Making the Case for Public Health Law as a Tool for Diverse Executives

by Dawn Hunter, JD, MPH, CPH

Every week, my husband and I place a grocery order. Sometimes we order online and pick it up, sometimes we have it delivered, and sometimes we do the shopping ourselves.

We often purchase our groceries without much thinking—if we order online, we are prompted to “buy it again” and even in person we tend to buy the same staples.

Prices are higher online than in store.

We live in a community where plastic bags are still an option, but we used to live in a community where plastic bags are banned.

We shop at an employee-owned supermarket chain known for its workplace culture.

Why am I sharing all of this? Nearly every aspect of our weekly grocery trip is shaped by the law. Laws impact food placement, packaging, expiration dates, and prices; employee wages and benefits; store location, hours, and accessibility; availability of rideshare drivers for delivery orders; and whether to choose paper or plastic.

Law impacts the way we experience our everyday lives by establishing the framework in which we operate. The grocery store is just one example of how law can shape our decisions and, more importantly, our choices. It is because law shapes the resources and opportunities available to us that law is an important determinant of health.

Exploring the Landscape of Public Health Law

What we think of as “law” can take many forms. It includes statutes, regulations, case law, organizational policy, and budgets and how they are interpreted and enforced. The law can be a set of requirements or prohibitions, establishing norms and expectations for our behavior as individuals, organizations, systems. The law can also be the processes and procedures associated with creating laws, making decisions, and interpreting existing laws.

Public health law, specifically, is important as a field because it includes the laws that are designed to protect and promote the public’s health and that define the power of the government to act on our behalf. In fact, law is behind every public health success of the 20th century. In a 1999 issue of the Morbidity and Mortality Weekly Report, vaccinations, motor vehicle safety, safer workplaces, healthier moms and babies, and recognition of tobacco as a health hazard were listed among those successes. These achievements would not be possible without:

• School vaccination laws

• Helmet and seatbelt laws

• Speed limits

• The Occupational Safety and Health Administration

• Food fortification

• School lunch programs

• The Women, Infants, and Children (WIC) program

• Newborn screening

• The Tobacco Master Settlement Agreement

• Clean indoor air laws

• Many others

At the same time, these laws have not benefited everyone equally. In fact, they have often operated as a tool of racism and other forms of structural discrimination. The lesson here is that the law can create the conditions that lead to differences in health outcomes, but it can also create the conditions for equity.

Civil Rights Movements and Transformations in Public Health Legislation

One must look only to the civil rights movement to see the potential. As just one example, today’s robust network of Community Health Centers was born from the activism of the Black Panther Party, which established free health clinics in response to continuing discrimination in the healthcare system, as well as the work of H. Jack Geiger and Count D. Gibson Jr., who established the first community health centers in 1965.

In fact, key legislation enacted during the civil rights movement led to significant, even if insufficient, improvements in health outcomes for Black Americans. For example, there is evidence that women’s suffrage, the Civil Rights Act of 1964, and the Voting Rights Act all led to improvements in premature mortality and infant mortality, among other benefits. Similar success was seen with the enactment of the Patient Protection and Affordable Care Act in 2010 and the resulting adoption of Medicaid Expansion. There is ample evidence of the impact that Medicaid Expansion has had on health outcomes and financial well-being, both at the individual and population level.

Addressing the Training Gaps in Public Health Law for Equitable, Informed Practices

The fact that law shapes how we experience our lives on a day-to-day basis is perhaps the most important reason that public health professionals should understand the relationship between the law and health outcomes and how to use the law to achieve more equitable, thriving communities. However, knowledge of public health law continues to be one of the biggest training gaps in the public health workforce.

The Public Health Workforce Interests and Needs Survey conducted by the de Beaumont Foundation and the Association of State and Territorial Health Officials issued a 2021 report that found that strategic and systems thinking was one of the top training needs as well as an increased interest in policy engagement and topics related to justice, equity, diversity, and inclusion. Another report in 2021 by the National Network of Public Health Institutes found a need for increased awareness among the public health workforce of the legal basis for public health authority and identified how to influence law and policy development—plus, how to understand the effects of law and policy on health among the top training needs.

These findings are aligned with public health accreditation standards. Whether or not you work for an accredited health department, the Public Health Accreditation Board Standards & Measures serve as a guidepost for the practice of public health. There are two specific examples of how this is relevant:

Domain

Domain 4: Strengthen, support, and mobilize communities and partnerships to improve health.

Domain 5: Create, champion, and implement policies, plans, and laws that impact health.

Measure

Measure 4.1.3 A: Engage with community members to address public health issues and promote health.

Measure 5.1.2 A: Examine and contribute to improving policies and laws.

Examples

• Making the decision-making structure inclusive and transparent to empower community members or developing mechanisms for shared ownership in the process.

• Enhancing residents’ capacity to understand levers of power or influence in policy change.

• Assessment of the impacts of the policy or law on equity.

• Input gathered from stakeholders or strategic partners.

Lessons Learned: Involving and Empowering Communities

The inclusion of community members in assessment, decision-making, and capacity-building efforts to understand levers of power or influence reinforce key lessons learned in the past three years—spurred by COVID-19 and the racial justice movement of the summer of 2020:

• The first lesson is the need to recognize and rectify historical injustices. It is important that we understand the historical legal context behind current health inequities. We must know and name the problem to solve it.

• The second is the need to rectify current inequities by analyzing and assessing the ways in which our current system of laws is creating and reinforcing inequities.

• The third is the need to engage impacted people in identifying, designing, and implementing solutions.

One of the lessons learned from the work of Geiger and Gibson was that there is a difference between what the health system thinks people need and what communities think they need. It seems we are still trying to learn this lesson today.

Leveraging Law to Drive Equity and Trust in Public Health

Law is the only way to truly change the game for inequities. It can give a voice to historically marginalized people by creating pathways to ensure inclusion and representation in the political process. It can also change systems and institutions by changing the way they operate and the way that people within those systems operate. It can also be a tool to enforce conditions that will lead to more equitable outcomes and to hold people in positions of power accountable.

We often hear in the COVID-19 era about the need to rebuild trust in public health. I’d like to reframe that to think about how we make public health as a field more trustworthy. It starts by increasing our understanding of the authority of public health to promote the public’s health and to use that authority to create systems in which we all can thrive.