Infusing Equity Into Organizational Culture at Governmental Public Health Agencies

In September 2020, the Public Health Center for Innovations and the de Beaumont Foundation released the updated version of the 10 Essential Public Health Services (EPHS).¹ The new EPHS, developed 25 years after the original framework, finally centered health equity—one of the core components of public health practice today. As health inequities drive the differences observed in mortality by race among the top 3 causes of death in the United States² (heart disease, cancer, and COVID-19), the focus on health equity is long overdue and has never been more urgent.

The framework includes direction to develop systems that enable equitable access to individual services and care needed to be healthy.¹ The diverse group of public health leaders who informed the refreshed EPHS framework included the need for health departments to “build and support a diverse and skilled public health workforce” and “build and maintain a strong organizational infrastructure for public health.” As a leader of color who has worked in governmental public health at the local and state levels, I can attest that these present a challenge to many public health departments.

The 2021 Public Health Workforce Interests and Needs Survey (PH WINS)³ reported that today's public health workforce remains less diverse than it needs to be. It is primarily White (54%), female (79%), and 40 years or older (63%). Only 14% of the public health workforce has a degree in public health.³ Lived experience brings a greater awareness and confidence to address health equity and is vital to informing appropriate public health approaches.⁴ Our lack of diversity, training, and lived experience is preventing us from reaching our collective vision of achieving health equity for all.

The gaps in representation in the public health workforce are particularly alarming considering the situational context within which we operate and events over the last few years. Between March 2020 and January 2022, the period in which PH WINS was conducted, we faced the COVID-19 pandemic, which has taken an unprecedented toll on communities and public health professionals' mental health and well-being.⁵ Deaths of unarmed black men and women at the hands of police led to a racial reckoning across America that has had a devastating impact on communities of color and political discourse that has undermined the essence of public health practice.

More than a quarter of the public health workforce plans to leave their positions for reasons other than retirement in the next year.³ With new federal funding to support infrastructure and workforce development, public health has a unique opportunity to rebuild our workforce in a way that is more representative of the populations we serve and better equipped to support health equity.

To truly make a difference, we need to create policy and make systems change. Here are some ways you can act quickly to build capacity for health equity work by diversifying your team:

1. Build a strong pipeline of diverse public health professionals and invest in developing diverse leaders: To address the lack of diversity in certain roles, I have found it helpful to start early by reaching out to local high schools and early college programs. Prior to the COVID-19 pandemic, few people were aware of what public health does. Now is the time to sell public health job opportunities and make sure we are educating future professionals about the array of opportunities our field has to offer. Collaboration with higher education is a great opportunity to develop symbiotic relationships between learners and health departments. In my earlier work, I was responsible for the oversight of an academic health collaborative at Worcester Department of Public Health in Massachusetts. The collaboration between public and private universities and the local health department provided numerous opportunities for diverse groups of learners including internships, practicums, doctoral research, and policy consulting. We often saw that interns who performed well were good candidates for future job openings.
2. Focus on diversity, equity, and inclusion (DEI) in recruitment, hiring, and retention: Employees who feel that their organization prioritizes DEI are more satisfied and less likely to leave their positions; this is more pronounced among people of color.⁶ While racism has been declared a public health crisis in many jurisdictions across the nation, employees, and particularly employees of color, want to see the real change in terms of policy and practice. Increasing diversity on a team starts from the recruiting process: Is your human resources/recruitment team diverse? If not, that is the first opportunity to make a change. I have recently had the opportunity to collaborate on a pilot initiative called the Diversity Hiring Team (DHT) working across administrations at Michigan Department of Health and Human Services (MDHHS) and with support from Michigan Public Health Institute to build capacity for a diverse, inclusive, and equitable interview process. DHT takes a diverse group of employees from various program areas and levels and places them in partnership with hiring managers to review position descriptions, screening and interview questions, and job applications. DHT members complete a series of required trainings covering topics including systemic racism, communication, conflict, DEI in hiring and elective modules such as disability cultural competency, and ADA Title I inclusive hiring practices.
3. Engage and build capacity among your partners: At the state level, MDHHS has a DEI plan and an active DEI council. I was also proud to work for a local health department that chose to identify racism and discrimination as the first domain area in its Community Health Improvement Plan. Whether you choose to explicitly identify addressing racism and discrimination as a goal in your community/state health improvement plan, provide training on Culturally and Linguistically Appropriate Services (CLAS), and/or create new trainings for your public health network. Follow it up with actionable items that will lead to real change, including an equity impact assessment, policy reviews, programmatic changes, and new initiatives to move health equity work forward. It is not always easy and if there are not examples to follow, I have learned it is important to have the commitment to build your own.