Shaping the ‘New Public Health’: Q&A with Paul Kuehnert
Each year hundreds of public health researchers and practitioners meet to share research and best practices on creating a stronger public health system at the annual Keeneland Conference in Lexington, Ky. The conference, which will be held this year April 8-11, is sponsored by the National Coordinating Center for Public Health Services and Systems Research, based at the University of Kentucky.
Paul Kuehnert, MS, RN, senior program officer and director of the Public Health Team at the Robert Wood Johnson Foundation (RWJF), will speak at the opening lunch about threats and opportunities for public health, and how we can re-shape the system to create a healthier future for all. We caught up with him to get his insights before the conference on the evolving role of public health. Prior to joining the Foundation, he was county health officer and executive director for health for Kane County, Ill., where he led a partnership between the health department, hospitals and other partners to assess and address the community’s health needs. Kuehnert is a Pediatric Nurse Practitioner and worked as a primary care provider in schools and other community settings in Missouri and Illinois.
NewPublicHealth: What are you going to talk about at Keeneland?
Paul Kuehnert: I think a lot of us are familiar with the data on our health care system, and the inter-twined issues of access, quality and cost. And the fact that younger Americans have a lower life expectancy than young people in other developed countries. We’re just not getting the health outcomes that one would expect from the amount we’re spending.
When you pit that against our legacy in public health, and what’s happening in the environment we operate in, I think there’s a real need to identify the threats and opportunities and re-imagine what we’re doing. We’re working from old models that need to be really questioned. What I’m hoping to do, and that others will do, is to provoke some creative thinking about where we need to go in public health to truly meet the challenges that face our communities and our nation.
NPH: What do you see as some of the major public health challenges today?
Kuehnert: For me, one of the first that comes to mind is that issue of life expectancy. With all the resources we have, we’re actually losing ground. It’s extremely concerning and has to do with a number of underlying dynamics—but particularly the epidemic of chronic disease, things such as obesity, heart disease, cancer, and all of those threats to our health. And there are also the incredible health disparities, the inequities that are reflected in our health across the country.
One of the other big challenges is that we’re in the midst of a recovery from probably the deepest recession since the Great Depression. For public health, the job losses have amounted to roughly 20 percent of the workforce in state and local health departments. And it’s not likely that those jobs are coming back. That has huge impact on the ability of public health to respond to critical health needs and help communities be ready for emergencies. To offer just one example, think about climate change and these catastrophic weather events we’ve been having. Public health has to be part of the comprehensive community response. With pressures from the downturn and slow recovery, and now sequestration, we have probably only 60 percent of the resources that we had at the height of the public health preparedness funding. That’s a real challenge.
NPH: What are some of the biggest opportunities for public health?
Kuehnert: In addition to the new resources for public health and prevention, one of the most significant I think is the provisions in health reform requiring nonprofit hospitals to do community health assessments, and be much more accountable to their communities. There’s a real opportunity here to reconnect health, public health and health care at the community level.
For instance, hospitals are going to start being penalized for people being readmitted after they’ve already been hospitalized, particularly for problems where community-based organizations could have helped. So say you get admitted and treated for congestive heart failure in a hospital, and get discharged because you’ve stabilized. Then when you go home, you don’t have access to good food, to your medications, you’re not getting any kind of exercise because your neighborhood isn’t safe—and lo and behold, you’re back in the emergency room. That’s been the cycle that many people with chronic diseases go through, particularly people that are of the lowest income and have the fewest resources.
So, there’s a real driver there for hospitals to come up with partners that are going to effectively work with them to serve these residents. Public health is in a great position to help do that either directly or to work with health care to build those partnerships on a community level. There are senior citizen case management programs. There are home-delivered meals. There are ways people can get connected with programs so they can take their medications on time. There are a lot of things that can be done, but again, hospitals typically don’t have that expertise. They need to find partners. Health departments should be able to be in the mix of helping make that happen.
NPH: The Trust for America’s Health has referred to public health agencies as the “chief health strategists for our communities.” What does this statement mean to you?
Kuehnert: First of all, I think it means public health has to have the capability to have relationships, particularly with health care providers and other institutions, where people would look to the health department for leadership. That presupposes health department staff having good relationships with people from various walks of life—education, business, health care institutions—and being really well-integrated into the community and looked to for leadership around health issues. What we know is that that’s true in many places, but hospital executives and physicians oftentimes don’t even know who the county health officer is.
So, the first step is the relationship. The second step is that there really has to be the capability for people in public health then to pull together and analyze a lot of data. And then, based on what the health department is seeing, they need to say what the health environment in their community looks like and really convene all the community members and stakeholders and get input on what health priorities should be. To me, that process of community assessment and prioritization and coming up with recommendations is the key thing of being a strategist. But it’s not something we can just expect is going to be given to us. I think it has to be earned.
NPH: Thinking about this evolution in the challenges and opportunities for public health, what are the ramifications for the structure of the public health field?
Kuehnert: First, we need to remember again that in 1900, life expectancy in this country was 43 years. Over the 20th century, it was to a large extent environmental changes around infectious disease that added 30 years on average to people’s lives. While innovation around technology and medicine played a huge role, this really happened because of a larger social movement that looked in a very comprehensive way at issues such as sanitation, sewers, hygiene, clean water and food production.
The result was that public health ended up having a very clearly defined space. At the end of the day, we had tremendous expertise in sanitation and control of infectious disease. That was our space. Nobody else in the community, in the private sector, was in this space like governmental public health. We were tremendously successful, and we should celebrate that. But at the same time, I think we’re stuck in that paradigm, and we have to re-imagine what we need to do, and what kind of movement we need to be a part of and contribute to, to recreate and address these 21st century challenges.
One thing we’re trying to do is hear what leaders and communities are doing that’s innovative and different. What are some new approaches? What are some new organizational forms? Things such as sharing across jurisdictions. We’re also looking to public/private partnerships between health care and public health, and communities where coalitions are being built that include business and schools and faith-based organizations, with a focus on what really builds health. All of this is probably part of the mix that becomes the new public health.