Ruth Ann Shepherd, MD, division director for maternal and child health in the Kentucky Department for Public Health, was an early pioneer in recognizing the critical public health problem of preterm births in Kentucky, and that the troubling trend was common to most states in the country. Dr. Shepherd’s research revealed that babies born at 37 or 38 weeks had far worse health outcomes than babies born at 39 or 40 weeks. With support from the leadership at the Kentucky Department of Health, and many other organizations who have since taken up the cause of helping to create conditions for healthier babies, many states are beginning to make strides in preventing early births. Last week, Dr. David Lakey acknowledged her leadership in preventing preterm birth and infant mortality by awarding her the Association of State and Territorial Health Officials (ASTHO) Presidential Meritorious Service Award.

Charles Kendell, MPA, chief of staff at the Kentucky Health Department, accepted the award on behalf of Dr. Shepherd, who was unable to attend the ASTHO meeting. NewPublicHealth caught up with Kendall to get his take on Kentucky’s role in catalyzing a national movement around healthier babies.

NewPublicHealth: Tell us about the award Dr. Shepherd received and what it was for.

Kendell: The award today was given by David Lakey as President of ASTHO for the last year. The Presidential Meritorious Service Award is given at the ASTHO president’s discretion for those he feels have contributed the most to the President’s Challenge that he or she has championed for the year. This year, he awarded it Dr. Ruth Shepherd, who was one of the early advocates for doing something about the prematurity birth rates in the country.

Dr. Shepherd has long championed that concern, and it was through her efforts that much of the initial data and advocacy and publicity about the issue became apparent to a lot of people. Through the connection of Dr. Shepherd to David Lakey, he was able to put a voice and a voice to the issue through his presidency. It’s really taken off from there, and connected with an awful lot of people.

NPH: What did the data Dr. Shepherd uncovered show?

The Transforming Public Health project supported by the Robert Wood Johnson Foundation (RWJF) and convened by RESOLVE brought together a group of local, state and national public health leaders to develop guidance for public health officials and policymakers in prioritizing critical public health functions in a changing political and funding landscape.

Recently, the Foundation hosted a webinar to discuss the Transforming Public Health project. Speakers included:

• Terry Cline, Oklahoma State Health Department
• David Fleming, Seattle-King County Health Department
• Abby Dilley, RESOLVE
• Abbey Cofsky, RWJF program officer
• Paul Kuehnert, senior program officer and director of the RWJF Public Health team

>>Read our recap of the discussion from the webinar.

But the conversation shouldn't stop there. We want to hear your thoughts on the future of public health. Below are some questions to get you started. Feel free to add your thoughts in the comments below, and help us chart the course for a new public health.

• How is your public health department adapting in the current changing landscape?
• How is your community prioritizing programs and services to take on new challenges in a time of declining resources?
• How have you engaged policy-makers and diverse partners in your community on issues critical to public health?

>>Read more: Check out these resources to get ready for the webinar and inform the discussion:

• Read the full Transforming Public Health report.
• Read a Q&A with Paul Jarris and Robert Pestronk on how the report’s findings can be implemented to help improve public health services and population health.
• Read our recap of the discussion during the webinar.

Crowds of public health officials thronged Mary Selecky, Secretary of the Washington State Department of Health since 1999 and a former ASTHO president, at the ASTHO annual meeting, likely for her wisdom as a long time health director grappling with some of the most critical problems facing public health.

NewPublicHealth caught up with Mary Selecky at the recent ASTHO meeting.

NewPublicHealth: What is the rest of the country learning from the recent pertussis (whooping cough) outbreak in Washington State?  

Mary Selecky: We have more than 4,000 cases confirmed. Sixty percent of cases are in school age kids, 20 percent in adults and 20 percent in kids under age five. The most worrisome statistics are the numbers of babies hospitalized. [Editor’s Note: Babies get whooping cough vaccines at ages two, four and six months and don’t have full immunity until after the last vaccine.] Most adults get a mild case—they don’t know they have it, they have a dry hacky cough and they’re spreading pertussis germs. One of our very fundamental pieces of information is to make sure your kids are vaccinated and up to date, and that teens and adults have gotten a booster shot. We know we’re reaching the public because our insurance companies are telling us that double the  amount of people have gotten the booster from last year. We know we’re getting some penetration there, but clearly not enough.  

It has not really gone away. We’re still seeing about 100 new cases every week. We are slowing down—it’s a little bit less every week. Nevertheless, 100 cases per week is still ten times more than it was a year ago. We reached out to the CDC to have their epidemiology investigators to come in and look at our data and see what is happening. They were able to show us that our 13- and 14-year-olds are getting hit hardest and many were vaccinated, so we are evaluating when the booster shot was given and how soon after they got pertussis and what we can learn.

We’re seeing more whooping cough in the U.S. than we have seen in multiple decades. Our own numbers are more than we’ve seen since 1941. It’s a bug, easily passed person to person. We do have an effective vaccine but what the CDC is able to glean may indicate that we need to give a booster more often.

NPH: While the CDC investigates, what’s your recommendation as a state health director? 

Jose T. Montero, MD, director of the Division of Public Health Services at the New Hampshire Department of Health and Human Services, was elected president of the Association of State and Territorial Health Officials (ASTHO) during the association’s recent annual meeting in Austin, Texas.

Dr. Montero began his medical career in Putumayo, Colombia, where he served as a local, county and state health official. He then went to teach family and preventive medicine and later became Colombia’s public health director. Dr. Montero began his service in New Hampshire in 1999 as chief of the New Hampshire Communicable Disease Section in the Division of Public Health. Before becoming director of the New Hampshire Division of Public Health Services, Dr. Montero was the state epidemiologist.  He is an adjunct professor of family medicine and a member of the preventive medicine residency advisory committee at Dartmouth Geisel School of Medicine.

NewPublicHealth spoke with Dr. Montero about the new ASTHO President's Challenge, which will focus this year on the integration of public health and health care.

NewPublicHealth: Why is so critical now to work toward the improved integration of public health and health care?

Dr. Montero: We keep talking about the health system but there is not much that is health-focused—it’s currently mostly about providing care after people becomes ill. From a public health perspective we’re trying to improve outcomes and quality, without spending the amount of money on health that we’re currently spending because we can’t sustain that. The system needs to continue changing and evolving, but we don’t yet know what exactly how it will look or how it should look. We need to create a new system. Based on the experiences of some states, such as Massachusetts and Oregon, we know gaining access to health insurance has expanded use, but we don’t know if they’ve achieved improved health outcomes yet. We’re working toward that. But we need to work on the right indicators that allow us to consistently measure total population health.

When you look across the country, you see that public health entities provide the continuum of care throughout the life cycle. We are already integrating health care and the public health system at several different places and levels, but it’s not consistent. To prepare ourselves for the future, we need to be able to look at public health and health delivery systems and integrate them philosophically. We need to capture examples, decode them, and see what works and what doesn’t and how to use which in different parts of the country. We have different cultures, different investment levels, and different expectations. We can’t just copy and paste.

NPH: What are the critical issues you’re looking at?

Health promoting hospitals—it sounds like an obvious concept, but a reimbursement-driven focus on treatment rather than prevention actually makes this a somewhat novel idea. Now, the World Health Organization health promoting hospitals initiative incorporates health promotion concepts, values and standards into the organizational culture and daily routines of hospitals around the world. The concept also allows all hospital employees and their families, patients and their families, and community residents to participate in health promotion together.

Taiwan has the largest network of health promoting hospitals in the world, Shu-Ti Chiou, MD, director-general of Taiwan’s Bureau of Health, told state health officers attending the ASTHO meeting. In Taiwan, one-quarter of all hospitals have received status as a health promoting hospital and many more have signed on to cancer screening initiatives that give reminders to patients about certain cancer screenings no matter the primary reason for their hospital or clinic visit.

Examples in Taiwan include a tobacco awareness campaign by the Pingtung Christian Hospital for community residents. Participants who smoked were provided with referrals for counseling services, and the outpatient smoking reminder system kicked into gear every three months to create contact with the smoker and discuss their smoking status or quit plans.

At the Cardinal Tien Hospital in Yung Ho, through the health promoting program of hospital, the rate of women hospital employees aged 30 and above who have had a Pap smear has increased from 30 percent to 80 percent, while those aged 50 and above who received mammography screening has reached 82 percent, thanks to a reminder system in place at the hospital.

In an interview with NewPublicHealth, Dr. Chiou says she has seen individual examples of health promotion at a number of hospitals in the United States, and two health promoting hospital networks are now in place—with three hospitals each—in Connecticut and Pennsylvania, both at early stages of their work.

“No matter the reason for a hospital visit, health promotion is an opportunity during an outpatient or inpatient stay,” says Dr. Chiou.

While so far only 25 percent of beds are in health promoting hospitals in Taiwan, the national cancer screening initiative is in place in 232 hospitals that have installed automatic reminder systems for cancer screening in outpatient services. The hospitals provide screening reminders for four types of cancer: oral, cervical, breast and colorectal. When an oral cancer screening reminder is prompted, health professionals also ask about smoking status “and the next step is to invite smokers to join cessation services,” says Dr. Chiou.

“We have found that many hospitals see the concept as a win/win and are applying for [health promoting hospital] status, and we look forward to meeting more hospital leaders in the U.S. to share the concept,” says Dr. Chiou.

The Office for State, Tribal, Local and Territorial Support (OSTLTS) at the Centers for Disease Control and Prevention (CDC), was launched in 2009 as a central office dedicated to advancing public health at the state and local levels and identifying both gaps and opportunities for collaboration. Judith Monroe, the office's director, spoke to us last year about challenges facing health departments in a tough time. Recently, at the ASTHO Annual Meeting, we had a chance to catch up with Dr. Monroe to hear what she and her office have been up to since we last spoke in the summer of 2011.

>>Read our earlier Q&A with Dr. Monroe.

NewPublicHealth: The focus of the ASTHO annual meeting this year is on the intersection of health care and public health. What efforts is CDC engaged in right now in that intersection?

Dr. Monroe: We’ve been involved in a number of areas. The IOM report on the integration of primary care and public health, was co-funded by the Health Resources and Services Administration and CDC. And CDC had a seat at the table when ASTHO and the IOM came together to develop the strategic map for the integration. We’re excited about that and we continue to be on those calls.

We have an office here at CDC recently created called the Office of Prevention Through Healthcare that is looking at this intersection and where the gains might be, working with the Centers for Medicare and Medicaid Services very closely. And, in addition, our office—the Office of State, Tribal, Local and Territorial Support—has forged a relationship with all of the primary care residency programs across the nation. That’s dear to my heart because I was a residency program director in family medicine for a number of years. We’ve had a number of educational venues taking the science from CDC and packaging it in a way that the residency programs can use. We’re looking toward some quality improvement projects with the residency programs as well as “playing matchmaker” in many ways, between health departments and residency programs. And, I am the point person here at CDC for our relationships between the American Academy of Family Physicians and the American College of Physicians so we have a lot going on. Those are the biggies, but there are many daily activities taking place as well.

NPH: Thank you for that overview. Since you’ve been at OSTLTS, what are some successes that you’d point to?

GUEST POST by Lisa Junker, CAE, director of communications for the Association of State and Territorial Health Officials (ASTHO)

At the opening session of the ASTHO Annual Meeting in Austin, Paul Wallace, vice president of The Lewin Group, pointed toward the need for collaboration and partnership between the health care and public health sectors to overcome key challenges and trends facing the United States at the federal, state and local level.

>>Read our earlier interview with Paul Wallace on public health and primary care integration.

“What are the opportunities to create a shared conversation around prevention?” asked Wallace, who chaired the Institute of Medicine (IOM) Committee on the Integration of Primary Care and Public Health.

He gave attendees an overview of the process his IOM committee underwent to develop the recently-released report “Primary Care and Public Health: Exploring Integration to Improve Population Health.”  The committee was charged with identifying the best examples of effective integration and the factors that promote and sustain those efforts, examining the ways federal agencies can use the provisions of the Affordable Care Act to promote integration, and discussing how Health Resources and Services Agency (HRSA) supported primary care systems and state and local public health can promote those efforts moving forward.

David L. Lakey, MD, Commissioner of the Texas Department of State Health Services, ends his term as president of the Association of State and Territorial Health Officers, (ASTHO)at the group’s annual meeting in Austin this week. NewPublicHealth spoke with Dr. Lakey about his tenure and about his Presidential Challenge to reduce the number of preterm births.  

NewPublicHealth: Did anything surprise you during your tenure as ASTHO president?

Dr. Lakey: I don’t think there was a specific surprise. It’s been a very busy year. Perhaps the one surprise might be that four years ago ASTHO started the Presidential Challenge under Judy Monroe, MD (then state health commissioner of Indiana, and now the head of the Office for State, Tribal, Local and Territorial Support at the Centers for Disease Control and Prevention) started this thing called the Presidential Challenge. Dr. Monroe started it as a charge to the state health officers to kind of walk the talk related to physical activity. And now, four years later, the Presidential Challenge really had its own legs and with a lot of support. This year’s challenge—reducing preterm births–became a pretty big initiative. We now have 49 states that have signed on to that initiative.

NPH:  What specific actions do you think have helped the decline of preterm births?

The Association of State and Territorial Health Officers (ASTHO) will be meeting in Austin, Texas, this week for their annual conference. NewPublicHealth spoke with ASTHO’s executive director, Paul Jarris, MD, about the key themes of this year’s meeting and the critical issues state health officers currently face.

>>Follow our ASTHO Annual Meeting coverage throughout the week. 

NewPublicHealth: What are the key issues the state health officers attending the ASTHO annual meeting will hear about in Austin?

Paul Jarris: I think there are two major areas we’ll be talking about. One will be last year’s ASTHO Presidential Challenge that Dr. David Lakey, the outgoing president of ASTHO, launched on healthy babies. This was a challenge to all the state health officials to make a pledge to lower preterm births by 8 percent by 2014. We’re pleased to say that 49 states have committed or pledged as well as Puerto Rico and Washington, D.C. Michael Lu, associate administrator of maternal and child health of the Health Resources and Services Administration, and the president of the March of Dimes, Jennifer Howse, will be speaking along with Dr. Lakey and other health officials about the tremendous progress that has been made and the work that needs to continue to actually decrease the preterm birth rates.

The incoming ASTHO president, Jose Montero, the public health director in New Hampshire, will speak about his presidential challenge—the integration of public health and health care, as well as Paul Wallace, who chaired the Institute of Medicine report on the topic. ASTHO co-sponsored a meeting with the IOM and many stakeholders from both health care and public health to develop a three-year strategic plan for integration of public health and primary care.

NPH: What are examples of that intersection?

The annual meeting of the Association of State and Territorial Health Officials (ASTHO) begins next week in Austin, Texas, bringing together chief health officials and other key public health leaders to talk about public health issues in the United States. NewPublicHealth will be on the ground throughout the meeting covering workshops, sessions and keynote speeches, as well as speaking with program speakers and conference attendees.

Discussions will highlight the critical opportunities for integrating and coordinating health care and public health. We will also capture stories from the front lines in Texas and beyond that illustrate the creativity, vision and impact of public health, including the role businesses can play in partnerships for prevention. Coverage will also include interviews with thought leaders including Paul Jarris, Judith Monroe, José Montero and more.

>>Follow NewPublicHealth coverage of the ASTHO meeting here.
>>Follow the coverage on Twitter @RWJF_PubHealth, and join the conversation using the hashtag #ASTHO12.