The downtown Denver area is unique. Here there's just so much more to do. There's plenty of historic sites, brand new businesses, museums, and cultural events happening every month. Denver is an extremely active city. It's an excellent place to try just about anything. People have come down here both to live and to play. It's full of shops, restaurants. It's really made it an enjoyable place to hang out. The changes to the downtown area are amazing. From Larimer Square into 16th Street Mall. 16th Street Mall is a really diverse area. Each block is a little bit different and unique. I really enjoy the Denver Pavilions, which has an open-air concept that combines outdoorsy Colorado but also a very urban feel. There's the Hard Rock Cafe, Jazz at Jack's. You can also catch a film at the United Artists Theater. I stopped by the iHeart Denver store in the Denver Pavilions. You can find a real gambit, gift items, fine art pieces, prints, t-shirts, and jewelry. All made by local designers, artists, or creative-minded businesses. Denver has a public art ordinance that allocates 1% of any new capital improvement project to public art. So when you're walking around downtown, you will see a large piece or some sort of art installation in almost every building and plaza. 14th Street in the Convention Center area has been revitalized just recently. The Denver Performing Arts Complex is one of the largest in the country. It takes up four city blocks. You can catch the symphony, the opera, the ballet. It really runs the gamut of popular music to classical. Then you can go a little farther down and hit the MCA. They're just very unique, very innovative with their shows. One of the nicest features about Lodo is the scale. Downtown Denver in general is extremely walkable. If you look at where Coors Field is, even to the Pepsi Center. Lodo is also very bike-friendly. We had one of the first electronic bike share systems. B-cycle stations, you can get on one, you can use it all over town. The heart of the city really is downtown. You have lots of bars, dance clubs, to places with really great views like the View House and nice rooftop decks like the Tavern. Denver's just great for those chef-driven, owned restaurant concepts that you really could pick from about 20 or 30. We have about 92 beers on tap here at Falling Rock. If you're interested in craft beer, Denver is definitely the destination of the United States. Stoic and Genuine is my newest restaurant in Denver Union Station. I love the renovation inside the station itself. It's an incredible transformation of that historic building. They really took care to bring back that era of what it looked like as a train station. So all light rail, buses, and even Amtrak will be coming out of there. It's our pathway to DIA, which takes you to the world. Some of the great places downtown are these historic hotels. One is the Brown Palace. The other is the Oxford Hotel. Also in our neighborhood is the Tattered Cover, which is one of the most amazing bookstores. You just have that really fun boutique feel when you walk in. Just the volume that we have here that makes downtown Denver special. There's really a lot of activity for shopping, too. Larimer Square gives you that kind of feeling like Rockefeller Center might in New York. It's the only historic block that still has all the historic buildings. Larimer Square has some really fun little boutiques that I think you can get some unique gifts. I always take people to Rock Mount Ranch Wear. They're attributed with popularizing the snap front western shirt. From rock stars to ranchers, it's people who are looking for something quintessentially Colorado. If I had one word for downtown Denver, it would be exciting. Active. Historic but emerging. Be very funky. Be very artsy. It's kind of the heart of this city. It's also a melting pot of our Denver culture, so if you're coming down here, you're getting a real sense of Denver. It's just a constant stream of unexpected surprises here. Hello, and welcome to this plenary session entitled Public Health Resilience, Health Officials on the Front Lines. I'm Dr. Wendy Braund, the COVID-19 Response Director for the Pennsylvania Department of Health, former Wyoming State Health Officer, and a fellow of the American College of Preventive Medicine. We have a terrific lineup of current and former health officials, each of whom will be offering their perspective for five to seven minutes, and then we'll engage in a facilitated discussion. Before I introduce our speakers, I want to acknowledge the toll that this extended pandemic response has taken on health department personnel and leadership. A large number of state and local health officers have quit or been fired since last April. It's a difficult job, and I want to thank our panelists up front for sharing their perspectives. I will now introduce them in the order in which they will be speaking. Dr. LaQuandra Nesbitt is a board-certified family physician with over a decade of experience leading population health initiatives in governmental public health agencies. Dr. Nesbitt currently serves as the director of the District of Columbia Department of Health in Washington, D.C., a position she has held since January 2015. As a physician leader, Dr. Nesbitt mobilizes organizations and communities to implement innovative solutions that promote health and wellness and achieve health equity. Throughout her career, she has led multi-sector collaborations to address innovations in healthcare delivery and its impact on high cost, high need, and other special populations, the integration of public health and healthcare, and the impact of medical marijuana and decriminalization of medical marijuana on the public's health. Prior to her role in D.C., Dr. Nesbitt served as the director of the Louisville Metro Department of Public Health and Wellness. Dr. Nesbitt received her Bachelor of Science degree in biochemistry from the University of Michigan, her medical degree from Wayne State University School of Medicine, and a Master of Public Health in Healthcare Management and Policy from the Harvard School of Public Health. She completed an internship in family medicine at the University Hospitals of Cleveland, East Western Reserve University, and completed the remainder of her family medicine residency in the University of Maryland's Department of Family Medicine, where she served as chief resident. Dr. Nesbitt completed her fellowship training with the Commonwealth Fund Harvard University Fellowship in Minority Health Policy. Dr. Wilma Wooten is the public health officer and director of public health services in the County of San Diego Health and Human Services Agency. She received both professional degrees from the University of North Carolina, Chapel Hill, followed by the completion of residency training at the Georgetown Providence Hospital Family Practice Residency Program in Washington, D.C. In 1989, she completed the joint San Diego State University Graduate School of Public Health, University of California, San Diego Preventive Medicine Residency, with an emphasis in sports medicine. Dr. Wooten practiced medicine as a faculty member in the UCSD Department of Family and Preventive Medicine from 1990 to 2001. She remains a UCSD volunteer associate clinical professor and is an adjunct professor at San Diego State University Graduate School of Public Health. She has been with the County of San Diego Health and Human Services Agency since 2001, initially as the deputy health officer, and now serving as the public health officer since February 2007. She has a strong interest in health disparities and health equity. Dr. Stephen Herring worked with the Virginia Department of Health from 2008 to 2021. He served as the director of the Lord Fairfax Health District for a year and a half, and then was appointed as the director of the Alexandria Health Department in August 2010. Dr. Herring earned his undergraduate degree cum laude from Duke University and his medical degree from the University of Louisville. He completed a family medicine internship at University of California Davis affiliated San Joaquin General Hospital in Stockton, California. Dr. Herring practiced clinical medicine for 12 years. He then earned his master of public health with a concentration in health and human rights from the Johns Hopkins Bloomberg School of Public Health, where he also completed training in the Hopkins Preventive Medicine Residency Program. He then served an additional year as the residency program chief resident. Dr. Herring is board certified in public health and general preventive medicine. He is an associate faculty member of the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, and he has been designated as a fellow of the American College of Preventive Medicine. Dr. Gianfranco Pizzino is a senior fellow at the Kansas Health Institute, where he focuses on the development and dissemination of best practices for the organization, including financing and delivery of public health services. He directs the Center for Sharing Public Health Services, a multi-year, multi-million dollar national initiative managed by the Kansas Health Institute and funded by the Robert Wood Johnson Foundation. Dr. Pizzino also served as the Shawnee County, Kansas health officer from 2006 to 2020. Prior to joining KHI, he most recently served as state epidemiologist and medical director for the bioterrorism program within the Kansas Department of Health and Environment. Dr. Pizzino earned a medical degree magna cum laude at the University of Bologna, Italy, and a master's degree in public health at the Johns Hopkins Bloomberg School of Public Health. He is a fellow of the American College of Preventive Medicine, is board certified in preventive medicine and public health, and a certified in evaluation practice from George Washington University. Dr. Nesbitt, I'll turn it over to you. Thank you so much, Wendy, and I want to thank the American College of Preventive Medicine for the opportunity to be with you all today, and with such an esteemed group, one of my regional colleagues, Dr. Herring, it's good to be here with you as well. This is a very critically important conversation, as Dr. Braun mentioned in her opening remarks, where our public health systems and our governmental public health agencies have been tasked to respond to the biggest threat to our health and well-being in nearly 100 years, and that responsibility has not been taken lightly by many of us in public health, at times making decisions that have been unpopular, despite our ability to be prepared for this response as much as one could be. I want to start today by first showing you all how we think here at DC Health in the nation's capital. We have five strategic priorities that guide our work, our work related to any health issue as well as to any health behavior, and our strategic priorities, if we focus on those as foundational components of our work, we're better prepared to address any health issue, whether it be a chronic health condition, an emerging infectious disease, or other emerging disease or behavioral risk. Our goal here is to really focus on health and wellness, so keeping people well to begin with. We recognize the impact that social determinants of health has on the health of our community. We aim to strengthen public and private partnerships. We do not believe that the government can achieve success alone, but we must do it with great partners. We endeavor to close this gap that has existed for quite some time between the practice of clinical medicine and public health practice. And we want to do all of this in a very data driven way. Now, the reason why I've decided to show these priorities in this brief talk today is because this foundation really prepared us for a successful response. Our ability to think broadly about connecting with health care providers who were on the front lines, especially in the very early part of the of the pandemic, being able to tell them what to look out for, but also their feedback loop back to us in public health, helping us to understand the magnitude of the situation we were dealing with. It's taken extraordinary collaboration between public and private entities here in the District of Columbia. The private sectors, I should call it tolerance of our public health mitigation strategies, have been quite rewarding here in our jurisdiction. And I recognize that some of my similarly situated colleagues have not had such the same experience. And our need to have data, data, data, data, data all the time. We were collecting data on not just case counts and the amount of disease in our community or how many tests were positive in our community, but really understanding which subpopulations were impacted so that we can appropriately allocate resources and interventions to the right groups. Very early in our response, Mayor Bowser convened our Emergency Operations Center. So if you can imagine that for about four or five months, every key decision maker in the city reported to work at the health department, including the mayor. She had an office across from mine. So we had a really integrated approach. But on the next slide, I want to show you how the health and medical branch of that emergency operations system or center was really structured. So we had a lot of things that we were responsible for in public health. We were the public health lead for the response. Our co-lead was our emergency management agency. But you can just see here that there are seven main areas where we created divisions within the health and medical branch for a huge focus. We needed to have a lot of data and surveillance to understand trends, as I mentioned before. We subscribed very early on to the Box It In strategy. So ramping up disease investigation and contact tracing, which resulted in the hiring of nearly 400 additional full-time staff. We published dozens, I think we may be in the hundreds now, of health guidance documents that are revised routinely as the science related to the pandemic evolved. And those guidance documents really were good companion tools to all of our risk communication strategy, letting people know what we knew and when we knew it and when we could expect to know more. And then we have all of these public assets that we've created that have always been core to public health, but they haven't been taken advantage of in the same way. So our ability to offer free testing seven days a week throughout the city has been remarkable. At one point, we boasted the highest testing rate per capita, and it is still ranked in the top 10. We've rolled out a vaccine program that now has over 100 sites within our 68 square miles. And the initial focus of the program was a pairing of both efficiency and equity, where we allocated 50% of our doses to our communities that were disproportionately impacted early in the response of the vaccine program's rollout back in January. And we've provided a substantial amount of technical assistance, really cementing our place in the community for the type of work that we have done. The next slide will just show you a synopsis of some of the things that I've highlighted in each one of those categories and the timeline by which it was done. In my last remaining time, I really want to emphasize that in my conversations with colleagues and my conversations with my public safety partners, first responders, about a month in, we realized that all of the continuity of operations plans and all hazards response plans that we have developed were not going to be something we could follow to a T or exactly. And we had to really rely on motivating all of our team members to think as leaders during this response, to become critical thinkers, to be able to imagine the road ahead. And this was no small task as we recognize that all of us have to some extent been impacted by COVID-19, whether it was the adjustment in our day-to-day lives. Some people working in public health have lost family members to COVID-19 or been impacted by it themselves. We've had team members who've succumbed. And so we rise up and we do this work, even as we have the same emotional stresses and toll as the rest of society. So it has not been a small undertaking. At times we are appreciated and at times we're criticized. The appreciation often comes in private and the criticism in public, but it's our commitment to serving the communities that we serve that keeps us going. And so, you know, I just want to really emphasize that this work has to be done intentionally with an infrastructure, but with the recognition that in a pandemic, you must be flexible and adaptable. And every leader is responsible for ensuring the emotional and mental health of its entire workforce during these trying times. So I look forward to the rest of the presentations and our robust discussion. Thank you. Okay. Do we have Dr. Wooten? Okay. Then let's move on to Dr. Herring. Hello. Thank you. And thanks, Dr. Nesbitt, for your words and your experience and really appreciate it. You know, I'm going to talk about several different things about how we helped to nourish resilience in Alexandria Health Department. And one of our biggest foci was our staff, the mental health of our staff in particular. And we accomplished that and we addressed that in a number of different ways. First of all, we really communicated a lot with staff and we asked them what they needed. Virginia Department of Health had moved to teleworking and there were a number of positions that quite frankly you can't telework in public health. We advocated and piloted some telehealth programs that had never been used in Virginia Department of Health and that helped to reduce stress of staff members that were able to do that. But that also had a ripple effect in that others who still had to come in knew that leadership was listening to staff. We also piloted an online mental health program in which people were, we actually paid for people to be able to access mental health services online. We essentially did everything that we could do and everybody eventually within about four to six weeks who wanted to telehealth or wanted to telework was able to telework. We emphasized the employee assistance programs and then we also told staff that we recognized that they are not just first responders in a public health emergency, they're first and continuous responders in public health emergencies. So really reiterated the necessity for them to take care of themselves, to take care of their families because like Dr. Nesbitt said, many of them were impacted directly. Family members hospitalized, we had staff member hospitalized, and this has had a tremendous emotional toll on our staff. The second thing in terms of people we really nourished our relationships with our partners. Whoever called that was already a partner or a new partner, we gave them basically concierge service. We would talk to them about personal concerns and issues and we got back to them quickly. It was very time-consuming to do this but it engendered a tremendous amount of trust and I believe that helped us longitudinally. When folks came up to us with ideas, many of the ideas we had challenges with. So early on, I would say in March, we extended beyond our strategic plan and similar to what Dr. Nesbitt was talking about, being able to use a North Star, being able to use the principles that you are guiding your organization. We actually developed new public health justice principles to help us address our response. Those public health justice principles were threefold. The first was to focus resources on saving lives. The second was to use science-based recommendations. The third was to engage and empower our vulnerable populations. That did a number of different things. It provided stability for the leadership and for the city during a rapidly changing environment. It also demonstrated that public health was very thoughtful and that we had direction and it gave us a lot of security, both the staff as well as the leadership. Importantly, we published this early on as well as a number of strategic action frameworks that centered around communications, vaccines, long-term care facilities, vulnerable population, houses of worship. Another thing that we did that really helped us in terms of resilience was early on we instituted our incident command system in early February 2020 and that consisted initially of daily meetings and that went to twice daily meetings and this was always integrated with the city of Alexandria emergency operations center which also had daily meetings as well as the emergency operations center of Virginia Department of Health and eventually the Commonwealth of Virginia. This actually helped people to understand that, okay, your normal supervisor is not going to be your supervisor during this incident. Your normal roles and responsibilities are going to be different during this incident and that gave stability to staff to know, okay, even though things are rapidly changing there are things that I'm going to do. Very importantly, another stress reducer, another resilient builder, is that we allowed a lot of innovation. The concept that I talked about before, the online mental health services and the telehealth, those were not leadership's ideas but we took them and we pushed for them and were able to implement them. Another one that we were able to use was an award-winning program that was called ALX promise in which our environmental health services program worked with businesses to give them an award, give them a decal that indicated that they were in compliance and plus beyond compliance with the executive orders. So that way it would give their patrons assurance that when they went to those businesses that they were going to be as safe as possible. So that idea of really listening to our staff and listening to our community was very helpful. Of course, constant communications was absolutely essential, both internal with our partners, with the public, with Virginia Department of Health, and that consisted of meetings and emails, daily e-newses, and of course phone calls every single day with every Northern Virginia health director, seven days a week for the first six months and then five days a week after that. And then finally, I think that the last thing, and I think it's one of the first things that frequently is to go, is to really nourish and look at what it is that helps one's spiritual, psychological, emotional support. The healthy habits of eating healthy, of sleeping, and I know we're not on the lifestyle track right now, but really refocusing on those sorts of things. And we emphasize this with staff and recommended staff to double down on those things, whether it's praying or journaling or reading or meditating, really to do anything that it takes. And I'm really directing this to perhaps our newer members of ACPM, doing anything that it takes to help nurture your compassion, your patience, your internal vitality during these times of stress are absolutely essential. So those are the really big components that we used at the Alexandria Health Department, and they're still using those that are there still. So thank you. Great, thank you Dr. Herring. I see that Dr. Wooten has joined us, so I will turn it over to you. Thank you, and good morning or good afternoon wherever you are. We unfortunately had some technical difficulties but persisted and prevailed and we're on, so thank you. So going to the next slide, I just want to share with you some of the approaches that help us to respond to the emergency or to the pandemic. And out of the gate, the Incident Command System, I echo that we utilized that when we responded to Hepatitis A about three years ago and found that to be very valuable. So under our Emergency Operation Center, we also have a Medical Operation Center, which was born out of our response to fires in 2003. So that group is almost like a mini EOC but responds to the medical community and provides any needs that are specified from whether it's our clinics, our hospitals, or our SNFs or long-term care facilities. And then because obviously early on we didn't have vaccines or any treatments, we focused on containment and mitigation, primarily with the non-pharmaceutical interventions as most jurisdictions did across the nation. We also leveraged our sector partnerships, and I'll talk about that in a few minutes, as well as focused on three strategies throughout the pandemic, our testing, tracing, and treatment, health equity, and then vaccines. Going to the next slide, this is just an overall view of the adaptive response that we utilized early on, managing or focusing on disease control, and then those non-pharmaceutical interventions. And we issued orders very early on in March about stay-at-home utilizing masks. And then we will talk more about vaccinations that were available in December. So going to the next slide, Live Well San Diego really is a region-wide vision that we have to build better health, create policies and systems for our regional residents to live safely and thrive. And if we go to the next slide, one of the primary components of Live Well San Diego is partnerships. And we have 502 partnerships as of the end of April that we leveraged. And if we go to the next slide, those four primary partnerships are businesses, community-based and faith-based organizations, governments, and then education. And these four original Live Well San Diego sectors were parlayed into 10 community sectors with 13 subsectors. And going to the next slide, these are the various locations, what we call our vaccination ecosystems. And this is probably the approach that we will focus on in the time remaining. But we have vaccination sites all across the county and more recently at its schools. If you go to the next slide, this shows that we have five superstations, 45 county and partner vaccination sites. There are 287 pharmacies and now 173 provider locations. So this is the map that shows the various vaccination sites throughout the county of San Diego. Moving to the next slide. Vaccinations, I want to give kudos not only to our staff, but our community partners. We could not have been able to vaccinate the individuals that we have vaccinated without the efforts of those individuals. So our eligible population is now with 12 to 15-year-olds added. We have about 2.8 million residents 12 years of age and older. 75% of that population would be just over 2.1. And in the next slide, I just want to share what our results are. And almost 86% of the residents of the eligible population or goal population, 85.6% of that population has been vaccinated with at least one dose. And then almost 65% have been fully vaccinated. And we feel this is a great accomplishment. San Diego actually has the highest vaccination rate in Southern California. Now, testing was very important as well as health equity and the state identified census tracts throughout the state and the county focused in those census tracts and the zip codes that those census tracts comprise various zip codes. So we have about 39 zip codes that we primarily focused to get them vaccinated, particularly Latinx population, as well as African-Americans and our Asian population, and then the Native American and Alaskan Native population. So we are very proud of the results that we've achieved there. And testing also, if we go to the next slide, this is our campaign, Be COVID Safe. And these are the strategies that we've promoted to help keep our residents safe. And obviously the first three non-pharmaceutical interventions, washing your hands, watching your distance and wearing your masks. Your mask, these are the three W's of CDC. And if anyone gets sick, whether they've been vaccinated or not, they should isolate themselves and get tested. And now that 12 years of age, individuals 12 years of age and older can be vaccinated. We are encouraging all of those individuals to be vaccinated. And we are partnering with anyone that will partner with us to get the word out and to get vaccinated. We actually did have contracts with community-based organizations to do outreach and education. So those are just some of our strategies and happy to answer questions later. Thank you. Excellent. Thank you so much, Dr. Wooten. And finally, Dr. Pezzino. Thank you. Good afternoon, everyone. I'm Gianfranco Pezzino and I'm an epidemiologist by training. And for 14 years between 2006 and last December, 2020, I was also the local health officer for Shawnee County in Kansas, where the capital Topeka is located. So what I want to share in the next few minutes is what I've learned from those tumultuous months when I was one of the leaders in charge to guide the response to a pandemic in a mid-sized jurisdiction like our county with about 130,000 people. So when the first pandemic started, I'm sure I'm not the only one who received or heard that comment made many times, especially by policymakers, who could have known? There was no way to know this. Who could have imagined that something of this magnitude would happen? And I think most people around this virtual table today will agree that a lot of people should have known because the people who are listening to public health officials would have heard for decades the comment that we are past due for a pandemic. And unfortunately, not many people were paying attention and our predictions went unheard. But I remember the very early days of the pandemic when the first news from Wuhan were coming. I remember one morning at breakfast, sitting at the breakfast table with my wife and shaking my head and saying, this is it. This is the big one. This is going to change the world as we know it. We are going to have a global slowdown and recession that is going to be thousands of people. Even my wife was a very bright family physician, had a hard time believing me. And unfortunately, we were right. So the first lesson that I learned from this is that maybe we need to do a better job at communicating with policymakers before the pandemic strikes, before the emergency strikes, and build our credibility. Maybe this particular example of the coronavirus can help us build the credibility that we should have. The second point I want to make is about data. And I, again, I was working and I live in a mid-sized jurisdiction in the Midwest, and I can tell you we had absolutely no data at the beginning, nothing. The only thing we had for the first several weeks, months, really, was counting the cases that were reported to us every day. That's it. We barely knew the age of these people. There was no analysis, no breakdown, nothing. And we were totally overwhelmed, of course. So we did use the little data that we had to make decisions and to explain and justify to the public our decisions, but it was definitely very limited and not sufficient. When we were able to follow our data, especially later on in the pandemic when data became more available, our actions were much stronger and much more targeted than before. And I will give you a quick example. We were the first county in September, the first county in Kansas, that relaxed the requirements for quarantine among students in elementary and middle schools because we observed from the data that there was virtually no transmission in the school environment in which a student was involved. So we relaxed those requirements. We would not have been able to do that without data. And by doing that, we allowed dozens and dozens of students to not lose any more education time than they already did. So lesson learned for me is let's pay attention to the data and resources that are necessary to have local actionable data early on. The next point I want to make is the big shift in attitude and behavior that happened at some point during the pandemic among policymakers and their constituents. I think what happened in the beginning is that everybody was so stunned by what was happening, that at least here, anything would go, essentially. And, you know, any kind of measure or recommendation that we weren't making, as long as we had some reasonable justification, there was really no pushback to speak of. That did not last for very long. And around June, elected officials here at the local level were given authority to overrule the decisions of a county health officer. So at that point, even though they, probably many of them had not asked, did not want that authority, they started to use it because now they had it. And they started overruling the decisions of the local health officers. Now these are, in general, are three county commissioners elected at large. And in many cases, they are retirees with certainly no training in public health and very little understanding of how data and evidence could guide and should guide policymaking. The data that these local policymakers use are the stories from some of their constituents. So they are stories, they are totally anecdotal, and they are from some of their constituents, those who scream the loudest. And so it was puzzling for me to witness this disconnect between hour-long meetings of the county commissions where angry constituents would show up advocating for no containment measures whatsoever against the virus. And on the other hand, my knowledge, and there were many other people that were supporting us. When I resigned finally in December, I put my letter of resignation on Facebook and that was shared about a thousand times. And I received about 300 and something positive comments. I'm not a big star on Facebook, but those thousand people were not the people who are coming at those meetings to talk and support us, to talk in our favor. So we must find the balance between accountability of elected officials and the ability of those trained professionals to make decisions. And the final point I want to make real quick is that, you know, I'm asked sometimes, what would you do different? And what I would do different probably in hindsight is pay more attention to communications. And that builds up a little bit on the points I've just made. We were too busy. I was too busy at least to pay attention to the reaction from the community and the leaders, but we should have paid more attention. And we need to build skills like community behavioral science, social psychology, not just to react to what people do and think and how they behave, but to anticipate how they will react and behave to our decisions. And that's, we did that, but it was a little bit too late and it's something that I wish I could do better next time. Thank you. Wow. Thank you all for offering your perspectives, sorry, there was a little echo there. And wow, there's just so much rich topic to cover. So I will kick it off with the first question and I would invite you all to offer comments and then also feel free to respond to each other's comments as well. So while nationally, the pandemic seems to be moving in the right direction, we're not done with COVID-19. What advice do you have for health officials regarding staying the course and guiding us through to a successful resolution? Anybody want to jump in there? Yeah, I'll start. Oh, okay. Can you hear me? Yes. Yes. So yeah, Wilma Wooten, Health Officer for San Diego County. Staying the course is one of my favorite statements and that is a life value, it's not an option. So partnering with community partners to implement strategies that are applicable to your region. I know many times when there are federal guidelines that are issued, we definitely want to align with them, but you also have to look at the stats for your local jurisdiction. For instance, San Diego with California using the tiered system, we are in what's called orange, which is moderate transmission. While there are some other counties, particularly like Los Angeles and Orange counties that are in yellow, which is minimal, but we are still in moderate transmission, getting anywhere between 100 and 200 cases a day with only rare, like yesterday where we had 47 cases. So that was a one-off, we are continuing to monitor that. And talking about data, we put a lot of data out into the community, but even with that, people still want more. So that's the way that we are staying the course, aligning with basically the science to make sure that we are implementing the right strategies for our region. So I'll add a bit to Dr. Wooten's commentary is that, you know, as public health officials, we have committed ourselves to leading in a science-driven way during this pandemic. And we should be clear that as the science evolves, as we have new information, the things that we recommend will evolve. And there are still some unknowns in this environment that we need to be very transparent about. One of the spaces that I believe we're navigating right now is moving from public health, creating a restrictive environment for people to control the pandemic, to now moving into a space where we're creating a permissive environment, especially for those who are fully vaccinated and have lower risk to their own health and potentially the risk of spreading the virus to others. And that can be a difficult space to navigate. Some of the reactions that we're seeing from individuals and businesses and organizations and some politicians as a result of policy decisions and recommendations made at the federal level or policies implemented at the state and local level is really a need to recognize the possibly psychological challenge we have as a nation of shifting from a restrictive way of containing the virus into creating more permission in our society while doing all we can to contain small outbreaks. If you think about all of the curves we see for outbreaks, there's an acceleration phase, there's a deceleration phase, and the long end of that deceleration phase suggests that we will have outbreaks here and there, but do we have the capacity to quickly contain them? Have we learned enough in the acceleration phase and the longer deceleration phase or the faster deceleration phase to inform how we're going to pounce on these outbreaks? And I think that's the kind of narrative that we've got to make sure people understand. The science of what we're dealing with with SARS-CoV-2 is new and evolving, but the way we manage pandemics in terms of the tools we have available is not that different. If I can add on to Dr. Wooten and Dr. Nesbitt, I think part of it is stay the course and part of that is really to think about, I'm going to get back to nourishing our staff. And because at the Alexandria Health Department with approximately 85 full-time staff, there were about a dozen to 15 people that had absolutely no time off, zero leave for more than 15 months. And these were people that were working six to six and a half days a week, 12 to 14 hours a day. I want to talk about staying the course. First of all, take care of those people, and secondly, we need to improve the course. China 100 years ago had an outbreak and they were shamed globally, and as a result, they actually boosted their public health infrastructure. When I look at the tragedy of 9-11 and somewhat over 5,000 people dying, absolutely tragic, and the response to that in terms of the increased funding for security infrastructure, and then start to compare that now to 500,000 people dying in the U.S. alone, over 500,000 people dying, and what is society's response to that to increase public health infrastructure? And this is one of the things I'm planning to look at over the next six months is really figuring out what should a local public health department look like? Because like Dr. Pacino was saying before, we knew this was coming. It's not going to be 100 years for another one to come. We've had Ebola, we've had Zika. Every couple of years, we have a major issue, and quite frankly, we're still underprepared, we're still under-infrastructured, and that needs to change. We need to be able to articulate that to policymakers, to society. I agree with everything that's been said. Let me just add one word of caution to that. Recently, I read somewhere, you probably are familiar with this quote. If you are a leader, but nobody's following you, you're just walking, you're not leading. And so one little piece of advice that I would add to everything else that's been said here, not instead of, but make sure that you're really leading. Make sure that people are with you. Keep the pulse of the situation. If you're just trying to stay the course because your data say that that's the right thing to do, but nobody's behind you, or too few people are behind you, that's not going to help your community. That's terrific, all of your responses. And I think, you know, building on that, you know, we are all well aware that the Biden administration has announced unprecedented investments in public health infrastructure. So what are some of the key areas or skill sets in need of investment to ensure that we are better prepared to respond to public health issues in the future? You know, this is an excellent question, Dr. Braun, and we will be publishing sometime in the next week our post-pandemic recovery report that has a framework in terms of what we need to do or what we need to have in our public health and health care ecosystem to improve the health of our population on the other side of this pandemic. And one of our core areas is workforce. So we have all these conversations, you know, about we need more school nurses to be able to do X, Y, Z in schools so schools can reopen in the fall. But it makes us miss the opportunity to recognize where we still need to make investments in health planners and health emergency professionals who have that combination of experience with working in emergency management, but understand the unique aspects of public health emergencies where the science is often evolving. You know, during any emergency, the information is evolving. But in a public health emergency, the science is what is often evolving. And I also believe that, you know, on a broader scale, we really need to bolster our data staff, our staff who have the ability to do data analysis in large volumes of data so that we have access to timely and accurate information. We've been very focused on it now in building that infrastructure for the emerging infectious disease. But could you imagine how much better prepared we would be if we had that kind of data for health broadly? Right. So we know that there are always going to be people with access and functional needs in our community. There are going to be people who may have a chronic condition that puts them at higher risk. How we have access to that information and have a better real time picture is going to be critically important. And then the last thing I'll say is that we really need a new cadre of public health leaders from a diverse background. We've got lots of physician executives, and I think that's absolutely a good investment and the right thing we need to do. We need nurse leaders. We need dentistry leaders. We need veterinarian leaders. I mean, we really need people who understand the One Health concept to be in these positions of leadership and able to remain connected to our communities. And so while we're creating diversity in terms of background and skill set, we need to be sure to ensure racial and ethnic diversity in our workforce moving forward as well. I agree with those comments. In San Diego, we have this, we call it the 3S, structure, staff and stuff. So when we talk about infrastructure, those are the three components. And for structure, I think what has been helpful for us is our partnership with our academic institutions to do whole genome sequencing. But we have the internal capacity to do that as well. But we need to increase that capacity. So that's one element. And staff, we contracted with organizations to utilize promotores or community health or outreach workers to go out into the community to help with those individuals that could not be reached through our case investigators or contact tracers, and then also to conduct outreach in the communities to get those individuals that are homebound or not IT savvy to sign them up for slots that were made available for vaccinations. And actually, even before the pandemic, in our five year forecasting for our workforce, we recommended that we create a new classification called Community Outreach Worker so we can do more of these efforts. And then the stuff is IT systems, improving those IT systems. We have a local immunization registry, which actually has served us well. And we are evaluating going forward. Are we going to join the state's registry or continue with our own self-developed registry, locally developed registry? And then data analysis and evaluation, I think, is very important. We have a lot of data. We distribute a lot of, we have portals and reports. But at the end of the day, analyzing really a deep dive analysis and evaluation of the data to help drive future policies, I think, will be important as well. Thank you. Dr. Wooten, I like your three yeses. I would add an additional one under staff and staff would be everything that it takes, all the administrative people that it takes to run a health department. Because as we were bringing new people on our case investigations, contact tracers, the thing that we found was that we actually lacked people that could onboard them, that could do the background investigation, get them IT set up, train them. And basically our infrastructure is stretched on a good day just because people are on vacation or they have unanticipated leave needs. And so even on a good day, we're stretched. So what we need is more of everything across the board, whether we talk about communications, outreach workers, planners, everything is needed and more of them. Then the other aspect, Dr. Braun, to talk about where this should go, and I know that the Biden administration is already directing it, we're always going to have people with access and functional needs, for sure, that will make them vulnerable or have certain chronic medical conditions. But those upstream environmental factors, jobs and housing that make a population, make individuals, make families vulnerable, they need to be addressed vigorously in order for us to have a healthy country. Yeah, you know, I don't have much to add, the good thing of being the last speaker is that everything important has been said already, so, but maybe let me just inject an additional element here, and that is that it's great that we are going to have hopefully some resources finally to rebuild the public health infrastructure. I think we should take this opportunity to think and reflect on what kind of public health system we want to rebuild. And I think it would be a terrible mistake to just throw hundreds of millions of billions, possibly of dollars, to a system that's broken. And I think I'm very proud of what we did in responding to this pandemic. But let's face it, we did within a system that's very deficient in many aspects. One element of the deficiency is its fragmentation. There is a vertical fragmentation, the roles between the federal, the state and the locals are not always well defined, and nor are there always good processes in place to make those levels work. And there is horizontal fragmentation. There are about 3,000 local departments who all deliver public health systems, mostly in isolation from each other. And that's not the most efficient way to do it. So let's make sure that we take this opportunity, which is probably one in a generation, to build something new and not just go back to work to do more of the same that may not work well. Wow, terrific comments by all of you. And I'm just I, for one, I'm really sad that we're almost at the end of our time. And I'm just really sad that we're almost at the end of our time. We need to attract people to governmental public health. We know the workforce has been shrinking and aging out. So if you could all offer some final thoughts, what advice would you give to preventive medicine residents who may not be able to go back to work? And what advice would you give to people who may not be able to go back to work? And what advice would you give to people who may not be able to go back to work? What advice would you give to preventive medicine residents, medical students, or others interested in a career in governmental public health? Well, in San Diego, we have a large cadre of volunteers, which is how we enroll graduate students, residents, and even undergraduate students to create that pipeline into public health. So I would encourage anyone who's near a health department, call the health officer or anyone that you might know to find out how you can participate in an elective in your local health department. The experience will be invaluable. You know, this is, I think, one of the public service jobs that has the opportunity to be extremely rewarding. You have a huge number of partners that are helping you lift so that the lift is lighter. You know, many hands make for light lifting. And so it's one of the things that someone in medicine who wants to transition to public health will be able to do and be able to see the impact of their work on a societal level. Some things move really fast and you see impact very quickly. Some things move a little bit slower and you have to hang in there to be able to see the tide turn. I would be remiss if I didn't mention that I know some people shy away from government roles in general because of compensation. But what we're seeing now with the pandemic and the need to recruit people is that compensation is going to become more competitive with what's happening in the private sector. So really have discussions with people, ask very candid questions, and get all the information you need, you can, to make an informed decision. All right. Can you hear me? Do I have time for just one final comment? Yeah. Okay. My only comment is that despite the trauma and the burden, I do not regret anything that I did. I don't regret doing for a minute what we did, and there is a sense of purpose that is really hard to beat, and that should be kept in mind. However, I would urge everybody to come into this career harmed with patience, tolerance, sympathy, empathy, and willingness to compromise. I don't think this is the time when we can just march on and live in isolation. We need to build bridges and involve everyone else in what we think is the right thing to do and the right decisions to make. And Dr. Herring, you were muted. Do you want to repeat what you were sharing? Oh, I'm sorry. Pretty much to say if you want a job, you want a career that is meaningful, that is productive, and that is exciting, this is it. You will not be bored. I can assure you of that. Great. Well, I want to thank each of you for your precious time and your wisdom in participating in this panel. Please extend our gratitude to your staffs and to all of our colleagues engaged in this public health pandemic response. It is really unprecedented, and hopefully the lessons that we learn and the investments that we will be making will really improve public health and make us ready for the future. So thank you again, and I hope that everybody continues to enjoy the remainder of the conference. Thanks, everybody. Thank you.

public health officials

pandemic response

investment

public health infrastructure

diverse workforce

data analysis

evaluation

partnerships

upstream determinants of health

population health