Budget cuts are taking their toll on many local and state health departments. Kanawha County in West Virginia is one of them. As the sole public health department for West Virginia’s largest county and city, Kanawha County Health Department (KCHD) is the public health department for approximately 11 percent of the state’s total population. The population also increases significantly as individuals commute to work in Charleston, the state Capitol. Additionally, KCHD experienced several funding reductions in federal grants through the West Virginia Department of Health & Human Resources. The largest of these cuts was the 13 percent reduction in funding to the KCHD’s Public Health Emergency Preparedness Grant during fiscal year 2012-2013. This is an especially significant cut since it affects the department’s ability to prepare for emergencies in a jurisdiction that includes the state Capitol as well as several chemical plants and coal mines. KCHD has also experienced funding decreases to clinical programs including the HIV/AIDS testing and counseling and tuberculosis surveillance and control.

So far, KCHD has been able to absorb the majority of the funding cuts by not filling vacant positions, decreasing expenses and cutting certain programs in environmental health. However, with additional cuts in funding anticipated and with increases in expenses, Rahul Gupta, MD, MPH, the Health Officer and Executive Director of Kanawha-Charleston Health Department, says the Health Department will have no choice than to cut more services in the coming year.

NewPublicHealth spoke with Rahul Gupta, MD, MPH, about the recent cuts. Dr. Gupta is also on the board of directors of the National Association of County and City Health Officials.

NewPublicHealth: Tell us about the nature of some of the budget cuts you’ve faced.

Dr. Gupta: The issue for us is not just the size of the cuts, though they have been steep, but some have also been sudden cuts, and some have been almost unexpected. In the 2011-2012 fiscal year, the city of Charleston cut financial support by half—that had not happened before and was a direct impact of the financial difficulties that they’re in. We are a City/County Health Department and for the 2011-2012 fiscal year we also saw a budget cut by 12.5 percent by the county. The same cuts have persisted for 2012-2013 and we’re just glad they didn’t cut any further.

NPH: Why are these cuts so critical right now?

At last month’s NACCHO 2012 conference, Susan Feinberg, MPH, communications specialist with the Cambridge Public Health Department in Massachusetts, led a discussion on the importance of a strong and reliable web presence for local health departments.

“Your site is the virtual face of your health department,” said Feinberg. “It’s your number one communications channel and anchor for everything you do.”

With more Americans relying on the web as their means of accessing resources and information, it’s more important than ever for local health departments to create and maintain sites that provide real benefits to the public. Among the aspects Feinberg highlighted, a quality health department website should help users locate services, provide a place to share feedback, as well as discuss how the department is using grants and funding.

A well-built department website provides many benefits to public health practitioners, as well, including streamlining permitting and licensing procedures, amplifying the reach of local staff and promoting credibility for the department.

When building local health department websites, many communities seek to model their online presence after “big city” sites. However, Feinberg warns that this is not always attainable or appropriate. The best health department websites are not always the flashiest, but the ones that provide users with information that is current and concise, guide users to the resources they want and need and reflect the unique vision and values of the individual health department and its surrounding community.

It’s also important to consider that many of the same traits that make common commercial websites popular and easy to use translate well into the public health sector. The website should be easy to navigate, professional and consistant in appearance, include functional and thoughful use of images and graphics  and some manner of searchability, both internally and across the web via search engines to make the site easier to locate. Sites should also include links to other agencies, both local and Federal, that offer related  services and information and access to information in various languages, depending on community needs.

Feinberg also suggests local health departments make use of tracking and reporting tools, such as Google Analytics, to help monitor visits and growth trends, adding that the ultimate goal of a well-constructed health department website is to be “a trusted source for accurate and verifiable information.”

>>Follow the rest of our coverage from the NACCHO Annual Conference.

The Transforming Public Health project supported by the Robert Wood Johnson Foundation 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. The report, which emerged from the discussions, stresses the need for public health leaders to take critical steps such as to develop policy goals, mobilize the community and forge partnerships with health care, business and other sectors.

On Friday, August 10, the Foundation will host a webinar to discuss the Transforming Public Health project. Speakers will include Terry Cline, Oklahoma State Health Department; David Fleming, Seattle-King County Health Department, who were both participants in the convenings, along with Abby Dilley, RESOLVE; Abbey Cofsky, RWJF program officer, and Paul Kuehnert, senior program officer and director of the RWJF Public Health team. (Read a NewPublicHealth interview with Paul Kuehnert on the future of public health and the growing importance of partnerships in creating stronger health departments and healthier communities.)

NewPublicHealth spoke with Paul Jarris, MD, executive director of the Association of State and Territorial Health Officers and Robert Pestronk, MPH, executive director of the National Association of County and City Health Officials, who were also participants, to discuss how the findings can be implemented to help improve public health services and population health.

NewPublicHealth: What were some of the key issues raised by the project?

Paul Jarris: The world is truly changing. It’s already changed at the state and local level, where we’ve lost the 62,000 [public health] jobs, where we are cutting programs that were unthinkable to cut in the past being reduced and in some cases eliminated. And then there are the impacts of the Affordable Care Act and changes coming in funding from the federal government, which, of course, is most of the money that comes into the states for public health. A lot of our discussion during the convenings focused on how we could be proactive in anticipating these changes – determining [how] we can preserve the core or foundational aspects of public health, and make sure it’s as efficient and effective as possible. And, keeping in mind that, at the same time, public health leaders need to look for and anticipate new opportunities to best protect and serve the needs of the public.

NPH: What were some of the critical lessons learned from the discussions?

>>EDITOR'S NOTE: On 9/13/2012 CeaseFire changed its name to Cure Violence.

NewPublicHealth was on the ground at the National Association of County and City Health Officials Annual 2012 conference, providing the latest conference news and in­-depth interviews with conference speakers, as well as local success stories and a glimpse into the Los Angeles public health scene. Coverage highlights included:

• A discussion with Paul Kuehnert, new senior program officer for the Robert Wood Johnson Foundation and director of the Foundation’s Public Health Team, and former executive director for health for Kane County, Ill.
• A Q&A with Jonathan Fielding, MD, MPH, MA, MBA, director of the Los Angeles County Department of Public Health.
• Violence prevention discussions around the special screening of The Interrupters, including a talk with CeaseFire violence interrupter Ricardo “Cobe” Williams and a Q&A with Baltimore Health Commissioner Oxiris Barbot
• A photo tour of the L.A. City Emergency Operations Center, a model for collaboration around preparedness
• A site visit and photo tour of a corner store participating in the Long Beach Health Department’s healthy corner store initiative through the Healthy Eating Active Living Zone program.

At the conference, we also spoke with attendees about how local health departments are forging innovative new partnerships across sectors and across communities to meet shared goals and leverage resources. We asked: What’s the most creative, outside-the-box partner you’ve engaged with from a sector beyond public health? What did they add to the conversation and your joint efforts? What successes have you achieved as a result of partnerships? Who do you see as the most critical partners for public health?

A sampling of responses we heard from attendees are recapped below. Themes that emerged included the critical nature of partnerships between health departments and hospitals, Community Health Assessments and Improvement Plans as a catalyst for partnerships and sustained community health changes, and diverse partnerships across the community that each bring something valuable to the table.

Corner Stores in Long Beach, Califor., Encourage Healthier Eating with Samples, Signage and Store Changes

Innovation to improve population health was a key part of Los Angeles County Health Director Jonathan Fielding’s talk to the attendees of the National Association of County and City Health Officials Annual Meeting in L.A. last week. And just a few miles from the conference hall, innovation was on delicious display, during a smoothie tasting outside a small corner in the L.A. suburb of Long Beach.

Giselle, age 2, who stopped into the demo with her mom, enjoyed her first healthy smoothie—vanilla yogurt, orange juice and strawberries—so much that her mother listened attentively as the Spanish-speaking staff working outside the tiny corner store showed her the ingredients she’d need, all available at the shop behind them, to easily make the drinks at home.

On July 12, a standing room only crowd of local health leaders took part in a 2012 NACCHO Annual Meeting session on the implications of the recent favorable Supreme Court ruling on the Affordable Care Act (ACA). As the law faces continued uncertainty amid renewed legal challenges and the forthcoming national election, proponents were urged to continue educating stakeholders about the work of public health. Laura Hanen, who leads government and public affairs for NACCHO, advised that public health needs increasingly to have a seat at table in health policy decision making at the national, state and local level–or risk being on it.

Lillian Shirley, director of the Multnomah County (Oregon) Health Department and immediate past president of NACCHO,  urged health department leaders in attendance that in addition to being more vocal about the return on investment of  public health, they need be more forthright about the added value they can bring to local decision making  in areas such as demonstrating evidence, measuring and evaluating, spreading best practices, and collecting data that can inform policy decisions. “We have been invited to be part of the solution,” Shirley said. “We shouldn’t be shy about the skills we bring.”

During the question and answer period, many participants voiced confusion they were feeling in the early stages of the law’s implementation. One raised the question of whether to continue to focus on clinical services, an issue that many health departments are grappling with now amidst budget cuts and increased partnership with health systems. Another participant asked whether local health departments will have to address complaints from residents of the communities they serve if some parts of the law are not upheld, such as a requirement that many companies establish dedicated break rooms and break time for nursing mothers. Hanen said that the answers to such questions will in many cases be dictated by policies set at the local level, and advised health department leaders to continue to be assertive–but cautious at the same time. “We can’t predict [everything] at this point.”

>>View a list of resources compiled by the Robert Wood Johnson Foundation regarding the Supreme Court decision on the ACA.
>>Check out other outlets to follow with analysis of the decision.

This year’s National Association of County and City Health Officials (NACCHO) Annual Meeting offered attendees a unique opportunity to get a behind-the-scenes look at the City of Los Angeles Emergency Operations Center (EOC), a central point for coordinating emergency planning, training, and response and recovery efforts for disasters such as fires, floods, earthquakes, and acts of terrorism. The EOC draws on best practices for preparedness by facilitating collaboration between multiple city departments. What is unique is that this cross-department teamwork is enabled by a state-of-the-art, 84,000 square feet, two-story, seismically-base-isolated facility that also houses the Fire Department Operations Center and the Police Department Real-Time Analysis and Critical Response (RACR) Division and Operations Center.

Because of this shared space, strong relationships are established across critical public health, preparedness, police and fire department contacts that enable working together in an emergency that much easier. In the event of an actual emergency, the Center serves as a base where, literally, the right people can all be brought to the table. While NACCHO visitors were at the facility, the staff were triaging the response to the National Weather Service Excessive Heat Warning in the Valley by opening additional cooling centers and arranging to have local libraries extend their hours to serve as additional cool spaces for the community, said James Featherstone, general manager of the Emergency Management Department.

Because of this shared space, strong relationships are established across critical public health, preparedness, police and fire department contacts that enable working together in an emergency that much easier. In the event of an actual emergency, the Center serves as a base where, literally, the right people can all be brought to the table. While NACCHO visitors were at the facility, the staff were triaging the response to the National Weather Service Excessive Heat Warning in the Valley by opening additional cooling centers and arranging to have local libraries extend their hours to serve as additional cool spaces for the community, said James Featherstone, general manager of the Emergency Management Department.

Rob Freeman, emergency preparedness coordinator for the City, showcased the Main Coordination Room—a 7,500 square-foot home base for the kinds of emergencies that necessitate nimble, timely coordination of both information and resources across departments. The room, said Freeman, is laid out and functions according to the National Incident Management System.

“This floor is designed with collaboration in mind,” said Freeman. The room is clustered into teams or pods of different roles, each with its own monitors and information screens, such as emergency management, operations, planning, logistics, and finance and administration. Each is color-coded and has a designated set of delineated roles that need to be at the table—but the teams are inter-disciplinary, and those roles might be drawn from any number of city departments such as transportation, public works, fire, police, housing and more. For example, Freeman said there is a “mass care” team that includes representatives from the Departments of Parks and Recreation, Disability and Animal Services, and also draws on partnerships with the Red Cross and school districts.

Freeman said it’s also critical that those specific roles, functions, objectives, workflow processes are all in place ahead of time. Constant training keeps the city ready. “That’s a challenge, though, because the city’s workforce is so fluid,” said Freeman. “We have more than 500 people who might be called to come to this location at any given point.”

Part of the idea of bringing all of these functions together regularly ahead of time is that the relationships are there when they’re needed. “We’re part of a public safety team,” said Freeman. “We work closely with the police and fire departments and the Mayor’s office all the time.”

The Command Center for the Los Angeles Police Department is also located in the same facility, again creating greater opportunities for tight integration, and is staffed 24 hours a day. Officer Modesta Smith described a situation when a major tanker erupted in a tunnel, blocking a major entrance into the city, which would threaten vital city operations like doctors getting to hospitals and police officers getting to work. “One of the first calls we made was to James Featherstone of the EOC,” said Smith. “Sharing information works better.”

>>Follow the rest of the NewPublicHealth coverage of the NACCHO Annual Meeting.

>>EDITOR'S NOTE: On 9/13/2012 CeaseFire changed its name to Cure Violence.

A group of impassioned attendees of the National Association of County and City Health Officials Annual Meeting attended a screening of The Interrupters, a documentary about the CeaseFire violence prevention program that began in Chicago and is now a prominent, effective program in other U.S. and international cities. CeaseFire takes a unique public health approach to stopping gun violence in communities. Findings from a study conducted by researchers at the Johns Hopkins Bloomberg School of Public Health show that shootings and killings in even America’s most violent communities can be reduced using the CeaseFire model—a model that employs disease control and behavior change strategies to reduce violence. CeaseFire employs ex-offenders who have unique credibility with community members and effectiveness in getting people to rethink the impulse to resolve disputes using guns.

Safe Streets Baltimore was launched by the Baltimore City Health Department in 2007 as a CeaseFire replication site. Speakers at last night’s screening included Ricardo “Cobe” Williams of CeaseFire Chicago and Oxiris Barbot, MD, the health director of the city of Baltimore in Maryland.

A health officer from Cambridge, Mass., asked the speakers about one thing they’d like to see changed in their communities. Dr. Barbot said: “We need a health in all policies approach with better housing, education [and other social changes] to improve the environment.” NewPublicHealth recently spoke with Dr. Barbot about the impact the program has made in the city.

NewPublicHealth: How does the Safe Streets program build on the CeaseFire model?

Dr. Barbot: We replicated what was done in Chicago, but our implementation differs in that the Baltimore health department houses the Safe Streets program–our name for the CeaseFire model—and we provide technical assistance for that community-based organization to actually carry out the model. We think that that works for us because it helps to create community ownership of the model, and it also allows us to focus on administering the program and making sure that the fidelity of the model is adhered to. We oversee the program and community groups implement it.

We’ve got staff on board that work intensively with the community-based organizations to make sure that they are tracking the number of mediations that occur, that they are tracking the number of face to face meetings, and if those numbers aren’t at a particular level, we do retraining so that the interrupters that are working in that particular neighborhood feel more comfortable in what they’re doing. Similar to any other chronic disease intervention model, the folks who are actually doing the work need to have ongoing professional development to make sure that their tools are as up to date as possible.

NPH: What has your success been since the program began?

Jonathan Fielding, MD, MPH, MBA, County Health Officer and director of the Los Angeles County Department of Public Health, responsible for all public health functions including surveillance and control of both communicable and chronic diseases, was the morning plenary speaker at the NACCHO’s Annual Meeting today. He challenged the thousands of local health officials meeting here to keep their attention on the most vulnerable in their communities and to realize how much policies can impact improved population health.

“The greatest changes will come not from tweaking programs but from getting new policies introduced,” said Fielding. To help policy-makers make those changes, he said, many  public health departments may need to add expertise in areas such as policy analysis and economics. He also urged health leaders to embrace the health-in-all-policies approach.

NewPublicHealth spoke with Dr. Fielding about his vision for public health.

NewPublicHealth: What changes do we need at the local level to improve population health?

Dr. Fielding: We all have to be advocates for the underlying social determinants of health. We need to think about education, poverty, the tax structure, mobility, social conventions and at the same time focus on our natural environment such as climate change and the built environment. And that includes the environment we find ourselves in with regard to marketing and advertising such as vending machines and billboards. And we need to enact policy and not just programs. In Los Angeles we are putting in a great deal of emphasis on policy by working with decision makers and other partners.

And we have to convince the funders at all levels of how essential core public health is to the quality of life we have now and how we aspire to improve it, to reduce the burden of risks and injury. Public health can’t do what it does if it keeps getting cut, and cut and further cut.

We also need to combine and enhance relationships so that the core capabilities we know are so critical in public health are broadly disseminated regardless of whether a health department is in a metropolitan area, a rural area or on an Indian reservation.

NPH: Big cities such as Los Angeles can offer model practices for smaller communities. What are some model practices to highlight in L.A.?

This summer, Paul Kuehnert, MS, RN, joined the Robert Wood Johnson Foundation (RWJF) as senior program officer and director of the Foundation’s Public Health Team. For nearly 20 years, Kuehnert has provided executive leadership to private and governmental organizations to build and improve systems to address complex health and human services needs. As the county health officer and executive director for health for Kane County, Ill, he led public-private partnerships, integrated planning with transportation, land use, parks and recreation and other diverse sectors, and a comprehensive wellness program for government workers that resulted in demonstrable improvements to the health of employees – as well as marked cost savings [watch an RWJF Public Health in Action video profile of Kuehnert].

NewPublicHealth caught up with Paul Kuehnert during the National Association of County and City Health Officials Annual Meeting this week to talk about the future of public health, and what his decades of leadership in government and private organizations to improve health has taught him.

NewPublicHealth: You were a health director at a time of great change in public health, and that includes massive budget cuts and incredibly rising rates of chronic disease, all creating a very challenging environment. How did that shape your approach to leadership at Kane County and how do you think it will inform what you’ll now be doing in your position?

Paul Kuehnert: I think we’re living through a time that there’s this incredible convergence of the recession, the epidemic of chronic diseases and other situations that all present challenges for public health. As a local public health leader, the key thing was to really develop a strategic focus and to find ways to engage policymakers and other community leaders and partners. That was and is so critical because I think what we have to do in these times is really sort out what it is that public health, and in particular, governmental public health really has to do in order to meet these challenges. And, what is it that other partners can do or, in fact, may do better than governmental public health, which has to be an excellent steward of the public resources. Governmental public health has to be really well versed in what the evidence is for the kinds of things that we’re doing, and be mindful of being very accountable and very transparent in the community as relatively scarce dollars are used to provide services to the community.

Those are the issues that were key for me when I was a local health director, and I think what that does for me in my new position at the Robert Wood Johnson Foundation is that it has really grounded me in the reality that these are very different and very difficult times for public health. So, I would say the same things that were true for me as a local health director really have to be true for Robert Wood Johnson Foundation as well. We need to be strategic, we need to be focused, we need to engage policymakers and stakeholders in our work and we need to be very transparent about what we’re doing. So, I feel like my recent experience, in the trenches really provides a grounding for me in this new position.

NPH: Partnerships are critical to the future of public health and health departments. What partnerships did you develop or advance that were most critical to the success of public health endeavors in Kane County?