The Association of State and Territorial Health Officials (ASTHO) was incorporated on March 23, 1942, and today remains a strong voice in governmental public health. This year marks ASTHO's 75th anniversary and offers a momentous opportunity to recognize the achievements of its members, many of whom have been at the forefront of promoting and protecting the public's health for decades.
As this article illustrates, many defining moments make up ASTHO's rich history and as we come together to celebrate advancements in public health, we must also bring a renewed focus to the important role that state and territorial health departments play in promoting health, wellness, and safety in our communities. - Jay C. Butler, MD 2017 ASTHO President Chief Medical Officer, Alaska Department of Health and Social Services Director, Division of Public Health
Nineteen years after John Snow deduced the famous link between London's Broad Street water pump and a deadly cholera epidemic ravaging the English capital, a second consequential cholera outbreak erupted on the other side of the Atlantic Ocean. The outbreak began in New Orleans in 1873 and spread along the major mercantile routes, killing hundreds of people.1 At the 1879 meeting of the Sanitary Council of the Mississippi Valley, with the recent epidemic still very much in mind, council members raised the idea of an association of health officials to ensure a uniform approach to sanitation, quarantine, and other infectious disease control measures: “... it can only be by the harmonious and conjoint action of the various local agencies, State (sic) and municipal, that we can hope to secure exemption from epidemic diseases.”2
Later, in 1884, while the Association of State and Territorial Health Officials (ASTHO) did not yet exist, 19 health officials met in Washington, District of Columbia, and established the National Conference of State Boards of Health for “mutual aid and advice” and “bringing the combined influence of the health organizations in the states to bear in securing such concert of action and national legislation as might be required... for the protection of the health interests of the whole country.”3
This sentiment led to the formation of the ASTHO—the national nonprofit organization that today represents public health agencies in the United States, US territories and freely associated states, and the District of Columbia—and today ASTHO espouses many of the same fundamental goals.
By 1900, the US surgeon general and state and territorial health officials began meeting annually to discuss how to control yellow fever and other diseases then prevalent. Over time, these conferences became a forum to discuss administrative issues, as well as disease control strategies. In 1935, after the Social Security Act was signed into law, state and territorial health officials realized the need for an organization that could help them navigate the rapidly changing world of public health policy and funding.
Association of State and Territorial Health Officials was incorporated 7 years later on March 23, 1942—4 years before the start of the Centers for Disease Control and Prevention (CDC). Now celebrating its 75th anniversary, the association has pursued a mission both focused and flexible: transforming public health within states and territories to help members dramatically improve health and wellness. Over the years, ASTHO and its members have devoted attention and resources to everything from infectious disease threats to workforce training to disaster preparedness.
Today, the association and its network of 21 affiliated organizations* are an integral part of the national public health system; ASTHO staff and members have informed federal policy making and served within CDC's emergency operations center, providing aid that has saved lives and reduced health care expenditures. While some contemporary ASTHO priorities, including water safety, maternal and child health, and control of mosquito-borne illnesses, would no doubt be familiar to America's early health commissioners, other priorities—such as public health informatics, tobacco prevention, health equity, and the response to the opioid epidemic—might surprise them.
Spanning the association's 75-year history, 2 vital ASTHO roles merit discussion: (1) its position as a catalyst, mediator, and bridge builder during times of crisis and across public and private sectors; and (2) its work to ensure robust public health systems, including legislatively mandated public health programs and measures to ensure public health competency and accountability.
Leveraging the Power to Convene in Times of Crisis
In many ways, the modern public health system, with its emphasis on all-hazards response, was forged in the crucible of 9/11 and the ensuing anthrax attacks in Washington, District of Columbia, New York City, and West Palm Beach, Florida.4 Mary Selecky, former Washington State secretary of health and ASTHO's president in 2002, says that prior to September 2001, there was little known about public health preparedness for bioterrorism and other large-scale homeland security threats.
“At the time,” recalls Selecky, “ASTHO played a pivotal role reaching out to put public health at tables we wouldn't [otherwise] be at, including meetings with White House staff and federal law enforcement and emergency response officials.” The association created an ad hoc antiterrorism task force—since elevated to the standing Preparedness Policy Committee—and developed a policy statement for advocacy at the state and national levels. Association of State and Territorial Health Officials' outreach was “groundbreaking,” Selecky says.
Working with partners, ASTHO pushed hard for federal public health preparedness funding. After Congress passed the Bioterrorism Act of 2002,5 Selecky says her role was working with CDC and the secretary of the US Department of Health & Human Services to “make sure that [millions of dollars of designated public health] funding came to health departments and didn't get stuck in other parts of government ... ASTHO's leadership in that was absolutely critical.”
In a separate discussion concerning these events, George Hardy Jr, MD, MPH, who served as ASTHO's executive director from 1999 to 2006, says that the association leveraged its power to convene to maximum effect in the post-9/11 world, assembling state health officials to explain to White House staff “what states could do and what role public health could play.” Hardy sent ASTHO staff to health agencies in the 3 jurisdictions affected by anthrax attacks to shadow public health responders and serve as liaisons with myriad partners. In addition, the association also convened several state health official-only conference calls, so members could candidly share their successes and failures and discern evolving best practices.
Association of State and Territorial Health Officials developed a basic playbook in the aftermath of the 2001 tragedies, which has since become the association's modus operandi following major public health events. “We don't deliver the services, but we help orchestrate the delivery of services by our members,” says Jim Blumenstock, MA, a former New Jersey deputy health commissioner and ASTHO's current chief of health security.
Claude Earl Fox, MD, MPH, a former Alabama state health official and past ASTHO president, aptly characterizes ASTHO's role as “the glue that has kept the public health community together,” ensuring a “cohesive, coherent, and continuous public health voice” when tensions run high.
During the 2009 Influenza A (H1N1) pandemic, it was the White House that reached out to ASTHO. Paul Jarris, MD, MBA, ASTHO's executive director from 2006 to 2015, remembers being called to the White House situation room to meet with the deputy national security advisor, acting CDC director, and other officials to help inform the national emergency response.
Association of State and Territorial Health Officials ended up filling a necessary role to address H1N1 by the following:
* Conducting an independent analysis of the funding needed to mount a national pandemic response, coming within $1 million of the total funding estimated by CDC and thus lending credibility to both analyses. In June 2009, following extensive congressional lobbying by ASTHO and other partners, President Obama signed a bill providing $1.9 billion in immediate funding and $5.8 billion in contingency funding.6 At least $350 million went to state and local health agencies.
* Making initial contacts with the National Association of Chain Drug Stores and leading the negotiating team that met with industry executives and lawyers to develop a model agreement enabling pharmacies to deliver influenza vaccinations using state-supplied vaccines from the Strategic National Stockpile. States subsequently contracted with their local pharmacy chains for rapid vaccine deployment to high-risk groups, including pregnant women and adolescents.
* Intervening with the American Medical Association to devise a temporary, administrative coding fix, enabling pharmacies and public health agencies to bill insurers for 2-dose vaccinations.
* Detailing Blumenstock to CDC's emergency operations center to inform real-time decision making—the first time a private sector partner was given official CDC liaison officer status.
* Mediating issues between the White House, which was eager for states to advertise influenza immunization clinics, and state health agencies, which were wary of advance advertising, given repeated delays in vaccine delivery from manufacturers.
* Working with partners to create a pandemic flu information campaign and a transparent, risk- and population-based process for weekly allocation of the limited vaccine supplies available.
Ultimately, Jarris says, it was ASTHO's role to provide “the ground truth” to federal officials.
As the 2009-2010 flu season was ending, another crisis arose: on April 20, 2010, the Deepwater Horizon/BP drilling rig exploded and sank in the Gulf of Mexico. Eleven workers were killed immediately, and an estimated 4 million barrels of crude oil poured into the gulf over the next 87 days, before the gushing seafloor wellhead was plugged.7 Kathy Vincent, MSW, was a senior deputy in the Alabama Department of Public Health at the time. “We know how to do hurricanes [in Alabama],” she recalls, “but this was something quite different.”
Vincent's boss, state health official Don Williamson, called Jarris for assistance. Within 2 hours, ASTHO convened all the Gulf Coast state health officials on a conference call, which evolved into a regularly scheduled call throughout the crisis. “We did exactly what our members asked for,” Blumenstock says.
We provided a platform for state health officials from Texas to Florida to come together in a neutral, trusted space and develop a unified approach to address key concerns, such as seafood safety, recreational water safety, economic impacts, health concerns of cleanup crews, community mental health, and ecosystem degradation.
With expert input and ASTHO support, the impacted southern states drafted common media statements, public health advisories, information sheets for state officials, and signs to warn beachgoers about the health and safety risks. As Blumenstock notes, “When dealing with something so visible and controversial, inconsistencies become significant.”
The association also quickly assumed its traditional role as a broker between state and national officials, including administrators from the US Environmental Protection Agency, US Department of Agriculture, Federal Emergency Management Agency, Occupational Safety and Health Administration, CDC, and other federal agencies. The goal was 2-fold: to obtain information, such as baseline (prespill) and real-time levels of toxic crude oil components on Gulf Coast beaches, and to help coordinate the state and federal responses for maximal efficiency. “In the end, we believe we were successful,” Blumenstock says.
Association of State and Territorial Health Officials' other critical, behind-the-scenes crisis interventions include the following:
* Urging federal officials and pharmaceutical manufacturers to authorize 2 shelf-life extensions for antiviral medications in the Strategic National Stockpile following the 2009 H1N1 pandemic, an effort that saved states millions of dollars otherwise needed to repurchase the drugs. Association of State and Territorial Health Officials supported subsequent legislation explicitly empowering the US Food and Drug Administration to scientifically evaluate and extend the expiration date for certain medical countermeasures stockpiled for emergency use.8
* Ensuring a unified public health voice to calm unwarranted fears of radioactive fallout in the United States following the partial meltdown of Japan's Fukushima Daiichi Nuclear Power Plant in early 2011. Association of State and Territorial Health Officials coordinated the dissemination of data to the states—about the distribution and levels of iodine-131 in particular—and helped interpret the data and inform public risk communications. The association also ensured that state health officials had input into possible federal interventions, such as a temporary program to screen travelers coming from Japan for radionuclide exposure.
Building Public Health Systems and Assuring Competency and Accountability
Given its involvement with virtually every significant public health crisis since the mid-20th century, ASTHO has been called a “mini-FEMA.” Yet, despite attending to the urgent events of the day, the association has remained attuned to the long-term needs of the public health system itself. “It's easy to lose sight of the larger picture when you're busy putting out fires. ASTHO maintains that view,” asserts Vincent.
The association has been a perennial and persistent advocate for much-needed public health funding. For example, it has championed important legislation, such as the AIDS Drug Assistance Program and the 1990 Ryan White CARE Act, which expanded access to human immunodeficiency virus/acquired immunodeficiency syndrome treatment.9 Association of State and Territorial Health Officials proposed and pushed the concept of a public health prevention fund beginning in the early 1990s; the fund was finally incorporated into the 2010 Affordable Care Act. “I guess we were a little ahead of our time,” says Fox.
One of the association's early strengths was its genuine interest in its membership. “The philosophy of really embracing and helping the state health officials learn and grow both personally and professionally in a really tough, high-stress, high-stakes job was a distinctive ASTHO achievement,” says Paul Halverson, DrPH, former Arkansas state health official and ASTHO's 2009-2010 president.
The ASTHO membership—just 59 health officials at any one time—is a “pretty exclusive club,” Selecky admits. Yet, those individuals are almost always political appointees who come into their positions with widely varying skills and government experience. Moreover, the typical tenure of these high-level officials is brief—2.7 years, on average, with a median of 1.7 years.10
In the summer of 1999, Selecky was one of a dozen newly appointed health officials in the inaugural class of ASTHO's State Health Leadership Institute, a weeklong program funded by the Robert Wood Johnson Foundation and hosted by Harvard University's John F. Kennedy School of Government. While the program focuses on incisive practical content, such as strategic planning, risk communications, and leadership skills, it also builds relationships that benefit public health writ large. “The institute fosters a sense of camaraderie that strengthens the body whole,” says Selecky. In her case, having a network of peers to both consult and commiserate with proved invaluable just 2 years later when the country was thrown into crisis after back-to-back terror attacks.
Beginning in 2009, ASTHO presidents began selecting a specific public health issue to work on during their terms. Later coined the President's Challenge, these initiatives have included everything from injury prevention to healthy aging to the reintegration of public health and health care. In 2011, ASTHO President David Lakey, MD, then Texas health commissioner, chose to elevate a long-standing concern among the southern states: infant mortality and prematurity. With support from the March of Dimes, the Health Resources and Services Administration, and other partners, the challenge morphed into the Collaborative Improvement and Innovation Network to Reduce Infant Mortality, which remains an active, nationwide program today.11
Association of State and Territorial Health Officials' key contribution to the Collaborative Improvement and Innovation Network focused on ending Medicaid payments for elective early deliveries, which increase risk for adverse infant health outcomes. Speaking about this effort, Jarris says that this is where ASTHO excels: “We changed policy,” he explains.
Once ASTHO members leave state or territorial service, many continue to be influential figures in public health. Fox, for example, was an ASTHO member when the association endorsed the National Vaccine Injury Compensation Program in the 1980s—an extrajudicial compensation system to keep liability issues from dampening vaccine production. In 1998, Fox became Health Resources and Services Administration's administrator and ran the billion-dollar program. Another former ASTHO member, Hugh Tilson, MD, DrPH, was one of the original authors of the seminal, 1988 Institute of Medicine report, “The Future of Public Health.”12 Former Maryland secretary of health, Georges Benjamin, MD, became head of the American Public Health Association. Other former ASTHO members now represent the public health world in academia, government, the nonprofit sector, and the health care and pharmaceutical industries.
Under Hardy's leadership, both the ASTHO Alumni Association and the ASTHO Affiliate Council (comprising executive directors of the ASTHO affiliate organizations) were reinvigorated. A seat was added to the ASTHO board for the alumni association chair and an ex officio seat was added for the elected affiliate council chair. Hardy says that alumni are particularly effective in legislative advocacy: “They can say things a sitting state health official can't.”
In addition to fortifying its members to deal effectively with the demands of their current and future positions, ASTHO has helped spark important public health institutions. Early on, it established the precedent of close collaboration between CDC leaders and the ASTHO board, including periodic meetings of the 2. This intercourse, says Halverson, “aided the advancement of public health science and helped CDC understand what's important in the field, what's working, what's not.” In fact, CDC has almost always had a unit dedicated to supporting health departments, and that unit—currently, the Office for State, Tribal, Local and Territorial Support—has typically been headed by an ASTHO alumnus.
The association was also an early proponent of public health competency and accountability related to state expenditures and performance. In 1970, after Congress established the first public health block grants, ASTHO set up a separate entity—the National Public Health Program Reporting System—to collect data on how states were spending their public health dollars, including the block grant funding now loosed from categorical restrictions. Sue Madden became involved in 1972 to help operate the reporting system, the first of its kind. “It was before computers,” she says. “We did all the data collection by hand, keyed it in and put those data out in a report on an annual basis working very closely with ASTHO.”
After Congress consolidated the separate block grants into the Preventive Health and Health Services Block Grant in 1981,13 ASTHO was incorporated as the ASTHO Foundation, with a mission to document the value of the public health system. The foundation—which solicited grants to support its work but never functioned as a traditional grant-making foundation—operated the reporting system up until 1990, when federal funding for the system ended amidst the promise of comprehensive health care reform and, presumably, “bigger and better reporting systems,” recalls Madden.
Two years later, when health care reform stalled and the reporting system failed to be reinstated, the foundation took on a new name: the Public Health Foundation. The foundation's new mission focused on quality improvement, performance management, and workforce development. Incidentally, Madden is now the chief financial officer and chief operating officer of the modern-day foundation.
Although it is no longer formally tied to ASTHO, Public Health Foundation bylaws require the foundation to have at least 2 state health officials or current senior deputies on its board. In addition, ASTHO members have always served on the Public Health Foundation Council on Linkages Between Academia and Public Health Practice, a body perhaps best known for developing the first core competencies for public health professionals (adopted by the Council in 2001 and now in their third iteration).14 Today, the former ASTHO Foundation is, among other things, a leading provider of continuing education for public health professionals, much of it aligned with the core competencies.
In parallel with its work on public health reporting, ASTHO was at the center of a national conversation regarding public health performance standards and the value of health system accreditation. With impetus from a 1978 Congressional mandate for creation of community preventive services standards, and later from 1988s “The Future of Public Health” report calling for clarification of governmental public health roles, ASTHO joined CDC and other partners to
* identify the 10 essential public health services15 and
* develop the first National Public Health Performance Standards, released in 2002.16,17
Even today, ASTHO manages the score sheets and reports for voluntary state health agency assessments based on these measures.
The same year the performance standards debuted, the Institute of Medicine released a second seminal report, “The Future of the Public's Health in the 21st Century,” this time explicitly noting the value of public health accreditation.18 Not long thereafter, the CDC and the Robert Wood Johnson Foundation cofunded a study on exploring accreditation to further the national dialogue.
Kaye Bender, PhD, RN, a former Mississippi deputy state health commissioner who represented ASTHO on the performance standards effort and served on the expert panel that drafted the 2003 Institute of Medicine report, chaired the study committee. “State health agencies had never been externally reviewed before,” she says. “So it was a little scary.”
Nonetheless, in 2007, that groundwork led to the creation of the Public Health Accreditation Board (PHAB), a nonprofit organization formed under the auspices of a board of incorporators including executives from ASTHO, the National Association of County & City Health Officials, the American Public Health Association, and the National Association of Local Boards of Health. Bender went on to serve as PHAB's executive director in 2009, a post she still holds in 2017.
From PHAB's inception, ASTHO and the National Association of County & City Health Officials have provided technical assistance to health agencies preparing for voluntary accreditation through PHAB. As of mid-March 2017, 20 state health departments have achieved accreditation and 18 more are in the process of applying. “There are a lot of milestones in public health that ASTHO can appropriately take credit for,” Bender says. “I think accreditation is one of those.”
Although no territorial health agency has yet been accredited, Bender expects that they will eventually attain that milestone: “The territories have unique public health challenges that make working on accreditation a bit more daunting than for the state health agencies,” she explains. “We're trying to figure out ways to assist the territories, and ASTHO's commitment to that effort is strong.”
A final ASTHO contribution to the measurement of public health came in the aftermath of the 2001 terror attacks when the association urged the development of public health emergency preparedness capabilities. “ASTHO helped us identify those capabilities and worked with CDC to develop technical assistance to build out those capabilities and capacities,” recalls Blumenstock, adding: “That work is paying off every day.”
Back to the Future
In 2017, the US public health system is far more sophisticated than the field's early pioneers could have imagined. Molecular epidemiology, telemedicine, performance standards, and countless other innovations are revolutionizing the work of public health professionals. At the same time, the field itself has expanded to encompass everything from microbiomes to global climate change.
Yet, on ASTHO's 75th anniversary, some challenges are all too familiar. Yellow fever is seeing a resurgence in the Americas.19 Drug-resistant superbugs threaten to return modern medicine to the preantibiotic era.20 And hard-won federal investments, such as the Prevention and Public Health Fund, must be championed anew.21
Current ASTHO Executive Director Michael Fraser, PhD, says that the most pressing issues facing state health agencies today fall into 2 categories:
* Operational internal challenges tied to the current antigovernment sentiment that stigmatizes and marginalizes the state governmental workforce and associated budget and workforce reductions. With potential federal cuts looming, these challenges will be passed on to states and organizations such as ASTHO will once again have to make the case to sustain investments in governmental public health.
* External environmental challenges related to understanding the ways in which public health agencies can support the work of the health care delivery system, while continuing to push for continued efforts around primary prevention, that is, working to improve the quality and reduce the costs of “downstream” care while trying to move “upstream” and focus on primary prevention. Fraser sees this work as core to demonstrating public health's value and the role of state governmental health agencies in saving lives and reducing health care costs through disease prevention and health protection and promotion.
Association of State and Territorial Health Officials' role, he notes, will continue to focus on legislative advocacy, convening and supporting health officials as transformational leaders, public health capacity building, and outreach to raise the visibility of state and territorial health agencies.
Already, ASTHO has taken a novel approach to capacity building in 2 US territories. At the request of the Puerto Rico Department of Health, the association reviewed the agency's 2016 Zika virus response, noting strengths and weaknesses, and drafted a plan to enhance key operations. In the US Virgin Islands, ASTHO hired—as its own employees—an administrator, 2 public health educators, 2 phlebotomists, and a laboratory technician to work on-site at the health department in St Thomas.
Other ASTHO endeavors may include a state health expert series, bringing cutting-edge technical assistance to association members to address complex public health priorities. Legislative work will continue to focus on disease prevention, emergency preparedness, strengthening the public health infrastructure, and delivering return on investments across the public health enterprise.22
Ultimately, in 2017—as on ASTHO's March 1942 birthday—the association aims to inform, facilitate, and optimize the important work its members do every day to protect and promote public health for all.