Reimagining Our Public Health Systems: The Robert Wood Johnson Foundation's National Commission to Transform Public Health Data Systems

Dr. Plough: It is really great to be with everybody here today. At Robert Wood Johnson Foundation (RWJF), we could not be more pleased to bring together these representatives of the 3 panels convened by our colleagues in health philanthropy, focused on these important topics of public health and health care. While all of us looked at this in a different way, targeting different topics, different sectors, and actors with our recommendations, each commission had a North Star of ensuring that the nation is prepared for the next public health emergency.

Together, we will benefit from RWJF's guidance on transforming how public health data are collected, shared, and used; combined with the de Beaumont Foundation's recommendations on workforce data, preparedness, and funding; and the Commonwealth Fund's focus on stronger federal improvements in our national public health system to improve the public health infrastructure.

All of these are really key components to a stronger future for governmental public health. Each group provided critical recommendations, all focused on an equity lens. They recommended deeper, true systemic change, sustainable change, and not just minor modifications of the way we have done this before on the public health practice side. So, at RWJF we continue to bring all these sectors to the table trying to create systemic change, people who are working on structural factors that impede anyone in the country from having their best health and well-being life course.

We have worked with Mary Ann Liebert, Inc., publishers on a set of articles to highlight how the technology industry is well positioned to help us produce and collaborate the next wave of data and methods that could spark innovation in public health sector data. Several of the commissioners are also working on journal articles, editorials around what those next steps might look like. There are going to be additional funding opportunities from Robert Wood Johnson Foundation, which will be a 2.0 version of the grants that funded the commission, and the current wave of grants that we are already partnering with folks on.

We will be doing another set of those next year at a similar scale, all aimed to really improve the challenges that we all know in public health data, and more collaboration across sectors, and an even heightened focus on equity and community engagement.

So, today our talk is around the many, many areas of alignment between the 3 groups: Explore how the recommendations are really positioned action. Really clarify why equity needs to be at the center of modernization. Highlight what each of our foundations is doing to move our recommendations forward, and how we are going to measure progress going forward. Now is a great time for this conversation, with our public health system authorities really being viewed so closely, given COVID-19, how we are able to use those experiences, build on our historic strengths in public health, and really begin to move forward in a way that is not just modernization or a marginal tweak, but a really fundamentally strengthened and more community-engaged practice in public health.

It is going to be a really great discussion. So, let me turn it over to Karen DeSalvo, a member of all 3 commissions, which makes her the perfect person to moderate this discussion.

Dr. Desalvo: Alonzo, thank you so very much, and just with gratitude to the Robert Wood Johnson Foundation for its incredible leadership in public health, and in health and medicine for the country, and setting the tone for the world. I am Karen DeSalvo. I am a physician by training. I am currently the chief health officer at Google, which is a part of the public health ecosystem. People come to us in the billions every day asking for health information. We have been proud to be able to amplify the messages of public health and be a part of the response.

But, I think it has also been true that, like many during the pandemic, we have seen the difficulties of helping people trust the information that they see and find, and that the voices that it is coming from. So, I am passionate about this work in my current role. I also have a former life of service in public health at the national level, and also as a local health officer.

I really think for me, serving in local public health was how I learned the definition of public health, which is “public health is what we do together as a society to create the conditions in which everyone can be healthy.” So, collective action on the ground and all the way up into the national ecosystem is important. Today we have an incredible group of people joining us who represent the points of view of reports that came out spurred by the crisis of the COVID-19 pandemic, and thinking about, in the face of all those challenges and pain that was inflicted on people because of that pandemic, what are the lessons that we could learn, and how could we take some action as a country to find opportunity in that crisis to do better by the people that we are here to serve in the United States and the world.

So, I am going to ask the folks who are joining us for the conversation to introduce themselves, and then we will jump into a set of questions that really mirror very much of what Alonzo shared. What is the action orientation we should think about? What are our challenges? What are the core tenets and ethos by which all these commissions recommended that public health goes forward into creating equitable health for all?

So, Gail, I will start with you.

Dr. Christopher: Thank you, Karen. It is an honor to be here with my colleagues. I am Gail Christopher, executive director of the National Collaborative for Health Equity (NCHE). The purpose of NCHE is to end health inequities by addressing structural racism as it manifests in the social determinants of health and well-being. I served as director of the Robert Wood Johnson Foundation's Commission to Transform Public Health Data Systems. The final report of the RWJF commission, entitled “Charting a Course for an Equity-Centered Data System,” made a comprehensive set of recommendations for leveraging data to help achieve health equity.

Dr. Desalvo: Thank you, Gail. And you did that very ably, by the way, as the leader of that commission. I very much loved being driven by you in very positive ways. Herminia, can you introduce yourself?

Dr. Palacio: Thank you, Karen. I am delighted to join this conversation. I am Herminia Palacio. I currently serve as a president and CEO of the Guttmacher Institute, a nonprofit think tank that is in the throes of the discussion around sexual and reproductive health rights and justice here in the United States and around the world. But, as Karen and others here on this panel, I have cut my teeth in governmental public health, almost exclusively at the local level, but across very different geopolitical jurisdictions in San Francisco, in Houston, and then finally as deputy mayor for health and human services in my hometown of New York City.

I am here as a representative to talk a little bit about the Commonwealth Commission. I am really looking forward to this conversation across the 3 reports.

Dr. Desalvo: Wonderful. And Brian.

Dr. Castrucci: Thank you, Karen. Just looking at the other folks who are here, this is like a public health fantasy camp. I am Brian Castrucci, and I am the president and CEO of the de Beaumont Foundation. We are dedicated to working on the systems and the policy changes necessary to ensure that every person in every community has the opportunity to achieve their best possible health. I am here representing the Public Health Forward commission, which was funded by several different groups across the United States, focusing on the tactical changes that we need to make to ensure that we have a public health system that can achieve equity for all, and the best health possible for the nation, and, in doing so, support our safety, security, and economic prosperity.

Dr. Desalvo: Terrific, Brian. It is a wonderful collection of public health minds. I am looking forward to the conversation. I think the place we certainly should start is for me to ask each of you to describe your respective commission, its focus, and some of the top line of the goals that were laid out. We will have an opportunity to talk about some of the recommendations further. I want people to understand the why, and how you all came together to think about the problems to solve and the audience for the reports.

Dr. Christopher: It was amazing to bring together 16 diverse participants on this commission, representing many facets of public health—from academia, to practice, to research—and, most importantly, diverse panelists. We also were very concerned that this was not just about tweaking the system in response to the criticisms. The foundation was very clear that the goal was to transform public health data systems, to seize this opportunity presented by the triple challenges: (1) the COVID-19 exposure and impact inequities, (2) the attendant economic upheavals and uncertainties, and (3) the unprecedented moment of racial reckoning that America faced as a consequence of the murder of George Floyd by a Minneapolis police officer.

This was a moment truly never seen before. The protests that followed were unparalleled. Over 25 million people marched calling for racial justice. So, this was a very rare moment. In preparations for the commission's deliberations, the foundation engaged RAND Corporation in amazing research to create an appropriate landscape analysis of the public health data system as it currently exists. There were many briefs and articles that were prepared, so that when the commissioners did their work, they could engage fully in the present moment, in the challenges before them. We decided that, since equity had to be centered in the recommendations, that we would adopt a framework that is being used to transform our country.

Launched by the W.K. Kellogg Foundation back in 2017—we adopted the Truth, Racial Healing, and Transformation (TRHT) framework for the deliberation processes of this commission. TRHT has 5 core pillars. The first is narrative change. The second has to do with relationships, and healing, and trust—all those things that I will talk about in a minute when I describe the core buckets of the recommendations. But then the bottom 3 pillars of that framework, they addressed how structural racism and its consequences—the inequities that we see today—how those have been embedded in our systems, particularly in our public health systems, but, as you said so eloquently, Karen, in all of the conditions that determine how we live.

The recommendations of this commission focus on those 3 tiers, as it were. So, you have the tier of centering equity as you change the narrative, as you change the story of what public health is, who is responsible. Most importantly, how do we move from a deficit frame to one of well-being? How do we really look at more than preventing, but actually creating an ethos that fosters well-being for all members of society?

The first tier of recommendations is really about changing the stories, the narratives, directing our conceptual approach to the work. The second tier of recommendations has to do with the relationship that communities and diverse stakeholders will have to the data. We focus on making sure that there is ownership by communities, and that there is equitable access to and ownership of the data and the information. And then the third tier of recommendations specifically require that we use our public health data systems, our measurement tools, to actually address and redress structural racism as it is embedded in all of those systems that contribute to the social determinants of well-being.

So, you have a large number of recommendations that speak of making sure that we look back and look forward, and address structural racism. For example, the climate-related emergencies, having a disparate impact on communities of color; the water crisis in Jackson, MS is exacerbated by a historically underfunded water infrastructure and protracted barriers to access to healthy drinking water for African Americans in that city. This is a public health crisis rooted in historic inequities that require a response from all sectors of the community and all levels of government. The recommendations of our commission engage multiple sectors.

It certainly is reflected in what you said, Karen. We all have a role to play. The recommendations of this commission, they speak to the federal level, the state level, and the local level of government. They speak to the health care system, the public health system, the role of the business community, the role of the nonprofit sector, and the role of the academic and educational community. That is just a broad picture of what our recommendations point toward in terms of centering equity and charting a comprehensive course for equity in the public health data systems. I would defer to Alonzo for things that I may not have mentioned yet.

Dr. Plough: You were very comprehensive in your remarks. I would just emphasize from the Foundation's perspective, that the catalyst for us was the co-occurrence of the pandemic and the impact of structural racism. The George Floyd murder was an indicator of the endemic nature of structural racism. When you put those two things together, you get the unequal impact of the pandemic. Those two things together were important for the Foundation to address. This was the first wave of large-scale funding that we did post-COVID, and is signaling a direction that we are going, particularly around data, equity, community-engaged and meaningful data, and emphasizing the important racial justice framing that Gail provided. The opportunity is to make clear that modernization does not mean just tweaking what we used to do. Modernization is a deeper dive to reconstruct our approach to data given the lessons of the endemic and the pandemic.

Dr. Desalvo: I think it was such a beautiful way that this commission thought about what you are saying, Alonzo, that it is not just modernizing data infrastructure, that there must be intention around it to address health equitably. It was perhaps getting a little lost, I think, in the public health narrative, that it is not just about the data, and standards, and pipelines, but the use cases, and making sure that we will be able to have the information that is necessary to do the really important work on the front lines—especially in multisectoral collaboratives.

I think, Herminia, the work of the Commonwealth Fund Commission looked more squarely at the role and responsibility of the federal government in public health. I hope that you could speak about that commission, and, at a high level, the recommendations there.

Dr. Palacio: Sure, I am happy to. I think I will begin by saying how struck I am as I listened to Gail and Alonzo about the description of your commission. And I am looking forward, Brian, to your description, because I think what is emerging is that these 3 commissions convened in a somewhat temporal relationship, but otherwise not directly related to each other, have struck a very similar chord of themes. What differentiates them is a matter of emphasis, not a matter of overall goal or approach.

As you said, Karen, and certainly as a member of the commission, you are aware that the Commonwealth Fund convened this commission to really think about, again, in the aftermath of the pandemic, but very explicitly not directed to be an after-action report. The goal was to build on the foundation of what we learned, and looking forward, about how it is that we can address things in the future.

This commission focused on the role of the federal government in terms of a leadership role, but also very much in terms of its role as part of a system, understanding that states and localities have various capacities, capabilities, roles, and responsibilities to ensure that no matter where people live, no matter who they are, that they should and must have equitable access to high-quality public health services. The recommendations were 3-fold in broad topics that really talked about things that Congress should do. What are the authorities of our federal legislators in terms of changing structure that can only be done through legislation?

What are the things that lie within the purview of the administration that they can do by regulatory acts, or by reorganization, and what are those roles and responsibilities that fall to state localities, tribes, and territories, and how do they relate to each other? As an example, for Congress, one of the recommendations was for Congress to have an undersecretary in health and human services, parallel to what it sees in other departments, to really serve that coordinating role across the many federal agencies involved in health.

Here I am going to step back a minute, and I am going to take off my commission hat. I am going to put on my hat as a physician who practiced primary care medicine, mostly in the early days of the HIV epidemic, for nearly 2 decades, and as a public health local official who lived in Harris County/Houston running the medical branch during Hurricane Katrina Astrodome shelter operation.

I was also in Texas running the H1N1 pandemic influenza in a very red state, under Governor Perry. And I will have to say that in all of those experiences across multiple geopolitical realities, I have never seen such an abject abdication of federal responsibility and leadership as I saw during the COVID-19 pandemic. As a former public health official, and a citizen of the United States and the world, this was nothing short of heartbreaking because there was no theory of the case to guide state and local officials in some unified way, and it was fertile ground for the misinformation and disinformation to not just take hold, to not just be planted … rather it was watered and nurtured at the expense of communities and, in particular, at the expense of vulnerable communities—those communities of color who always get left behind.

And Alonzo and Gail to your comments about George Floyd, and the racial protests, and the pandemic, these things are related. Alonzo, as you said, we have seen Black men be killed at the hands of police on video many times before. But, before as a nation, we were not all home, forced to watch this video over, and over, and over again, because we were deep into a pandemic. Watching that video when people were already primed with fear for their own safety, for fear for the safety and health of their families, when it was a galvanizing moment, and so important to all 3 commissions. And I will say it remains important, for the impact of all 3 commissions, to keep pedal to the metal.

Because again, taking my commission hat off my hat here, as an Afro-Latina woman, I had hope, and yet I understood that the window for real transformative change on the racial equity and eliminating racism would be small and closing fast. It is closing faster than I think any of us had imagined… I am happy to be part of this panel, and to be part of this commission that centers equity. Because intentionality, as you said, Karen, is key. And we must be intentional before our attention gets distracted by any number of things.

The report also talked about things that the administration could do. For example, if Congress takes its time, or does not appoint an undersecretary of health and human services, the administration certainly has the authority to be able to vest the assistant secretary of health with more authority, more oversight responsibility. That is something they could do right now without having to wait for congressional action. The commission talked about things that are longer term, but also things that we can do right now to begin this transformation.

The commission built on work that had been done around foundational capabilities of public health, thinking about accreditation. We were not reinventing the wheel. We were standing on the shoulders of much work that is already there, and stepping on those steps. To advance transformation is I think the core of some of the recommendations in the Commonwealth Commission report.

Dr. Desalvo: Thank you so much. One of the things many people do not know about public health in America is that it is a Byzantine patchwork of federal, state, local, tribal, and territorial health departments, that there is not line authority. So, to your point, there is not a theory of change, or a plan of action, or even directionality, including in moments of crisis. I think one of the things that the Commonwealth Fund report brings to the table so well is clarity on the challenge of the lack of federal authorities in the space.

Yet, as you described so well, there are actions that can be taken in the absence of any constitutional or federal change, and it will give people on the front lines more clarity, including the population, but also public health leaders. Which I think, Brian, brings me to you and the work that you all did with the Bipartisan Policy Center. Please, give some more context, and share high-level recommendations.

Dr. Castrucci: We brought together multiple funders from the health funding community—the Kresge Foundation, the CDC Foundation, the Sunflower Foundation, Pew Charitable Trusts, de Beaumont, and our partners at the Big Cities Health Coalition. We were all tired of the growing gap between what we know we should do and what we actually do. We are aligned—all of our reports, all of those on this call—in where we need to go, the world we want to have, the equitable communities we want to see. The challenge is that the thousands of health departments that are out there are all at different starting points and have different contexts in which they have to work.

Yet we have this historic opportunity to invest in a new and transformative, modern, governmental public health system. We have long complained that we are understaffed and underfunded. That concern is, for now, gone. We are funded in a way that we never have been before in public health. But that does not mean that money alone will fix everything. The Beatles told us that money cannot buy you love, and it certainly cannot fix the health system alone. We need a set of recommendations that are practical, prioritized, and bipartisan that we can give to policymakers and public health officials to guide the strategic investments and decision making that we need to achieve the equitable communities and health that we want.

In not making these necessary movements, we are gambling with our entire nation's safety, security, and economic prosperity. There is not much else that we can put on the line—a million American lives lost, countless businesses lost, the disruption of our schools and communities.

Public Health Forward sought to meet each of our state and local health departments where they are, giving them the practical steps that they must consider, whether it is financing, data, workforce, laws and governance, partnerships, or community engagement. There are any number of things we can do. We must begin to make appreciable steps forward. The challenge is taking on the whole public health system, that Byzantine patchwork. Trying to take a patchwork quilt and turn it into a cashmere blanket is really hard. But let us work on each patch, on 1 step forward, whether it is financing, whether it is health equity, whether it is achieving a diverse workforce, or engaging the community in a way that they have never been engaged before.

We have one shot at this. This is our time at the plate. What Public Health Forward was trying to do was give the batter all the tips—do not hit this pitch, really focus on that pitch—so that hopefully we can get a single and keep at bat going forward. Because this cannot be a 5-year celebration of public health, only to end. It must be a way that we change how we fundamentally think about public health. Health, to me, is like the foundation of your house. If it is cracked, everything else is in jeopardy. We need to stop debating what color to paint the walls and how to hang the drapes, and fix the actual foundation of our society, because there is nothing you can do if you are not healthy.

To continue to perpetuate a society that is founded on racism and white supremacy, and having decades, if not centuries, of racist state, and local and federal policy dictating our health, we must challenge that narrative.

We must understand that only policy can fix what policy has broken, and the unique role of our public health infrastructure in making these changes. That is how we will have the strong nation that we want, that is continuing the greatness of our country and repairing the harms of our past.

Dr. Desalvo: I love the call to reality about accountability that you are talking about, Brian. And I think it is thematic in all these reports, that it is not enough to describe the problem, but people have to own some actions. We need to work with the resources in some cases, like for the governmental public health, more than they have had in the past.

I want to get you to think about 1 or 2 top-level recommendations. If you could pick the one thing that you think should happen, that could happen in the next 6 to 12 months that is part of the report recommendations.

Dr. Christopher: It is thematic, because it comes through all of the different tiers of the recommendations. But it has to do with community. Who is the “we,” right? I loved hearing my colleagues talk about the opportunity we face, and what we need to do. But I kept thinking, and who is the “we”? I think the listening aspect, the engagement of community, the respect for tribal sovereignty and tribal ownership, if there is a theme that runs through this work—and this was a function of the diversity of the participants in the commission—it really has to do with enhancing our capacity for authentic engagement with those who are most dramatically affected by the decisions that were and were not made.

So, specific recommendations leading to the engagement of community members, giving them voice, making sure, or listening to the voices that they already have, and engaging stakeholders—multiple stakeholders—in this process of finding out where are the locks into which we can put the keys that will open up the doors to achieving real equity.

We were fortunate to deliver our preliminary report in draft to the Biden administration. There are many things that are happening right now at the federal level that reflect some of the recommendations that we made. For example, we suggested that every federal agency assess what role it could play in helping to leverage more equitable outcomes for diverse communities.

Housing, for instance, was a critical factor in vulnerability during the pandemic, particularly in communities of color. Housing continues to be a major factor that influences most aspects of the social determinants of health. Therefore, a priority is making sure that there is a new course being chartered for creating equitable housing policies in our country. This process requires listening to those who are homeless and to people who do not have access to affordable or fair housing. I would say the big takeaway that runs throughout all tiers of our commission's recommendations is the primacy of intentional community engagement and accountability.

We have worked and spoken with people in the Biden administration. We have interacted with folks at the Centers for Disease Control. Our conversations have really focused on determining how we shift—again, defining the we, and making sure that the we is expansive enough to allow for true community ownership as well as engagement. I always defer to Alonzo for other examples because I know that the foundation is actually funding projects that enable us to actualize, or enable communities to begin to actualize these recommendations.

Dr. Desalvo: Alonzo, could you give an example of some of the community funding that you all have done?

Dr. Plough: Well, one of our partners is on this panel. In order to generate some of the action related to what Gail just said, we learned that modernization is not just better connectivity of the existing data we have. It is different data that better addresses the social determinants mandate, the health equity, the cross-sectional data that we need.. It is a whole re-envisioning of what is a public health data system, and how dependent that is on other data sources. Ones that can only actually be meaningful aggregated at a local level. All of us who were local health practitioners understand that those collaborations happen when that collaboration is meaningful to you in the place where you live, your population lives. It is hard to do that nationally. One of the largest and first out-of-the-gate projects was a collaboration between de Beaumont and the Foundation to figure out what it means to have community meaningful, better local, less time-lagged data that address all the equitability issues that Gail just raised, and that can help transform the way local public health departments think about their role with community and with data. I hear, Brian, that you are down to 15 finalists or so, and vetting them, and soon there will be five places in the nation to really understand what it means to have a set of anti-racist data available for action in those communities.

Dr. Castrucci: It was so exciting to have this opportunity to work with RWJF on our new project, Modernizing Anti-racist Data Ecosystems for Health Justice. Because I am one of those folks who practiced at a local level, and realize that from a data standpoint, if we treated patients in health care the way that we treat our communities, we would all be arrested for malpractice. As a local public health practitioner, you do not have your own data. Could you imagine getting public health data in a clinical setting—well, here are the data from a whole lot of people who are not you from 3 years ago?

When I am sick, I get my own data right then and there to help inform my decision making. And yet public health did not have that real-time information during the COVID-19 pandemic. We are excited to break down the silos of epidemiology and vital statistics.

I know when I Google a pair of shoes, 5 weeks later, I get advertisements for shoes. So, it is not a technology problem. The technology is not what is in our way. It is our people. It is our beliefs. It is our political will to liberate and democratize these data to inform the people who are closest to the problem. But if we keep data behind walls and away from the people who need it most to make decisions, we will perpetuate the same problems we have seen in the past. This is an exciting opportunity, and it is led by some amazing people. Jamila Porter from our team is the principal investigator on the project.

They are doing amazing work to set up 5 communities that will have an opportunity to do something we have not seen in the past. It is bringing reality to the democratizing data movement. I have learned a lot from listening to Abigail Echo-Hawk and her thoughts. If we can proliferate those ideas into a world where people are making decisions with the data they need—not just the data they have, which are often insufficient, but all of the data that they need—we will achieve a healthier America.

Dr. Desalvo: Brian, can I just very quickly, before I turn to Herminia, ask you, is there a couple of things that you would want to say about the workforce recommendations you all have in the report, given how much work de Beaumont has done on workforce in the past? You cannot just have data. There actually need to be humans that can work with data.

Dr. Castrucci: Absolutely. I think, when I look at the report, we stand on your shoulders with Public Health 3.0. Because Public Health 3.0 identified partnership as a major part of the public health system moving forward. You once said you can get a long way with a nickel and some friends. We have the nickel now. I do not know that we have the friends. We have practiced public health all too often as an individual sport, and we have neglected our team members. I think most critical is rebuilding those partnerships and defining community engagement.

This is one of the things we like to say in public health. We need to engage the community. What does that mean? Does that mean a meeting at 3 o'clock with no childcare that we ask people to show up to for free? Or does it mean changing job specifications so that we are reflecting lived experience, that you do not need a master's degree for every public health job? We now need to prioritize rebuilding partnerships and defining community engagement. And the report speaks of that.

It is going to be critical, because one of our challenges in COVID-19 was you had public health leaders meeting business leaders for the very first time, and as part of that meeting saying, by the way, we are closing all the businesses in the county. That is a bad first date. No one is swiping right on you after that. We must make public health much more enticing, and understandable, and accessible to the people we are impacting. We can never be in a situation again where people feel that public health was doing things to them without them.

Even though they were the right things, I do not know that we had enough credibility in our community and in our business community to have people accept the policy decisions that were critical to achieving our health. So, building partnerships and engaging the community in a real and authentic way. If we did that, even if we do not have the nickel, we still have our friends. And you can get a lot done with those relationships.

Dr. Desalvo: I want to ask you all to weigh in on the fact that trust is a critical underpinning of any relationship or any work. In technology, we say data move at the speed of trust, but everything does. There are a lot of headlines about how public health is not trusted or believed in by the population. But I think at the local level maybe that is not always the case. So, there is a little myth-busting I am going to ask you to do about what does the data tell us about whether public health is trusted.

But more broadly, I wonder whether you all could talk about recommendations you had and how your deliberations thought about the importance of trust with community, with the business sector, with others, as just as relevant as the workforce, the money, and the data for doing the work of public health. Gail, are you going to start?

Dr. Christopher: I do know that Brian's organization has issued a polling report that does help to burst that myth that there is no trust in the public health system. I believe the figure you quoted, Brian, was that 90% of those who responded do have trust in the public health system at this moment. And I think we all know that is a time-sensitive or temporal issue. That same question was asked at the height of the pandemic, and due to the politicalization and the polarization, there were not such levels of positive response. But our commission's report, again, really emphasizes the listening aspect.

Trust is not built on giving orders, and dictating, and showing up to hold people accountable for having done something wrong. Trust is built through long-term repeated levels of engagement and deep listening, and also engaging representatives from multiple sectors, emphasizing that everyone has a role to play in building trust in public health.

I think that trust is critical. But let us be clear. If you are a person of color, you would be naive and probably a little stupid to trust most of the systems with which you have to deal, because the legacy of racism, and the legacy of devaluing human beings based on their physical characteristics are a defining feature of American culture.

I was so proud of the foundation for centering not just equity, but also structural racism. The commission acknowledged that we must address the legacy of structural racism, the present day reality of structural racism, and be up front about that intentionality. Having this explicit language, while making sure that you are calling people in, not just calling people out, but also calling people in to the collective work that must be done to create a society that values all people equally.

The commission was clear that the goal of overcoming structural racism will not be accomplished by intention alone, that we have to go back and redress the harms of the legacy of the past. The commission's recommendations emphasized the importance of approaching communities, and demonstrating authentic levels of honesty as requirements for trusted engagement. Leveraging this unique moment of opportunity to transform public health data systems requires that everyone acknowledges that inequitable levels of exposures, mortality, and morbidity outcomes revealed by COVID-19 embody long-standing structural racism and inequities.

Dr. Desalvo: That is such an incredibly important point—I want to underline it—that distrust in public health and in other institutions, including governmental institutions, was not new to COVID-19. It was amplified by COVID-19.

Dr. Plough: Absolutely.

Dr. Desalvo: So there is deep work to do that is generational. Alonzo, do you want to contribute?

Dr. Plough: We had trust-building challenges throughout all my experience in local public health. Trust was always something that had to be built, sustained, and, with any actions that were not as thoughtful or engaged as they should be, the trust could be quickly eroded. We all know that from our practice.

So, as we think about how we rebuild trust in public health, we were far from having solved that, but we were not as bad as we have been left with the collateral damage from the politicizing of just traditional public health things, like vaccination and masking, where you become a villain. I never did a tabletop exercise in pandemic planning where that was one of the scenarios.

Herminia, can I get you to weigh in? As we are thinking about modernization and data systems, we often talk about the integrity of the data. One of the things that the Commonwealth Commission did, which I am particularly proud of, is it really talked about integrity in all of its facets. We often think about integrity of the data in terms of the methodological approach, and was it quote-unquote “scientifically sound.” Well, I submit Tuskegee was scientifically sound—it was just wildly unethical. So, unless we put ethics as a value, unless those 2 things are woven in hand-in-hand, we are certainly not going to encourage folks to have more trust.

And we may end up recapitulating the same errors of the past. So, I think that the Commonwealth Commission really talking about ethics as part of the framework, in terms of both the integrity of the data and an ethical approach to community engagement, again, these are difficult concepts. But I do think that holding those values dear and central as we start to think about how we move these recommendations into actual transformation, how we take the $1 billion in ARPA funding, and translate it in. Who gets to decide how that is spent? Who gets to decide what questions are important to ask? Who gets to decide what are the data that, as Brian said, that communities need? I think thinking about the ethics and ethical frameworks is critically important.

Dr. Desalvo: I think that is so well said. And you are reminding me of something about all these reports, that I think it has to do with power. Everything we are talking about—money, data, control—these are power issues. I think trust is so related to this, that you need to trust those who hold the power, that are the gatekeepers, to have the intentionality of doing the right thing, and doing it with community—not to or for community. So, what you all are describing, even though they are actions in many ways, it is a change in a way that we want to work in and approach public health in the country.

I agree with your opening comments, Herminia. I am worried the window is closing. So, we must make sure this stays on people's radar. So, Brian, let me turn it to you and ask you about trust in public health, and what you all have learned and know, and how you think we should be thinking about this going forward.

Dr. Castrucci: Well, I think what we know is that most people really value health departments and see them as essential to community health, and that 61% of Americans in our recent poll actually had a favorable view of their local health department. So, there is a very small, but very loud, minority of Americans who are suggesting that we should not trust our local health departments, or that vaccines do not work. And they get a lot of attention in the media.

But what we need to do is start going back and building trust 1 person at a time. I was disappointed as the pandemic's first wave came to a close, and I heard leaders in public health say, “Thank God I do not need to do the Instagram Lives anymore.” No, no. You must double down on the Instagram Lives. We are not partisan, but we are political. We need to build relationships, and run a campaign every day and be the person whom they know.

I always draw comparisons to health care. If I walked into a physician's office, and I never met them, and I do not think they have even seen my personal health history, and they say, “You need bypass surgery,” I am going to say, “Hold on, friend. Let me think about that.” I am not going to let you just cut me open and start messing around with my heart. I need to have a trusting relationship with you. This is something that is missing from our training in public health—how to build trust with communities and different stakeholders. How to develop that trust. How to make sure you are nurturing it, where I think in medicine, it is inherent in that patient–provider relationship. It needs to become equally inherent in the public health relationship with our communities in our jurisdictions.

We know we have heard that cliche that things move at the speed of trust. And right now, when someone stands up in front of you that you have never met, and you have never spoken to, or you have never heard from, and they are shutting down your community, or taking away an opportunity for you to go to a concert that you really loved, or meet with your relatives at a holiday, making those hard decisions will only be made at the speed of trust. That is something that we must hold extraordinarily dear in our modernized public health systems. Because I think Alonzo and Gail both pointed out that not only does the public health system need to change, but also the field on which we are playing has changed. Politicization has indelibly changed how public health will be practiced. Now we need to respond to that new reality.

Dr. Desalvo: Fantastic. I agree that there is a lot of iteration and learning to be done, but there is also action that can be taken to create a strong foundation and structure, and to give people the data insights, information to be able to know how we are doing, and where we are going. So, I really appreciate the report so much. For those who I was engaged in, it was a wonderful process of elimination and camaraderie during a really difficult time in history for public health. I do hope that people will continue to take heed of the actions. I agree, there has been a lot of good forward motion from the federal and local governments. But there is plenty more to be done, and I think a lot of trust to be built across communities.