Seven Years, 3 Surveys, a Changed World: The State Public Health Workforce 2014-2021.

CONTEXT: The COVID-19 pandemic and other public health challenges have increased the need for longitudinal data quantifying the changes in the state public health workforce. OBJECTIVE: To characterize the state of governmental public health workforce among state health agency (SHA) staff across the United States and provide longitudinal comparisons to 2 prior fieldings of the survey. DESIGN: State health agency leaders were invited to have their workforce to participate in PH WINS 2021. As in prior fieldings, participating agencies provided staff lists used to send e-mail invitations to employees to participate in this electronic survey. SETTING AND PARTICIPANTS: State health agency staff. MAIN OUTCOME MEASURES: PH WINS 2021 maintains the 4 primary domains from 2014 and 2017 (ie, workplace engagement, training needs assessment, emerging public health concepts, and demographics) and includes new questions related to the mental and emotional well-being; the impact of the COVID-19 pandemic on staff retention; and the workforce's awareness of and confidence in emerging public health concepts. RESULTS: The percentage of SHA staff who self-identify as Black, Indigenous, and people of color increased from 30% (95% confidence interval [CI]: 29%-32%) to 35% (95% CI: 35%-37%) between 2014 and 2021. Staff younger than 31 years accounted for 11% (95% CI: 10%-12%) of the SHA workforce in 2021 compared with 8% in 2014 (95% CI: 8%-9%). From 2014 to 2021, staff who self-identify as a woman increased from 72% (95% CI: 71%-74%) to 76% (95% CI: 75%-77%). Overall, 22% (95% CI: 21%-23%) of the SHA workforce rated their mental health as poor/fair. CONCLUSION: The 2021 PH WINS results represent unique and current perspectives on the SHA workforce and can inform future public health infrastructure investments, research, and field practice to ensure a strong public health system.

Emergency powers and the pandemic: Reflecting on state legislative reforms and the future of public health response.

The first 2 years of combatting the COVID-19 pandemic necessitated an unprecedented use of emergency powers. States responded with an equally unprecedented flurry of legislative changes to the legal underpinnings of emergency response and public health authorities. In this article, we provide a brief background on the framework and use of governors and state health officials' emergency powers. We then analyze several key themes, including both the enhancement and restriction of powers, emerging from emergency management and public health legislation introduced in state and territorial legislatures. During the 2020 and 2021 state and territorial legislative sessions, we tracked legislation related to the emergency powers of governors and state health officials. Legislators introduced hundreds of bills impacting these powers, some enhancing and others restricting emergency powers. Enhancements included increasing vaccine access and expanding the pool of eligible medical professions that could administer vaccinations, strengthening public health investigation and enforcement authority for state agencies, and preclusion of local orders by orders at the state level. Restrictions included establishing oversight mechanisms for executive actions, limits on the duration of the emergency, limiting the scope of emergency powers allowed during a declared emergency, and other restraints. By -describing these legislative trends, we hope to inform governors, state health officials, -policymakers, and emergency managers about how changes in the law may impact future public health and emergency response capabilities. Understanding this new legal landscape is critical to effectively preparing for future threats.

Medicaid, the Supreme Court, and Safe Care for Nursing Home Residents.

This Viewpoint details the risk to Medicaid beneficiaries if the Supreme Court supports a decision that will allow states to deny benefits to eligible recipients and deny beneficiaries' ability to hold states accountable in federal court.

Fix the backlash against public health.

Societies generally have reacted to deadly epidemics by strengthening health systems, including laws. Under American federalism (the constitutional division of power between states and the federal government), individual states hold primary public health powers. State legislatures have historically granted health officials wide-ranging authority. After the anthrax attacks in the United States in 2001, the US Centers for Disease Control and Prevention (CDC) supported the Model State Emergency Health Powers Act, which granted public health officials even more expansive powers to declare a health emergency and respond swiftly. But all that ended with COVID-19, as state legislatures and courts gutted this authority. The next pandemic could be far deadlier than COVID-19, but when the public looks to federal and state governments to protect them, they may find that health officials have their hands tied behind their backs.

The coordination role of Rio Grande do Norte state government in response to covid-19: Innovation in times of crisis? / A atuação coordenadora do governo do Rio Grande do Norte no combate à covid-19: inovação em tempos de crise?

Resumo A partir de um estudo de caso do Rio Grande do Norte, este artigo discute o papel dos estados na coordenação da saúde durante a pandemia do novo coronavírus. A ausência de coordenação federal no enfrentamento do surto pandêmico no Brasil tem sido compreendida por diversos analistas como algo inédito na federação brasileira, rompendo com um padrão recorrente de normatização e indução nacional por diferentes governos desde a Constituição de 1988. Nesse sentido, estados e municípios passaram a adotar iniciativas próprias para o enfrentamento da pandemia. A partir de uma pesquisa qualitativa baseada em dados documentais - mídia local, boletins epidemiológicos e regulamentações estaduais - e em entrevistas semiestruturadas com gestores estaduais e municipais, foi possível identificar mudanças na relação estado-municípios durante a pandemia no Rio Grande do Norte, caso marcado, historicamente, pela ausência de cooperação estadual. A pandemia, dessa forma, funcionou como um choque exógeno, que induziu uma mudança no padrão de atuação do governo estadual na saúde. Não está claro, porém, se essas alterações são pontuais ou permanentes, na medida em que o peso do autorreforço - especificação dos efeitos do legado histórico - atua como um mecanismo que produz dinâmicas inerciais de difícil rompimento com o passado.

Abstract From a case study of the State of Rio Grande do Norte, in Brazil, this article discusses the role of states in coordinating healthcare with its local governments in the context of the new coronavirus pandemic. The absence of federal government initiatives in responding to the pandemic in Brazil have been acknowledged by several specialists as an unprecedented event in the Brazilian federation, breaking with a recurrent pattern of national coordination and regulation by different governments since the 1988 Constitution. In this sense, states and municipalities had to adopt their own initiatives to respond to the pandemic. Qualitative research based on the collection of documents (local media, epidemiological reports, and state regulations) and in-depth interviews with state and municipal managers reveals significant changes in the state-municipal relationship throughout the pandemic period in Rio Grande do Norte, a state historically characterized by the lack of state coordination. The pandemic, thus, functioned as an exogenous shock, which induced changes in the pattern of state coordination in healthcare. It is unclear, however, whether these changes are one-off or permanent since the weight of increasing returns - a specification of a path dependency process - seem to work as a mechanism producing inertial dynamics of difficult disruption with the past.

How Preemption Can Lead to Inequity.

American cities and localities have historically been places of innovation and incubation when it comes to advancing equity and inclusion. Now, local governments in many states are leading the fight for stronger public health protections against COVID-19-through mask mandates, stay-at-home orders, and paid leave provisions, among other actions. However, state lawmakers have long used preemption-state laws that block, override, or limit local ordinances-to stifle local government action, often under pressure from corporate interests and political ideology. Through preemption, state lawmakers have obstructed local communities-often majority-minority communities-from responding to the expressed needs and values of their residents through policies. In this article, we first look at the context behind preemption and its disparate effects. After establishing a conceptual framework for measuring disparities, we discuss how the current COVID-19 pandemic is disproportionately harming the same communities that have been preempted from taking local action, limiting their ability to effectively combat the public health crisis. We argue that all stakeholders interested in health equity have a role to play in addressing the misuse of state preemption.

Navigating the Pharmaceutical Benefits Scheme: federal versus state government funding for high-cost medicines – a problem for public hospitals.

The funding of medication supply in Australian public hospitals is divided between the federal government's Pharmaceutical Benefits Scheme (PBS) and thestate or territory government who pay for the remaining medications not covered under the PBS. For some high-cost medications, such as the monoclonal antibody blinatumomab, the current criteria for PBS funding in public hospitals are challenging. The strict requirement for inpatient admission, due to the risk of potentially serious adverse effects, alongside a lack of PBS reimbursement, while a hospital inpatient, may result in the state bearing the cost. A retrospective review of five patients receiving blinatumomab at our hospital found that, on average, patients remained inpatients for longer than that stipulated to meet PBS funding criteria, predominantly due to adverse effects associated with the medication. This resulted in the state government paying for the medication in full. The upcoming National Medicines Policy review should address the increasing complexity of new medications and their access and funding.

Americans' Trust in COVID-19 Information from Governmental Sources in the Trump Era: Individuals' Adoption of Preventive Measures, and Health Implications.

This study analyzes differences among Americans in their trust in COVID-19 information from governmental sources and how trust is associated with personal adoption of preventative measures under the Trump administration. Based on our analysis of data from a nationally representative survey conducted in October 2020 (effective sample size after weighting = 2615), we find that Americans in general have more trust in COVID-19 information from state/local governments than from the federal government. Variables such as age, party affiliation, religiosity, and race are significantly associated with Americans' trust or lack of trust in COVID-19 information from governmental sources. During the study period, Republicans had more trust in the federal government as a COVID-19 information source than Democrats did, while Democrats had more trust in state/local governments. African Americans had the least trust in the federal and state/local governments as COVID-19 information sources, while Asian Americans had the most trust in both institutions. Trust in the state/local governments as COVID-19 information sources was positively associated with physical distancing and mask-wearing while trust in the federal government as a COVID-19 information source was negatively associated with physical distancing and mask-wearing, suggesting the distinctive roles that state/local governments and the federal government played in mobilizing Americans to adopt preventive measures.

Assessment of Epidemiology Capacity in State Health Departments - United States, 2021.

In 2021, during the COVID-19 response, the Council of State and Territorial Epidemiologists (CSTE) conducted its seventh periodic Epidemiology Capacity Assessment (ECA), a national assessment that evaluates trends in applied epidemiology workforce size, funding, and epidemiology capacity at state health departments.* A standardized web-based questionnaire was sent to state epidemiologists in 50 states and the District of Columbia (DC). The questionnaire assessed the number of current and optimal epidemiologist positions; sources of epidemiology activity and personnel funding; and each health department's self-perceived capacity to lead activities, provide subject matter expertise, and obtain and manage resources for the three essential public health services (EPHS) most closely linked to epidemiology.† CSTE enumerated 4,136 epidemiology positions across the United States, with an additional 2,196 positions needed to provide basic public health services. From 2017 to 2021, the number of epidemiologists in state health departments increased 23%, an increase primarily accounted for by the number of those supporting the COVID-19 response§. The number of staff members decreased in program areas of infectious diseases, chronic diseases, and maternal and child health (MCH). Federal funding supports most epidemiology activities (85%) and epidemiology personnel (83%). Overall capacity to deliver the EPHS has declined, and epidemiology workforce and capacity needs remain unmet. More epidemiologists and sustainable funding are needed to consistently and effectively deliver EPHS. Additional resources (e.g., funding for competitive compensation and pathways for career advancement) are essential for recruitment and retention of epidemiologists to support public health activities across all program areas.

A Rapid Survey of State and Territorial Public Health Partnerships With Faith-Based Organizations to Promote COVID-19 Vaccination.

During the COVID-19 pandemic, media accounts emerged describing faith-based organizations (FBOs) working alongside health departments to support the COVID-19 response. In May 2021, the Department of Health and Human Services, Centers for Disease Control and Prevention, and the Association of State and Territorial Health Officials (ASTHO) sent an electronic survey to the 59 ASTHO member jurisdictions and four major US cities to assess state and territorial engagement with FBOs. Findings suggest that public health officials in many jurisdictions were able to work effectively with FBOs during the COVID-19 pandemic to provide essential education and mitigation tools to diverse communities. (Am J Public Health. 2022;112(3):397-400. https://doi.org/10.2105/AJPH.2021.306620).

Health Disparities of Coronavirus Disease 2019 in Texas, March-July 2020.

OBJECTIVES: Although disparities in coronavirus disease 2019 (COVID-19) prevalence are known, knowledge of the recent surge of COVID-19 in Texas and factors affecting fatality rates is limited. Understanding the health disparities associated with COVID-19 can help healthcare professionals determine the populations that are most in need of COVID-19 preventive care and treatment. The aim of this study was to assess COVID-19-related case and mortality rates. METHODS: Our cross-sectional analysis used Texas Department of State Health Services COVID-19 case surveillance counts. Case, hospitalization, and mortality counts were obtained from March to July 2020. RESULTS: From March to July 2020, there were 420,397 COVID-19-related cases and 6954 deaths in Texas. There were 3277 new cases and 104 deaths in March, and 261,876 new cases and 3660 deaths in July. The number of new COVID-19 cases was the highest from March to April (relative risk 1.77, 95% confidence interval [CI] 1.76-1.78). Although the death rate in June was a 30% increase over the rate in May, death rates nearly tripled by the end of July, for a total of 3660 deaths. Of the 3958 deaths, demographic data were available for 753 deaths. Of these, 440 were male, 16 Asian, 95 Black, 221 Hispanic, 325 White, and 96 were "Other" or "Unknown." Males were associated with a slightly higher chance of acquiring COVID-19 than females (odds ratio [OR] 1.11, 95% CI 1.09-1.14) and nearly a 29% higher chance of dying of COVID-19 compared with females (OR 1.29, 95% CI 1.11-1.49). Bivariate analysis revealed that the probability of acquiring COVID-19 was 12% higher in older adults compared with individuals younger than 65 years old (OR 1.12, 95% CI 1.08-1.16), and older adults had an 18.8 times higher risk of death when compared with the rate of younger individuals (OR 18.79, 95% CI 15.93-22.15). Hispanics and Blacks were 70% and 48%, respectively, more likely to contract COVID-19 than Whites. All races had lower significant chance of death when compared with Whites. At the end of July, there was a total of 430,485 Texas COVID-19 cases and 6387 fatalities (8.8% of all cases and 4% of all deaths in the United States.). Case fatality ratios were the highest in older adults. As we continued to observe data, in contrast to previous study time points, we found that Asians and Hispanics had no significant difference in COVID mortality rates and were comparable in terms of mortality odds and death case ratios when compared with Whites. CONCLUSIONS: This time period represents the highest COVID-19 surge time in Texas. Although our data consist of a short time period of population-level data in an ongoing pandemic and are limited by information reported to the Texas Department of State Health Services, older age, male sex, Hispanics, and Blacks are currently associated with higher infection rates, whereas older age, male sex, and Whites are associated with higher mortality rates. Clinicians and decision makers should be aware of the COVID-19 health disparities and risk factors for mortality to better promote targeted interventions and allocate resources accordingly.