Banks KP and Gouveia T. A movement in the making: building collaborations with public health experts and policymakers. HPHR. 2021;35.
For public health to meet the challenges of COVID-19 and beyond, to increase evidence-based decision making, and to realize public health as a public good, we need a broad, intentional movement to build coalitions among public health experts in academia, research, practice, and the public sector. The authors discuss how failure to invest in public health systems, inadequate health communications, and poor public health practice during the COVID-19 pandemic opened the door for informal systems of information sharing and the consequences thereof. The lesson that public health professionals and public health associations need to draw from the COVID-19 pandemic is that communicating effectively is critical to ensuring that evidence, even emerging evidence, guides decision-makers. We discuss the challenges of evidence-based decision-making in public health policymaking and highlight examples of academic institutions that have invested in public health knowledge translation. Finally, we describe how the Doctor of Public Health (DrPH) degree was designed to bridge communities of practice, and what is needed for those with DrPH training to stand up and meet the moment.
The path to creating a healthy population is influenced by investments made by governments and other parties that are intrinsic to a society’s health and welfare, such as humane housing, reliable transportation, and safe neighborhoods (Bradley et al., 2016; Nichols & Taylor, 2018; Taylor et al., 2016). Effective public health is therefore attained when it is treated as a public good; no one individual is explicitly excluded from benefiting from these collective investments and no one person’s utilization of a public health good or service prevents others from accessing it (Galea, 2016). Emergency preparedness, immunization policies, and policies to mitigate climate change are prime examples of public health–collective investments that benefit the collective good.
Generally, the private sector does not engage or invest in public health activities, leaving the primary responsibility for public health financing to federal, state, and local governments. Public health planning, research, data collection, surveillance, communications, intervention design and implementation, emergency preparedness, and workforce development rely on working within government bureaucracy, including budget cycles and competing values. Although public health leaders have the regulatory authority and police powers granted to them by state and local governments, they cannot effectively execute their duties without adequate resources (Hunter, 2016). The Coronavirus pandemic exacerbated the cracks in American public health systems, clearly demonstrating the myriad ways in which public health has been poorly funded for decades. Similarly, we are witnessing the urgency required to advocate for the full-scale investments needed to execute core competencies in the public health sector, including data-informed responses to public health emergencies and deploying diverse communications strategies to bring public health information to broad audiences (Centers for Disease Control and Prevention, 2020).
Since the World Health Organization declared Coronavirus a global pandemic in March 2020, we have watched federal and state government leaders in the United States willfully ignore public health expertise while developing policies. In the absence of a strong, evidence-driven governmental response to the pandemic, access to vaccines and personal protective equipment was privatized, stakeholders were pitted against each other, and COVID-19 vaccination roll-out and economic reopening plans were politicized (Mazer, 2020; Menasce Horowirz, 2020). When the Trump Administration refused to fully activate the Defense Production Act for the production and distribution of personal protective equipment (PPE), governors were left to fend for themselves and compete on the open market with the highest bidder winning the contracts (Galston, 2020). Pandemic emergency preparedness plans that local and state public health leaders built over the last two decades were sidelined. (Gardizy, Lazar, & Vaccaro, 2021; Lazar, 2021) These failures in our COVID-19 response contributed to inequities not only in the U.S., but also global inequities in access to PPE and other medical supplies, therapeutics, testing supplies and equipment, and vaccines (International Finance Corporation, n.d.).
The politicized dynamics between key decision makers at the national, state, and local levels only further exacerbated the public’s already dwindling trust in academic, governmental, and other institutions (Gardizy et al., 2021; Rathe & Baskin, 2021; Weisman & Stout, 2021). Two Pew Research Center polls conducted in 2020 found that 20% of U.S. adults trusted the federal government to “do the right thing,” and 26% believed that the federal government has utilized public health expertise in responding to the pandemic (Funk, Kennedy, & Johnson, 2020; Pew Research Center, 2020). Public sentiment about state government’s use of public health expertise was more promising with 43% of Americans reporting that public health experts influence state governments’ pandemic response policies (Funk et al., 2020).
Fulfilling the promise of public health as a public good hinges on the ability of public health practitioners and researchers to broaden access to public health information; increase the transparency of decision making; shift economic resources to ensure sound investments in the common good, and; democratize and create shared power (Hunter, 2016; Jones, Atkeson, Goodman, & Houston, 2021; Wong, Rahman, Warren, & Warren, 2020). This work is not unlike other public health change efforts in that it is inherently political (Jones et al., 2021).
Yet, many public health leaders steer clear of policy debates, citing frustrations with the political process that deprioritizes or completely ignores evidence; their own discomfort with making decisions under the pressures of an increasingly distrustful public and in hotly contested contexts; and the desire to avoid ethical conflicts that may occur when advocating for certain policies through the application of sound public health science (Bowen & Graham, 2015; Hunter, 2016; Jones et al., 2021). But what happens when sound public health science is not at the ready? In looking back, we see that early in the pandemic, public health professionals were slow to state absolutes on how to respond to the pandemic and many did not engage at all in public discourse. By June 2020, editorial commentaries and letters to the editor calling for haste in using limited data and published research to draw conclusions on epidemiological trends and treatment options cluttered prominent public health journals (Saitz & Schwitzer, 2020). Indeed, the majority (77.7%) of COVID-19 publications from April to June 2020 in medical journals were opinion pieces; of the remaining observational studies, the most prominent were retrospective and/or cross-sectional studies (Elgendy et al., 2020). Evidence-driven policies were impossible to develop, let alone enact.
Without a steady stream of publicly available data and guidelines from the federal and state public health authorities in early 2020, the sharing of misinformation became rampant. Vague guidelines and false claims from the White House stymied policymakers and the public about the ways to safely navigate daily living in the face of the novel virus. Frustrated epidemiologists and public health practitioners collated their knowledge and shared on social media to provide as much accurate guidance to the public as quickly as possible. Public health scientists who were never before in the spotlight now had to quickly adjust to providing expert opinions on Twitter (Bartlett, 2020; Graham, 2021). Frontline health workers also took the social media plunge, with clinicians leaving their hospital shifts in the COVID wards to write about their experiences on Facebook. Most often these content creators were parents who saw online parent groups of people who were struggling with ever-changing guidelines and evidence, or simply just wanted to know whether or not it was safe for their children to attend school (Dockterman, 2021). Notably, these efforts were unpaid and largely undertaken by women and racial and ethnic minorities in the medical and public health fields.
Given the public health profession’s historical hesitancy to “politicize” data into digestible sound bites, it was not long before scholars and professional associations began to police and criticize their colleagues for using social media. The International Network for Epidemiology in Policy, a consortium of 24 epidemiological societies, released a formal statement about the importance of epidemiologists “to serve as voices of reason and moderation media or traditional media outlets such as radio, print, and television” (APHA Epidemiology Section, 2020). A commentary to the British Medical Journal lamented the lack of civility in academic discourse during COVID-19, and called for a code of conduct on how to provide perspective that was “cool” and “unbiased” (Bhopal & Munro, 2021). Like many finger-wagging scholars, the main offense cited was misinformation shared with the public through social media, most often Twitter. However, in their flogging, critics failed to acknowledge that their colleagues disseminated persuasive information through social media largely because government officials publicly eschewed the knowledge and value of public health experts and scientists. Interestingly, the Infectious Disease Society of America took an opposite approach to public health professional associations; they embraced social media, recognizing that the future and proliferation of their field was dependent on social media engagement that showed the value of their expertise for patient care, and invested their resources in a digital strategies advisory group for their members (Marcelin et al., 2021).
While public health experts dithered waiting for peer-reviewed evidence, politicians and misinformation campaigns used the dearth of information as an opportunity to undermine the value of public health expertise. During that time, media and others jumped in to address the COVID-19 concerns of policymakers and the American people. Without real-time data from the Centers for Disease Control and Prevention (CDC) or the White House, multiple media outlets, such as The New York Times, developed their own tracking systems to observe trends in infection, positivity rate, and hospitalizations (New York Times, 2021). Easily one of the most important contributions to COVID-19 data access was The Atlantic COVID Tracker, a multidisciplinary effort that brought academics, statisticians, journalists, and people collecting data on the ground to capture important data on race, ethnicity, hospitalizations, and long-term care facilities (The Atlantic, 2021). Reporters, data scientists and others used this data to derive their own opinions on how policymakers should proceed, often using shorthand that made for good sound bites, but poor public health guidance and practice. One of the more notorious missteps was that of economist and writer Emily Oster, who used data that she procured to insist that parents should equate unvaccinated children as having the same risk of infection as vaccinated grandparents, and that it was safe for children to go back to school when the CDC had yet to make a formal conclusion (Oster, 2021). If there is a single lesson that public health professionals and public health associations need to draw from the COVID-19 pandemic, it is that nature abhors a vacuum; communicating effectively is critical to ensuring that evidence, even emerging evidence, guides decision makers, whether for policymakers or for parents who are trying to make choices about how to keep their families safe.
Although the media filled the data gap for decision makers, it has been difficult to ascertain exactly what and how much data has been used to inform policymakers throughout the pandemic. For public health to serve as a public good during the coming phases of the pandemic, evidence translation for widespread policies and programs is critical.
Still, evidence-informed decision making in health policy and programs is not a new challenge. Evidence-informed policymaking is difficult in practice because of its entrenched biases, resource scarcity, lack of systems thinking, measurement precision, political context, and values (Bowen, Erickson, Martens, & Crockett, 2009). Translational science, implementation science, dissemination and implementation research, knowledge translation– researchers have created many frameworks and iterations over the years to address the inherent complexity in health policy. (Rychetnik et al., 2012; Tabak, Khoong, Chambers, & Brownson, 2012; Ward, House, & Hamer, 2009). Bowen and Graham (2015) contend that knowledge translation is not the end of building evidence, but an integral part of research from the beginning if it is to be relevant to strengthen health systems or support policymaking (Bowen & Graham, 2015).
Fortunately, there is a growing trend within academia to improve knowledge translation to support public servants in creating policy. Stony Brook University’s Science Training and Research to Inform Decisions (STRIDE) program trains STEM graduate students, their goal being to create a cadre of scientists who can translate evidence to the general public and policymakers (Stony Brook University, n.d.). The key elements of the training are analysis, visualization, communication, and decision support, the last being critical for scientists to work with policymakers during a crisis. Other academic centers of note include the Center for Community Resilience at George Washington University, which engages community leaders, policymakers, researchers, and the private sector to improve health outcomes through creating resilient communities (George Washington University, n.d.). and the Population Health Institute at the University of Wisconsin in Madison, which brings together academics, community leaders and policymakers for the purposes of using evidence to push forward health equity (University of Wisconsin-Madison, n.d.). Leveraging partnerships to train researchers on how to engage in the political arena should be a goal of all public health curriculum. Whether or not public health graduates decide to pursue health policy as a vocation, their exposure to the process will give them preliminary tools on how to use their knowledge should the moment call for their expertise.
While the public health field lost its footing during the pandemic, practitioners can use the lessons learned to strengthen ties between researchers and policymakers to create the infrastructure that aids knowledge translation. To do so will entail fostering relationships across public, private, non-profit, and academic sectors.
Facilitating change and building movements is intrinsic to those of us who have pursued a Doctor of Public Health degree (DrPH). We are trained in situational assessments, evidence translation, health equity, human rights, coalition building, strategic planning, advocacy, and policy. The Association of Schools and Programs for Public Health defined the DrPH degree as one where graduates should be prepared to generate practice-based evidence, as well as lead evidence-based policies and programs (Association of Schools and Programs of Public, 2014). As a practice-based degree, we are naturally poised to lead academics to work in partnership with policymakers, creating an environment in which identifying and using compelling evidence making is integral to developing public health programs and policies. To do so in the current political environment, more investment in intensive training on advocacy and systems thinking for DrPH professionals will be necessary for us to meet the moment beyond COVID-19.
Kathleen P. Banks is a public health practitioner focused on translating evidence for decision makers. She has collaborated with policymakers and officials from the grassroots to the global level, and uses that experience to bridge understanding on how to design and implement effective programs and policies. Her work has been published in peer-reviewed literature as well as mainstream media. Currently, Ms. Banks is the Policy Fellow for Rep. Tami Gouveia, 14th Middlesex, Massachusetts House of Representatives, and the Chair for the Public Policy and Advocacy Committee for the DrPH Coalition. Her dissertation for the Doctor of Public Health program at Boston University School of Public Health explores scaling-up access to noncommunicable disease medicines in Kenya.
Tami L. Gouveia is the State Representative for the 14th Middlesex District in the Massachusetts House of Representatives and a candidate for Lieutenant Governor. Policy and systems change continues to be central to her public health social work practice. Her doctoral research explored “The Political Feasibility of Non-Arrest Policies for Opioid Use and Addiction in Massachusetts”. She earned a Doctor of Public Health in 2020, a Master of Public Health in 2001, and a Master of Social Work in 2002 from Boston University, as well as a Bachelor of Arts from Mount Holyoke College.