomes as they unfold on the ground. For decision-makers and the 

public, however, the value may be less clear and often, it isn’t clear at all. In today’s fiscal environment, 

being able to effectively communicate the value of a robust public health system is an 

essential component in moving forward to promote prevention and eliminate disparities. 

Glen Mays, a professor in health services and systems research at the University of Kentucky, 

has been doing such value-oriented data gathering, though he notes that research remains 

scarce and imperfect. 

“There’s not enough of this kind of research currently going on within our nation and our communities 

and there’s still lots of uncertainties,” he told meeting attendees. “But hopefully, this 

kind of research can give you a taste of what’s possible and certainly what we need to be doing 

more of to produce the evidence to make the case with the policy community and with the public 

at-large.” 

First, Mays remarked that the United States is falling further and further behind other comparable 

nations in terms of health indicators, despite spending the most on health care. He said 

there’s a “real dysfunction and lack of logic” in how we deploy resources in relation to what is 

known about the major drivers and determinants of health. For example, more than two-thirds 

of health care spending goes toward chronic disease, much of which is preventable; yet less 

than 3 percent of resources are directed toward public health activities that target chronic disease 

prevention. 

“There are lots of targets for realizing value in public health spending that spill over into the 

medical care system,” Mays said.

32 



Fortunately, the ACA recognizes this connection via the Prevention and Public Health Fund. 

Still, the fund remains somewhat controversial, Mays said, because we don’t have a lot of sound 

evidence on the return on investments in public health. Mays and his colleagues are gathering 

that evidence, however, and here’s what they’ve found. 

Communities with higher public health spending saw larger reductions in preventable mortality 

measures, such as cancer, heart disease, diabetes and infant mortality. Also, communities at 

the bottom levels of per capita public health spending have the highest levels of per capita medical 

spending. The findings illustrate the real health returns associated with growing investments 

in local public health as well as the chance to offset medical costs. Mays projected that 

the additional federal spending authorized via the Prevention and Public Health Fund works out 

to about a 1.2 percent increase in public health spending in communities over 10 years. Every 

new dollar in federal public health spending will get back about 87 cents in Medicare spending 

over a decade — “that’s a fairly sizeable economic impact suggesting that, yes, public health 

spending can be useful in reigning in medical cost growth,” Mays told attendees. 

Such federal spending can also avert nearly 180 preventable deaths in an average community, 

resulting in about 1,800 life years gained. Public health, he said, “is a good buy.” 

“We’re certainly just at the tip of the iceberg in terms of our current research technology for 

estimating these benefits,” Mays said. “But we think this, in part, shows us what’s possible 

not only with expanded investment in public health, but also what’s possible with expanded 

research into helping us look at the benefits and return from investments in the public health 

system.” 

From session 3003, Public Health Funding: Why Should They Care?, June 28

33 



Refocus on Social Justice 

Eliminating health inequities is a daunting task, even for the most well-funded health department. 

Such is the case in Boston, where black residents experience disproportionately higher rates of 

illness and death, despite near-universal access to health care services in Massachusetts. 

“Black residents have worse health and the neighborhoods in which they live also have the 

worst health outcomes,” said Barbara Ferrer, executive director of the Boston Public Health 

Commission, the nation’s oldest health department. 

To address the problem, the commission restructured its work to zero in on the social determinants 

that shape people’s health outcomes with a strong focus on racism, which Ferrer said has 

an “impact on pretty much every other social determinant of health, including people’s access 

to education and jobs, the healthy environments where they live.” In fact, eight years ago, Boston’s 

mayor convened a task force dedicated to ridding inequities in health outcomes. So, what 

does that mean for a health department? 

“We alone can’t fix much of anything,” Ferrer told meeting attendees. “It is our job to acknowledge 

that the reality is that it is those very conditions that’s going to affect people’s health 

status and then align ourselves up as institutions to really put our work in places where we’re 

going to make a difference in those social conditions.” 

The health department developed a set of core strategies and guiding principles to support 

activities designed to achieve equity through community, policy and systems change, with an 

explicit commitment to racial justice. To build institutional capacity, Ferrer said every program 

at the commission must now integrate the elimination of health inequities into their goals. 

The health department also realigned its resources to achieve three overarching goals within 

five years: reduce the gap in low birthweight rates, reduce obesity/overweight disparities, and 

reduce the gap in chlamydia incidence. In addition, all employees must take training focused on 

racial and social justice.

34 



“If we say we’re interested in promoting the health equity agenda, it only makes sense that we 

actually do something to narrow the gap,” she told attendees. 

Here’s an example of how Boston public health workers are doing things differently. The commission 

began working in five neighborhoods with the highest rates of violence, providing 

funds so that community-based groups can hire community organizers and block captains. The 

community workers engage residents, connect people to support services and work to make 

improvements in the built environment. To facilitate the last point, leaders from various city 

departments meet regularly with each group about fixing problems that residents have identified, 

such as broken-down buildings and littered playgrounds. The process results in immediate 

gains in the built environment, said Ferrer, who added that the effort is based on “engaging 

residents who are there to come up with their own plans for building a culture of peace.” 

Ferrer said one of the biggest vehicles for change has been policy, adding that “we can, in fact, 

change the landscape.” For instance, in 1999, about 85 percent of dumpster storage lots, junkyards 

and transfer stations were located in communities of color. So in 2001, the local board of 

health passed a regulation requiring all such facilities be inspected and permitted. Ten years 

later, the number of such businesses has dropped dramatically and fewer than 40 percent 

remain in neighborhoods of color. 

“It’s not how can we promote healthy behavior; it’s how do we target dangerous conditions and 

reorganize land-use policies and transportation policies,” Ferrer said. “It’s not how to reduce 

disparities and the distribution of illness; it’s how to eliminate inequities in the distribution 

of resources and power. It’s not what social programs and services are needed; it’s what kind 

of social change is needed to really make lasting change. It’s not how can individuals protect 

themselves against health disparities; it’s what kind of community organizing and alliance 

building and partnerships do we need to create that would actually protect our communities.” 

From session 1003, Achieving Health Equity: Solutions from the Field, June 26 


• ENGAGE communities in 

culturally competent ways 

so that they will become 

supporters of strong public 

health systems. 

• COLLECT the data 

and stories that not only 

illustrate the value of public 

health in improving people’s 

health, but its critical role 

in curbing medical costs. 

Americans value prevention, 

but it’s up to us to show 

people why public health is 

worth the money. 

• ZERO in on social justice 

and the environmental 

conditions that contribute to 

poor health and premature 

mortality. Recognize that 

eliminating health inequities 

takes looking beyond 

traditional public health 

services.



5 

STRATEGIES FOR HEALTH: 

EMBRACING TECHNOLOGY, 

MEDIA & ADVOCACY 

“We are in a fight for our lives. Plain and 

simple...And this is just the beginning. We 

are facing the biggest threats we’ve seen in 

decades.” 

— Emily Holubowich, executive director, 

Coalition for Health Funding

36 



Speak Up for Public Health 

The ability to advocate effectively doesn’t come naturally; like many things in public health, first 

you have to build the capacity. 

Lora Wier, director of Montana’s Teton County Health Department, told meeting attendees 

about the experience of the Montana Public Health Association in becoming a force for public 

health. It began in 2004, when the governor appointed a new director to lead the state’s health 

department. At the time, Weir was serving as president of the state association and received a 

call asking for its position on the appointment. She said she didn’t really know what to say. But 

then she thought: If anybody should have a position, it should be us. In response, the association 

contacted the governor’s office and met with staff (she said the association was concerned 

the appointment wasn’t a good fit for the health department). It was the association’s first foray 

into advocacy and policy. 

From there, capacity continued to grow. The association assembled a committee dedicated to 

advocacy and policy and got active during the 2007 state legislative session — we did what we 

could with limited experience, Wier said. They also tried to engage association members and 

along the way, learned a lot about their capabilities and barriers. Wier said members didn’t 

know how to advocate and were insecure about trying. In turn, the Montana association began 

offering advocacy education during all of their annual meetings. 

Feeling good about its state-level work, the association moved to the federal level. And as they 

got more active, they became more visible in Montana, attracting new partners and strengthening 

their role as a voice for public health and prevention. When it came time to take part in 

APHA’s 2011 Public Health ACTion (PHACT) grassroots advocacy campaign, they were ready. 

Along with their organizational partners, the Montana association sent out letters to the editor; 

had guest opinion columns published in four of the state’s seven major daily newspapers; 

had four congressional district meetings; and organized a public health call-in day, asking its 

members to call their national representatives and show their support for the ACA’s Prevention 

and Public Health Fund.

37 



Offering advocacy education at every opportunity was the biggest lesson learned during the 

campaign, Wier said. Provide potential advocates with prepared talking points, tips and information 

— make it easy for them, she suggested. 

“Don’t assume someone else will act. We are the grassroots, we are the boots on the ground. 

Make it easy to act — I can’t stress that enough,” Wier said. “If you don’t speak up for public 

health, who’s going to speak up for public health?” 

From session 3002, Successful Advocacy: The How, What and Where, June 28 

Attendees at APHA’s 2012 Midyear Meeting 

react to the news that the Affordable Care 

Act is constitutional and will be upheld.

38 



Building Systems for Action 

The impact of health information isn’t in its collection; it’s about how the information is put to 

use. And putting it to use means sharing, collaborating on and creating systems that leverage 

health resources and workers already on the ground. 

That was the big message from Dan Jensen, associate director at Olmsted County, Minn., Public 

Health Services. Introduced as an “evangelist” for health information technology, Jensen reported 

that the agency is in the midst of working to become “informatics savvy.” In other words, 

transforming data into effective practice. But to make electronic health records and information 

systems “work for us,” information technology must be connected to patient outcomes — that’s 

where we’ll drive change, Jensen told session attendees. But what was the “secret sauce” to 

making that happen, he asked. 

The answer was building communities of practice. Today, the public health agency works 

with three such communities: one consisting of large medical providers, another of mid-sized 

providers (which includes local public health) and the last of under-utilized organizations and 

workers, such as nursing homes and school nurses. But coming together as general communities 

of practice wasn’t good enough, Jensen said; it’s critical to engage all stakeholders, including 

residents. 

“We’re used to bringing people together and having these conversations,” he said. “Now, we 

don’t have the dollars that primary care providers have...but public health does have a lot of 

experience in bringing communities of practice together, working together to build systems.”

39 



Using this model — information + communities of practice = improved outcomes — is already 

seeing success. One such area is in childhood asthma. Of the 84,000 schoolchildren in southeast 

Minnesota, 5,000 had high enough levels of asthma to warrant having an asthma action 

plan on file with their schools. Unfortunately, at the time the public health agency took up the 

issue, there were less than 400 paper-based action plans on file — “that’s pretty scary,” Jensen 

said. It meant that school nurses didn’t always know how to protect students’ health or even 

which students were living with asthma. 

So working within a community of practice of schools, providers, public health and parents, the 

effort first took aim at improving the flow of paperwork, which resulted in adding thousands 

more asthma action plans to school files as of 2012. Jensen and colleagues are now working 

to build an electronic school nurse portal called “Kids eHealth,” a health information exchange 

that will initially focus on asthma but could be used for kids with seizures, allergies and diabetes 

too, Jensen said. In talking with 14 focus groups of diverse stakeholders, Jensen said they 

learned that parents were comfortable in letting asthma action plans be included in the portal, 

as long as it was only public health staff and nurses who had access. With the new portal, 

school nurses will be able to log in no matter what school they’re at, view the asthma action 

plans relevant to that school and be prepared in case of an asthma attack. 

“We can build better systems,” Jensen said. 

From session 2003/2008, Technological Strategies to Advance Public Health, June 27 

Lydia Ogden, director of health reform strategy 

at CDC, speaks during the closing session.

40 



Brave New (Public Health) World 

Public health 2.0: It’s the future and it’s time to get on board. That was the message from presenter 

Jay Bernhardt, a professor in the Department of Health Education and Behavior at the 

University of Florida, who called on attendees to start — and continue — leveraging new social 

and communications technology to improve people’s health. 

First, Bernhardt provided a quick overview of today’s trends, which further illustrate that using 

new media isn’t so much a choice anymore; it’s becoming key to successful public health 

efforts. As expected, Internet use in the United States is very high, with young people using it 

most, but other age groups steadily climbing. And understanding what people do when they 

venture online is important as well. Social networking, watching videos, playing games, searching 

for information — different age groups use the Internet for different reasons. 

“The Internet is not a channel,” he told attendees. “It’s a diverse media platform that people do 

all kinds of different activities on.” 

However, Bernhardt cautioned that not all Internet access is created equal. To truly take advantage 

of the Internet today, people must have home broadband (high-speed Internet connection), 

he said, noting that dial-up access doesn’t offer nearly as rich of an experience. This digital 

divide means that public health campaigns that rely solely on the Internet will be missing those 

residents who can’t afford such access. The alternative, however, is mobile and cellular technology, 

the fastest growing technology out there. 

People use their cell phones for much more than phone calls; in fact, data shows that actual 

phone calls are taking a back seat to text messaging. Bernhardt noted that households with cell 

phones only — no landline — have gone up from 8 percent in 2005 to 27 percent in 2010. And 

nearly half the cell phones sold in the United States are smartphones, which Bernhardt said 

hold huge potential for public health.

41 



The nation is becoming home to more screens and smaller screens. If what you’re creating 

doesn’t look good on a small screen, you might be wasting your time, Bernhardt said. (He noted 

that he’d previously seen a presentation by Google’s chief technology officer who predicted that 

in the coming years, 95 percent of all Internet searches will be via mobile devices.) 

So, what does it all mean for public health? Bernhardt took to the 10 essential public health 

services to show how new media and communication fit — and are already fitting — into each 

category. For example, in monitoring disease and health status, public health workers can mine 

social media sites, like Twitter, to see who and where people are reporting symptoms and talking 

about illness. In mobilizing partnerships, public health can help keep members active via 

online activities. And in the world of health promotion and education...well, the possibilities are 

nearly endless. 

“Health promotion folks are all over the new media space,” Bernhardt said. 

He ended his presentation with a powerful analogy to John Snow, the British doctor often referred 

to as the father of modern epidemiology and famous for tracking the source of an 1850s 

cholera outbreak to a water pump. If he were alive today, Bernhardt said, he probably would 

have detected the cholera epidemic via an uptick in bar code scanning data for toilet paper and 

Kaopectate. He’d use the info to help pinpoint certain geographic hotspots and look for Twitterers 

complaining of gastrointestinal distress. He’d examine data coming out of health care 

settings and check Foursquare to see who checked in at the suspicious water pump. And then 

he’d send out his own tweets on Twitter (along with a specialized Twitter hashtag) telling his 

followers to stop drinking the contaminated water. 

From session 3001, Engaging Fans, Followers and Friends: Using Social Media for Improving Health, 

June 28 


• ADVOCATE for public 

health and learn how to do 

it effectively. Even if you’re a 

public employee, there are 

ways you can support public 

health. As a constituent, you 

can make a difference, but 

you have to make your voice 

heard. 

• EMBRACE new health 

information technologies and 

use them to leverage public 

health skills and systems to 

expand the field’s reach. 

• MAKE social media 

your friend. Online and 

mobile communications 

and networking hold huge 

potential for helping to 

improve people’s health, and 

public health can’t be on the 

cutting edge without it.

42 



2012 MIDYEAR MEETING CLOSING SESSION: ‘WE HAVE SOME VERY HARD CHOICES AHEAD’ 

The Charlotte meeting’s closing session started out with a bang. And 

hoots and hollers and tears of sheer joy. It was the same morning the 

Supreme Court released its ruling upholding nearly every provision of 

the Affordable Care Act. It was an absolutely joyous moment. 

But by no means did it secure public health’s future — “we have some 

very hard choices ahead,” said Lydia Ogden, the closing session’s first 

speaker and director of the Centers for Disease Control and Prevention’s 

Health Reform Strategy, Policy and Coordination Office. There 

are strong forces driving change in the health system and public health 

needs to get prepared and adapt, Ogden said. For example, she said, 

about 10,000 Americans celebrate their 65th birthday every day — and 

that trend will continue for nearly the next two decades. 

“This is a profound change,” Ogden said. 

But perhaps an even bigger question comes down to spending and 

today’s new fiscal environment. With the feds borrowing about a third of 

every dollar it spends, Ogden said one of the most fundamental questions 

public health must ask itself is this: Is what we’re about to do 

worth it? 

“We owe it to the people we serve that what we’re doing is of the very 

highest value,” she told attendees. “We don’t do ourselves any favors by 

asserting that everything is worth doing.” 

Speaker Joseph Thompson, Arkansas state surgeon general and director 

of the Arkansas Center for Health Improvement, called on public 

health workers who organize and provide clinical health services to 

start figuring out how to bill for them. He said it’s going to be incredibly 

difficult to maintain revenue and funding supports for such services and 

“we have to have a viable future.” Thompson said he doesn’t use the 

term “public health” outside of public health circles, as the term often 

comes with preconceived notions that may cause important audiences 

to simply tune out. But that doesn’t mean people aren’t interested in 

joining the prevention cause. 

“We have new players who are thinking about denominator medicine,” 

Thompson said. “We don’t need to argue about whether it’s public 

health.” 

Among those new players is the private sector. Session speaker Cara 

McNulty, a senior group manager with Target tasked with improving 

the health and well-being of hundreds of thousands of employees, said 

even though Target isn’t in the business of health, it has a direct interest 

in keeping its workers healthy. And it needs public health’s help to 

do it. She called on attendees to invite business leaders to the table and 

educate them on the policy, systems and environmental changes that 

keep people healthy. 

“Health isn’t our primary business and we need your partnership,” Mc- 

Nulty said. “Help us understand what you’re trying to achieve because, 

believe me, as employers, we want to improve health.”

43 



THE NEW PUBLIC HEALTH 

Is public health facing difficult and uncertain times? Yes. Does that mean we can’t move forward 

to improve community health and eliminate health inequities? Definitely not. But it will 

take a sincere dedication to adapting today’s public health practice to new constraints, resource 

levels and an era in which quality, efficiency and results reign. This isn’t to say that devastating 

public health budget cuts are justified or sensible, especially in a time when everyone is talking 

about curbing health care spending and preventable chronic diseases continue on an upward 

tick. These cuts most certainly threaten public health capacity as well as hard-fought gains in 

community health. 

But public health doesn’t easily back down from a challenge. Our history is packed with lifesaving 

success stories that were only possible thanks to public health’s keen ability to adapt 

and see the bigger picture — to see the wider connections that create the opportunities for 

some people, neighborhoods and communities to thrive against disease and poor health and 

for others to not. This public health framework for better health is beginning to permeate even 

deeper at the highest levels of government and health care systems. So even though today’s 

funding levels might not always reflect it, the role for public health and the opportunities for 

prevention and equity may actually be bigger than ever. 

We hope this report chronicling insights from APHA’s 2012 Midyear Meeting will help you navigate 

today’s tricky new territories. Public health works — but it’s up to us to prove it. 

To learn more about APHA meetings, visit www.apha.org/meetings.

AMERICAN PUBLIC HEALTH ASSOCIATION 

APHA Public Health ACTion Campaign: 

www.apha.org/advocacy/tips/PHACT+Campaign.htm 

APHA public health advocacy tools: www.apha.org/advocacy/ 

APHA Center for Public Health Policy: www.apha.org/ 

Center+for+Public+Health+Policy.htm 



RESOURCES FOR ACTION 

& INSPIRATION 

APHA public health policy capacity tools: www.apha.org/programs/cba/ 

CBA/default 

APHA health reform resources: 

www.apha.org/advocacy/Health+Reform 

APHA Public Health Newswire: 

www.publichealthnewswire.org 

CDC LEARNING CONNECTION 

www.cdc.gov/learning 

CDC QUICK LEARN LESSONS 

www.cdc.gov/training/quicklearns 

MILLION HEARTS CAMPAIGN 

millionhearts.hhs.gov/index.html 

COMMUNITY TRANSFORMATION GRANTS 

www.cdc.gov/communitytransformation 

MARYLAND HEALTH DATA INNOVATION CONTEST 

themarylandprize.maryland.spigit.com/Page/Home

YMCA HEALTHIER COMMUNITIES INITIATIVE 

www.ymca.net/healthier-communities 

PREVENTION INSTITUTE 

www.preventioninstitute.org 

UNNATURAL CAUSES 

(Resources for addressing health inequity) 

www.unnaturalcauses.org 

PUBLIC HEALTH VALUE RESEARCH 

(An article from APHA’s American Journal of Public Health) 

ajph.aphapublications.org/doi/full/10.2105/AJPH.2007.127134 

COALITION FOR HEALTH FUNDING 

publichealthfunding.org 



PUBLIC HEALTH ACCREDITATION BOARD 

www.phaboard.org 

PUBLIC HEALTH & SOCIAL MEDIA 

www.cdc.gov/socialmedia 

NETWORK FOR PUBLIC HEALTH LAW 

www.networkforphl.org 

CENTER FOR INNOVATION AND 

TECHNOLOGY IN PUBLIC HEALTH 

citph.org 

FRAMEWORKS INSTITUTE 

(Changing the public dialogue about social problems) 

www.frameworksinstitute.org

INSIGHT & INSPIRATION FROM APHA’S 2012 MIDYEAR MEETING

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