Building Back Public Health

Contagious Conversations  /  Special Edition: Building Back Public Health




Claire Stinson: Hello, and welcome to Contagious Conversations. I'm your host, Claire Stinson. Thanks for tuning in to our special edition podcast in conjunction with Public Health On Call, a podcast from the Johns Hopkins Bloomberg School of Public Health. Contagious Conversations is brought to you by the CDC Foundation, an independent nonprofit that builds partnerships to help the Centers for Disease Control and Prevention save and improve more lives. We're pleased to bring you this special edition podcast today featuring a discussion between CDC Foundation President and CEO Dr. Judy Monroe and Dr. Joshua Sharfstein, vice dean for public health practice and community engagement at Johns Hopkins Bloomberg School of Public Health.

Dr. Josh Sharfstein: Dr. Judy Monroe, thank you so much for coming to the Public Health On Call audience today. I want to just start by asking you to introduce yourself to this group of people.

Dr. Judy Monroe: Sure. Well, first of all, thanks for having me. I'm a public health practitioner at heart. I started my career actually as a practicing physician in Appalachia and then got into medical education, but found myself becoming the State Health Officer in Indiana when Governor Daniels appointed me. From there, I went to CDC and became deputy director under Tom Frieden, where I oversaw the Office of State, Tribal, Local, and Territorial Support. The last six years, I've now been President and CEO of the CDC Foundation, where we support CDC and the public health system.

Dr. Josh Sharfstein: It's hard, I think, for me and others I know, to think of state public health without thinking of Judy Monroe.

Dr. Judy Monroe: Well, thanks for that. I think I really did become known for that, particularly as president of ASTHO when I was State Health Officer of Indiana, and then, certainly, my work at CDC and beyond.

Dr. Josh Sharfstein: Great. You have now been pulled back to the state level by this interesting process happening in Indiana, your state where you were the health commissioner. Tell us what's going on in Indiana now.

Dr. Judy Monroe: Yes, I was quite surprised, actually, last summer, when I received a call saying that the governor of Indiana, Governor Holcomb, was going to start a Governor's Public Health Commission, and he wanted me to be the co-chair of that commission. They're really taking things seriously in Indiana, so the Governor wants the commission to do a deep dive. We're into our work now. We meet monthly and we're looking at the public health system in Indiana. Then ultimately, the greatest part about the commission is that next summer we will give a report to the governor that will actually have proposed draft language for future legislation that they could take forward in the long session.

Dr. Josh Sharfstein: A commission on the public health system, could you maybe take a half a step back? I mean, I might have some ideas why this is a good idea, but why did the governor of Indiana think this was a good idea?

Dr. Judy Monroe: Indiana's a state that has really been focused on excellence in education, their higher education institutions, improving those. They've done a lot for their economic development, drawing new businesses in, and quite frankly, the Governor said that public health was the Achilles heel of a state that is trying to improve in all these other measures, and so based on those national measures of success for a state, he said, "Let's do this systematically. Let's take this really seriously and get folks in there that understand the state and understand public health."

Dr. Josh Sharfstein: How did the pandemic factor in?

Dr. Judy Monroe: Oh, I think the pandemic played a role, but it's not the entire reason that the Governor decided to do this, but certainly, with public health being in the news every single day for the last two years, now is a prime time to take a hard look at our public health systems and fortifying those and improving them for the future.

Dr. Josh Sharfstein: Got it. You get the call. How long did it take for you to think about whether to do it or not?

Dr. Judy Monroe: I am a CEO of a nonprofit, so doing something this public at the state level, I thought it's probably something I ought to do. But luckily, I had a board meeting within a couple of days. I went to my board and the board said, "Absolutely, you must do this," so I got approval from the board, and so it was a very short period of time.

Dr. Josh Sharfstein: Got it. How is this commission structured? What are you really trying to find out?

Dr. Judy Monroe: Yeah, it's got a outline structure to it. The charge for this is to take a look, as I mentioned, analyzing the public health system, and to do that, we're taking a hard look at the workforce. We're looking at the financing, the governance, looking at things like public health preparedness. We are charged to look at, at the response during the pandemic, as part of this overall assessment, we're looking at things like healthcare and public health working together, that integration, and how do we do that better. Childhood and adolescent health is part of the charge as well, so it's a very deep dive. Then very importantly are the data systems for public health and how Indiana, which Indiana's been a state that's been a leader with the Regenstrief Institute in electronic medical records and so forth, where are they now with their public health data system, and the interoperability.

Dr. Josh Sharfstein: Where are they now with the data system and interoperability, as an example, of a state trying to get data to work? We certainly have all heard about data gaps in the COVID pandemic.

Dr. Judy Monroe: Yeah, coming back, after having been health commissioner there, it's quite interesting to see how they've advanced. One of the things Indiana was able to do because of their system during COVID, and I think across the country, we've seen this with CDC and others, where there has been advancement of our data systems, and so if you look at their dashboard for putting out to the public at the start of the pandemic to where they are now, it's light-years difference. I mean, they have really made vast improvements, but if you go under the hood a little bit and take a deeper look, the interoperability capabilities only are there for a few of the counties. It doesn't reach the rural areas, the small health departments, and so there's a disparity for the citizens of the state in terms of what type of public health services they're able to get, and of course, data is the backbone. Between workforce and data, you must have those as cornerstones for public health.

Dr. Josh Sharfstein: What is the state of the workforce, now that you mention that? You're looking into where the data can be improved. A lot of states have lost public health workers over the last decade. Is Indiana one of those? Are you seriously looking at turning that around?

Dr. Judy Monroe: Yes, it's a critical area. When you begin to unpack governmental public health, the workforce, in part, has to do with the salaries that are paid and whether or not at the local level, and at the state level, for that matter, as well, do they have - what's the hiring authority? Even if they have funding, can they hire who they need, and then can they pay competitive salaries? The answer is no. I mean, one of the things we've learned through the commission are there are some of the local health departments that are still paying the same salaries as years ago, and because of the way their governance is structured, they're unable to increase salaries, even sometimes with cost of living, or anything, so there's a huge need for improving the skillset of the public health workforce, the numbers in that workforce, and we're taking a hard look at that because financing is part of the equation and part of the question.

Dr. Josh Sharfstein: I wonder, what the political dimension of this commission is? I don't mean partisan politics, I mean lowercase p politics. This is not a moment where it has been very easy to be in the field of public health. It's not just that public health is in the news, but harassment and attacks on public health officials are also in the news. If you're talking about, "Look, we need to invest to improve the data. We need to hire more workers. We need to pay them better.” What's the appetite to hear that in Indiana?

Dr. Judy Monroe: It depends on who you talk to. That's going to be a large portion of the work that needs to happen is to assure that the legislators understand the needs and why the investment in public health is so critical to the state of Indiana as it is in all of our states, so you're asking a really critical question. There are certainly champions within the state of people that really understand this well, that it's a no-brainer that we need to do this, but many of the decision-makers need to be educated and understand the needs.

Dr. Josh Sharfstein: What's the best way to do that? We can talk beyond Indiana because obviously, you work across the country. This is a moment for people to understand the needs and to understand public health. What are the strategies you've used that are the most effective?

Dr. Judy Monroe: I will tell you one of the strategies that I'm actually rather excited about is actually bringing the arts into the communications. We've had such a divide in our country. You talked about it. I mean, our health officers have been under fire, they've had protests at their homes, and all of these things that have happened. We need to get to people in ways that they'll be receptive to the information. One way is through the arts.

The other thing I would say is children, talking about the needs of the next generation, our children. That tends to be an area that most people will be more receptive to hearing the message about than others. Then coalition building. Bill Foege, I think he is certainly one of my heroes, and I think for a lot of people in public health. He always talked about the fact we need to be a good ancestor in our own work and leave behind better, but we also must have coalitions. He talked a lot about the power of coalitions, so I think that's another strategy as well.

Dr. Josh Sharfstein: Coalitions, it's definitely a strategy. It can be lonely to be in public health these days. Where have you looked for that? As you think about maybe in Indiana or others to make this case, who do you think would be lining up behind a proposal to strengthen the public health system?

Dr. Judy Monroe: The obvious folks, starting with the American Public Health Association and all of their affiliates at the state level, and quite frankly, many of them are not as resourced as they could be, so that's something that anyone in any state that wants to help fortify public health, look to your affiliate of the American Public Health Association. Then I think our schools of public health and our academic partners can be really a great force. But one of the things in Indiana that has been a great pleasure to me is I'm going back now on a regular basis, I'm meeting with some of my former colleagues, and they're out of medicine. There are a lot of retirees that really care a lot about the future, so I think we can mobilize folks that really understand, and then I would go to the students. I think I've always found that mobilizing students at all levels is important when we're trying to get attention around these important issues.

Dr. Josh Sharfstein: Anything in this commission process that surprised you as you've gotten going and you're leading this effort to help people understand the gaps in public health, think through what could improve the situation…what has been surprising to you about the reception or the nature of the problem? I'm curious.

Dr. Judy Monroe: One, I've been very pleased because we're doing listening sessions, they're doing numerous listening sessions across the state as part of the process, and the ones that I've participated in have had tremendous engagement. Again, I think the pandemic has set the stage for that type of engagement. The other partners that we really need to see come into this are the businesses. I didn't mention that early on, but there are many Indiana businesses that are taking note and are engaging, so that's good news.

One of the areas that's been fun has been watching the commission itself meeting on a regular basis and beginning to gel. I think some of the commission members, because we have members on the commission from all over the state, we have some elected officials like mayors. We have former commissioners of health, or hospital CEOs, and then different organizations. And it's been really amazing to see them see the data, begin to understand the problems in Indiana, and then begin to coalesce around what, what types of recommendations we may make. We're not to the point of recommendations yet, but it's been fun to see that coalescing, so I'm a big believer that if folks really pay attention and begin to learn and understand, I think they'll come around if they're anti-public health on the starting point.

Dr. Josh Sharfstein: Interesting. You think that focusing on the details can help people avoid the noise?

Dr. Judy Monroe: I think so.

Dr. Josh Sharfstein: Well, that brings us to the national challenge. This is obviously an issue for more than Indiana. We have all kinds of gaps in our national public health fabric that have been, made bare by the pandemic. How do you assess the situation? The CDC Director recently said, "You can't expect CDC, with what it has now, to fix every problem that exists in the country. This is a much bigger challenge." How do you think about that challenge and the path forward at a time where there's just so much political division?

Dr. Judy Monroe: I couldn't agree more with that statement. I mean, CDC certainly needs help, and this is an all-in effort as far as I'm concerned, so that's why I do believe we need the businesses, we need community engagement. At the CDC Foundation, we've been leading a series of national summits that actually have been called a family meeting where we're drawing over 2,000 registrants to come in and talk about the issues that need to take place across the country. It is a diverse country, so I think we all need to be listening. Those of us in public health leadership positions need to give the space and time to hear from folks. Equity is a big area across the country. It needs to be central to what we do in public health, central to our data systems, those types of things. That was the summit that we had last week and had some marvelous panels in discussion.

I think it's just that, it's engagement at all levels, and I think we at the national level need to help set the table for the local level, because at the end of the day, public health can become pretty hyper-local in terms of county commissioners and local decisions that have great impact on the communities.

Dr. Josh Sharfstein: Now, there's an interesting opportunity at the national level that's coming up for public health, which is the American Rescue Plan had a substantial investment in public health resources, the president's budget adds additional resources. How do you see that playing out? Do you think that these new resources are going to make a difference for rebuilding the public health system? Or maybe I should ask it a little bit differently, how do we make sure that these new resources make a difference for the public health system?

Dr. Judy Monroe: Yeah, no, that's a terrific question. A lot of people are asking that question right now. We do need to assure that our state and local partners have the tools that they need to be able to utilize the funding well. That's playing out differently across the country. They're using intermediaries if they don't have hiring authority, as an example, for workforce. One area that's super exciting is CDC, in a short period of time, will be releasing $3 billion that's going to be quite flexible, very different than usual funding that will be a five-year availability of funds to go to the state and local areas for hiring workforce, but as the leaders of CDC will tell you, it will not be enough funding. There's still going to need to be state funding and local funding to help augment that, which is why Indiana's looking at the funding that the state is providing for public health, and I would encourage all states to do that.

Then on the data modernization side, CDC has received considerable funding to modernize the data systems and to create more interoperability, to have more real-time, actionable data, which is key to public health practice. A lot of those funds are obviously going out to the states as well. This is why the national conversations and the support, coming either from CDC, or coming from other support like schools of public health, are playing a key role, I think, in a number of states.

Dr. Josh Sharfstein: If Indiana is developing this plan, perhaps the plan could inform the spending of some of the money that'll come to the state.

Dr. Judy Monroe: Yes, and actually, that's one of the areas that we're looking at is, how does that flow of money coming from the federal government to the state get to the locals? What are the big barriers to the local jurisdictions? Because there are real barriers sometimes for that money to flow to the local level. I can be a pretty tight manager and I hate waste, so how do we make sure that those funds are being used really strategically and wisely? We're going to have to learn from one another. I mean, there's no one that's going to have a corner on the market, so I think we need to be lifting up those bright spots, and sharing those in real time with folks.

Dr. Josh Sharfstein: Do you think other states should be doing this kind of intense reflection on their public health system to get ready for the funding like Indiana's doing?

Dr. Judy Monroe: Some states are, maybe not from a governor's executive order, but there are states, like North Carolina and Oklahoma, Washington state, I think, was ahead of the game, as an example, so there are definitely states that are taking a hard look at this.

Dr. Josh Sharfstein: I think it'll be particularly interesting how the story of these resources is told. Part of the challenge public health has is that it's often invisible. The question is whether or not these new funds are going to be invisible, too.

Dr. Judy Monroe: I hope not, no, and I think we've all talked about how storytelling is so important, we need to make sure that it's visible the impact of these dollars, and that they have been wise investments, no question about it. On the workforce, what's great about the workforce is they're also looking at that holistically, so it's all the way from hiring, some of these dollars can be used for training, which, again, brings in schools of public health and, and the academic partners, which I know, obviously, your work that you're doing at Hopkins is critical. I don't know how you see the role of the schools of public health in this landscape?

Dr. Josh Sharfstein: Well, good question. I think it's an extremely important moment for the field, and so public health schools have to be a part of it. For us at the School of Public Health, that looks like speaking out in support of local and state public health officers who've often been under threat, helping to define the needs of state and local public health and the kinds of activities that really deserve to be invested in and often maybe overlooked, really make sure people appreciate the value that public health brings. We do that through all kinds of different partnerships and projects, but it is a moment. I think all of us who have worked in public health realize that these moments don't come around all that often.

Dr. Judy Monroe: Yeah, I couldn't agree more. It's incumbent on all of us to give our best in this moment and to work together, maybe more effectively than we've ever done before.

Dr. Josh Sharfstein: Well, Dr. Monroe, thank you so much for joining me to talk about your work in Indiana and this battle for the future of public health.

Dr. Judy Monroe: Thanks. Great to join you. Thanks for all that you do, Josh.

Claire Stinson: Thanks for listening to this special edition podcast, produced in conjunction with the Johns Hopkins Bloomberg School of Public Health Public Health On Call podcast. Contagious Conversations is produced by the CDC Foundation and available wherever you get your podcasts. Please visit for show notes and be sure to check out more episodes of Public Health On Call, available wherever you get your podcasts. Thanks again for tuning in and join us next time for another episode of Contagious Conversations.