Professional Documents
Culture Documents
Texas Advisory On Public Health Infrastructure Improvement
Texas Advisory On Public Health Infrastructure Improvement
Health Infrastructure
Improvement
2020 Recommendations
Texas Advisory on Public
Health Infrastructure
Improvement
2020 Recommendations
Fall 2020
1
Copyright © Jon Comola, 2020
Table of Contents
Overview: Texas Advisory on Public Health Infrastructure Improvement 3
Background 8
References 46
2
Copyright © Jon Comola, 2020
Overview: Texas Advisory on Public Health
Infrastructure Improvement
3
Copyright © Jon Comola, 2020
Overview: Texas Advisory on Public Health Infrastructure Improvement
Our Advisors provided their counsel in four areas for a high performing,
responsive public health system for Texans: the workforce, data and technology,
public health infrastructure, and ancillary recommendations. They addressed
these topics with a critical focus on improvements in Texas’ public policy and
public health/population health practices looking ahead mid-term to long- term,
months to years.
4
Copyright © Jon Comola, 2020
Overview: Texas Advisory on Public Health Infrastructure Improvement
Advisors:
o John M. Zerwas, M.D. Executive Vice Chancellor for Health Affairs, The
University of Texas System
o Mary Dale Peterson, M.D., MSHCA, FACHE, FASA, Executive Vice President
and Chief Operating Officer of Driscoll Health System
o Nancy Dickey, M.D. Executive Director, Texas A&M Rural and Community
Health Institute
o Edward B. Burger, PhD, President and Chief Executive Officer of St. David's
Foundation
o Greg Hartman, Vice Chancellor for Strategic Initiatives for the Texas A&M
University System and Senior Vice President of the Texas A&M University
Health Science Center
5
Copyright © Jon Comola, 2020
6
Copyright © Jon Comola, 2020
Overview: Texas Advisory on Public Health Infrastructure Improvement
The Advisors started with a set of consensus PRINCIPLES to guide Texas’ public
health policies moving forward. These include:
1. A comprehensive public health system that is resilient, adequately
resourced, and data driven.
2. A system that is devoted to disease prevention and health promotion and is
equipped to detect, investigate, and predict emerging threats and retain
agility and capacity to respond effectively, when needed.
3. Proactive public health practices that are science-driven with adequate
funding, competent staff, and well executed coordination
and communication throughout all phases of a public health emergency.
4. A Texas preparedness strategic plan that will result in sustainable strategic
capacity to successfully respond to future public health emergencies and
needs.
5. A Texas public health system with sustainable funding and capacity to
optimize the use of data and technology across multiple platforms to
support the public health system’s ability to competently and effectively
assess and protect the health of Texans.
6. A Texas public health system that does its work with health equity as a goal,
engenders the public’s trust, participation, confidence, security, and even
pride as a public health crisis ensues, is responded to, and recedes.
7
Copyright © Jon Comola, 2020
Overview: Texas Advisory on Public Health Infrastructure Improvement
The US public health system is fragmented in both organization and funding, with
significant variability at local, county, and state levels. Nationally, public health
spending represents 2-3% of total health spending. The inadequate funding
undermines the health of individuals and families and places national security and
economic viability at risk. COVID-19 has amply demonstrated that we can no
longer accept or afford public policy practices that react to, rather than prepare
for, public health crises.
The Advisors recommend we create a plan, fund the plan, train to the plan, and
maintain the plan.
The Advisors wish to thank Anita D'Souza and Cailyn Stewart for their tireless
volunteer support and dedicated guidance in researching and writing this report.
It is our intent and hope that these principles and recommendations are helpful
to our state leadership.
“In Texas, we talk a lot about healthcare. But we don’t talk enough about
health. The poor health of many Texans, particularly Black and Hispanic
Texans, and the disparate impact of Covid-19, are the product of social,
economic, and behavioral conditions. This is where public health works—on
the ground, in communities, with prevention-oriented, upstream strategies.
When we invest in public health, we’re investing in people, families, and
communities.”
8
Copyright © Jon Comola, 2020
9
Copyright © Jon Comola, 2020
Background
Public health systems are large interconnected systems that serve to protect the
health of populations – particularly in times of public health crisis. In Texas, public
health has to have the capacity to serve the public health needs of 29 million
people living in urban, rural, and border communities.
Source: https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html
Ten Essential Public Health Services recently revised by the Centers for Disease
Control delineate the requirements of a complete public health system, which
includes social determinants of health and preventive care.
10
Copyright © Jon Comola, 2020
Background
The 10 CDC (Centers for Disease Control) Essential Public Health Services (revised
in 2020) are as follows:
1. Assess and monitor population health status, factors that influence health,
and community needs and assets
5. Create, champion, and implement policies, plans, and laws that impact
health
6. Utilize legal and regulatory actions designed to improve and protect the
public’s health
11
Copyright © Jon Comola, 2020
Background
The 10 Texas Essential Public Health Services codified in state law in Texas
(originally developed in 1994) are as follows:
5. Develop policies and plans that support individual and community efforts to
improve health
6. Enforce laws and rules that protect the public health and ensure safety in
accordance with those laws and rules
7. Link individuals who have a need for community and personal health
services to appropriate community and private providers
In 1999, the Texas legislature passed HB 1444 (Representative Dianne Delisi and
Senator Mike Moncrief) that defined and set a strategy for implementing the 10
essential public health services in Texas.
https://www.texashealthinstitute.org/uploads/1/3/5/3/13535548/ph_primer_2012_final.pdf
12
Copyright © Jon Comola, 2020
Background
“Disasters frequently have those famous silver linings. Clearly the learnings
from the COVID 19 pandemic will have many lessons that will prepare us for
future disaster conditions. Certainly, the availability of domestically
produced PPE is at the forefront. Better state of the art IT such that
decisions can be made in real time is essential to better public health
response. Reassuring is the capability of our health care systems to absorb
the surge of patients. And the ability of our research universities to quickly
identify effective treatments has proven the value of this investment in
higher education.”
13
Copyright © Jon Comola, 2020
Executive Summary of Recommendations
Recommendation 2: Create & train surge capacity workforce. For example, use a
certification program and workforce extenders.
14
Copyright © Jon Comola, 2020
programs and increase the number of accredited health departments including
DSHS and not yet accredited local health departments.
Recommendation 10: Build the system that can “know” in real time the health
status of individuals to enable appropriate mobilization of health and health
care resources.
15
Copyright © Jon Comola, 2020
Workforce
Six of the 25 most populated cities in the US are in Texas, but nearly half of the
epidemiologists in Texas work in the Houston metro area.
16
Copyright © Jon Comola, 2020
collaborations among care givers, and the role technology can play in
health care delivery.
17
Copyright © Jon Comola, 2020
Workforce
The real challenge now is to learn from these experiences: To fix failures
and adopt successes to achieve a ready, robust, and accessible public health
care system.”
Epidemiologists in Government
18
Copyright © Jon Comola, 2020
Workforce
19
Copyright © Jon Comola, 2020
Workforce
Recommendation 2: Create & train surge capacity workforce. For example, use a
certification program and workforce extenders.
Public health emergencies take many forms - they can occur as a result of a
natural disaster like a hurricane or infectious disease outbreak or a man-made
disaster such as a chemical spill. They can be limited by geography or time or be
global, such as a pandemic. Public health emergencies can appear suddenly with
little or no warning or they can build slowly over time. Each of these scenarios
involves different skill sets and workforce requirements. Therefore, it is extremely
difficult to precisely anticipate the size and qualifications of the workforce needed
during any given public health emergency, and strategies to address surge
capacity should be part of a long-term plan to address public health
preparedness.
20
Copyright © Jon Comola, 2020
Workforce
Once core public health workforce and capacity as well as estimated public surge
need in a worst case scenario is assessed, Texas should look at options to create a
surge/reserve workforce that is available and can be activated to supplement
existing assets and identify the public health training available or needed as well
as the arrangements that might be operationalized (for example, telemarketing
organizations and trained employees might be able to augment contact tracing
related work). Currently, Texas Commissioner Dr. Hellerstedt reports that his
agency contracts with various professionals locally to be able to control quality
and have them available at the flip of a switch.
The US Military maintains a surge force that can mobilize in times of crises. This is
a practice Texas should consider for civilians to help Texas be better prepared for
public health crises in the future. A surge force or reserve could be trained to
support front line public health and healthcare workers in contact tracing, testing,
performing logistical support, food distribution and disinfection and provide relief
to exhausted public health and medical staff. When not deployed, this reserve
would be working their usual jobs in their communities. Maintaining a pool of
trained reservists and keeping their skills current through periodic training would
ensure that Texas has the personnel needed to successfully overcome the many
challenges of a health crisis.
Our Advisors suggest we should expand the option of Bachelor of Arts in Public
Health within more Texas universities and expand opportunities for students to
be placed in experiential internships in health departments across the state.
21
Copyright © Jon Comola, 2020
Data and Technology
Data that public health relies upon comes from a variety of sources: patients,
health care system (electronic medical records), public health entities (including
public health laboratories), clinical laboratories, pharmacies, schools. In Texas,
public health entities encompass local health departments, local health units, and
public health districts and their laboratories, if they have them.
Driving Public Health in the Fast Lane, Council of State and Territorial
Epidemiologists, available at https://resources.cste.org/data-superhighway/mobile/index.html ).
22
Copyright © Jon Comola, 2020
Data and Technology
The number of systems and the manner in which these systems collect, store, and
transmit data affects the accuracy and timeliness of data available in a pandemic.
Texas has made strides in syndromic detection and investigation. The Texas
Department of State Health Services (DSHS), “in collaboration with local health
departments across Texas and with Tarrant County Public health and Houston
Health Department...has established a statewide syndromic network” that helps
“identify emerging health threats and inform local decision-making while
protecting individual’s privacy.” (https://www.dshs.texas.gov/mu/syndromic.aspx)
Today, there are new technologies that are changing both the ability to collect
data and the type of data that can be collected. Cell phone technology can
provide multiple types of data: location data; activity data, self-reported data as
to an individual’s condition via apps.
23
Copyright © Jon Comola, 2020
Data and Technology
In summary, quality data that can be collected in real time can support contact
tracing systems, state public health systems, and help private health entities
make better data-dependent decisions. In addition, schools, universities, and
employers would also be able to make better decisions. Continued
standardization and consolidation of data systems to streamline data input and
availability and the introduction of new technologies is essential for the timely
and robust epidemiological analysis required in pandemic situations.
24
Copyright © Jon Comola, 2020
Data and Technology
Mary Dale Peterson, M.D., MSHCA, FACHE, FASA, Executive Vice President
and Chief Operating Officer of Driscoll Health System
A rapidly evolving situation such as a pandemic involves both immediate and less
time sensitive responses as well as the ability to revise and update responses, as
new data and insights become available.
The value of traditional sources of data for public health considerations is clear.
However, a large amount of electronic data is collected in and from other
traditional and non-traditional sources that may be useful during a public health
crisis such as a pandemic. Some real-time dataset examples are commercial
laboratory feeds, pharmacy databases, consumer purchasing databases,
databases containing self-reported information, databases documenting
movement of individuals, wearable device data, and databases on internet
searches. Insurance claims data are also useful but can often lag in time.
Having an understanding of real time data sets and resources and the ability to
access relevant data quickly will ensure that Texas can detect and respond
proactively in a data-driven manner to the next public health crisis and be able to
tailor responses to unique community needs.
25
Copyright © Jon Comola, 2020
26
Copyright © Jon Comola, 2020
Data and Technology
Texas policy makers recognize the importance of ensuring all Texans have access
to broadband. Passage of SB 14 in 2019 empowers Texas electric cooperatives to
deploy broadband to the members they serve by allowing them to utilize their
existing electricity easements. More can and should be done.
27
Copyright © Jon Comola, 2020
Data and Technology
28
Copyright © Jon Comola, 2020
29
Copyright © Jon Comola, 2020
Data and Technology
30
Copyright © Jon Comola, 2020
Public Health Infrastructure
“COVID-19 has shown the nation the value of a robust public health system
and the need for strategic and sustained investments in public health. The
health and economic wellbeing of the nation depends on it.”
In the U.S., 97 cents of every health dollar go to medical care and only 3 cents to
public health! Many argue that the imbalance needs rebalancing.
We have two health care systems: public health and health care delivery. They
operate mostly independently in silos. At this time of the COVID pandemic, public
health works to prevent people from getting COVID-19 and the health care
system treats those sickened with COVID-19. The science and practice of public
health is focused on the health of the overall population (population health),
concentrating on being a catalyst for things like safe food, clean water, vaccines,
injury prevention, clean air, sanitation, and control of communicable diseases
such as COVID-19. In the U.S., public health is under-resourced and
underappreciated until there is a crisis. But managing disease outbreaks is not a
new idea and is why, in 1879, Texas Governor Oran Roberts was made head of a
state health department, called the Texas Quarantine Department, with authority
to appoint a state health officer.
Those choices haunt us today in the wake of 4,649,102 COVID infections and
154,471 deaths as of August 3rd, 2020.
Texas has a history of ignoring the importance of maintaining robust, reliable, and
sustainable funding for public health activities. Public health is responsible for
epidemiologic disease detection and investigation, immunization, vaccination,
disease prevention, public health laboratories and other population health
services. The Institute of Medicine’s, now known as the National Academy of
Medicine, Committee on Public Health Strategies to Improve Health, concluded in
2012 that in order to improve physical and environmental health data collection,
reporting, and action that the laws and policy need improvement and are
inadequate. The Committee found issues with insufficient funding for public
health and dysfunction in how public health infrastructure is funded, organized
and equipped to use its funding. In short, the nation does not invest sufficiently in
public health and that funding for governmental public health is inadequate,
unstable, and unsustainable in light of its responsibilities and the expectations of
the public.
32
Copyright © Jon Comola, 2020
Public Health Infrastructure
33
Copyright © Jon Comola, 2020
34
Copyright © Jon Comola, 2020
Public Health Infrastructure
35
Copyright © Jon Comola, 2020
Public Health Infrastructure
The lack of reliable funding reduces the ability of public health departments to
prevent disease, promote health, and protect the health of their communities in
the face of a variety of threats. In the last 6 years, we have faced Ebola, Zika and
Chikungunya viruses and a resurgence of Sexually Transmitted Disease (STDs),
including syphilis. All the while, the burden of chronic conditions such as obesity is
increasing in Texas which increases the risk of death in pandemics like COVID-19.
36
Copyright © Jon Comola, 2020
Public Health Infrastructure
From the onset of a public health crisis, public health authorities are expected to
provide the general public with timely, accurate information and answers about
its impact. News media are among the critical channels to inform and educate the
public. When public health officials manage health crisis risk communication, they
are helping community members know what to do and how to cope with both
physical and mental health impacts. Public health is expected to use medical,
epidemiological, behavioral, and statistical knowledge and good data and
synthesize it all into useful information converted into messages and readily
understandable and actionable concepts. Public health communications operate
on the principles of transparency, reliability, and trust.
37
Copyright © Jon Comola, 2020
Public Health Infrastructure
The third of the 10 Essential Public Health Services is to “inform, educate, and
empower people about health issues.” Emphasis on accessibility of resources to
serve the culturally and linguistically diverse population is essential.
38
Copyright © Jon Comola, 2020
Public Health Infrastructure
39
Copyright © Jon Comola, 2020
Public Health Infrastructure
40
Copyright © Jon Comola, 2020
Ancillary to Public Health
COVID-19 is a grey swan event, a highly probable event that it is predictable and
carries an impact that can easily cascade. The convergence of a pandemic that
would disproportionately impact vulnerable segments of a population and its
impact was predictable.
A clear pattern has emerged. In addition to persons age 65 and older and persons
with some underlying medical conditions being at higher risk of severe or fatal
COVID-19, Black Americans, Latino/Hispanic persons, and indigenous Americans
and the poor are being disproportionately adversely affected by COVID-19 in
terms of cases, hospitalizations, and deaths. Before COVID-19, persons with lower
educational attainment, lower household income, and no health insurance
experienced worse health outcomes, had higher prevalence of disease risk factors
and struggled more to access the health system than persons who were better
educated, had higher income, had more wealth, and had a higher likelihood of
having health insurance. COVID-19 has highlighted the impact of those
differences.
41
Copyright © Jon Comola, 2020
Ancillary to Public Health
These health inequities are driven in large measure by public policies. Health is
influenced by a range of social, environmental, and economic factors: educational
attainment (which is affected by quality of education), health insurance status,
affordability and quality and location of housing, food, and quality of medical
care. Until we appropriately and equitably invest in these health equity pillars,
health disparities will persist, and our society and economy cannot thrive.
“COVID-19 has put a finer point on the historical inequities that are
pervasive in our country and throughout Texas’ most vulnerable
communities – including vast differences in health status, health access and
the distribution of health resources based on age, race, gender or
geography. The heavy and difficult days faced by our community have
served as an awakening for some, and a reminder for others, of the health
inequity all around us. We must work together—state and local
governments with municipalities and non-profit and for-profit organizations
—to inspire real change. Let’s seize this historic moment today and
commitment to a better tomorrow.”
The third of the 10 Essential Public Health Services is to “inform, educate, and
empower people about health issues.” Emphasis on accessibility of resources to
serve the culturally and linguistically diverse population is essential.
42
Copyright © Jon Comola, 2020
common vernacular, a narrative and emotional appeal, and a driving fact, but not
overly data ridden.
Ancillary to Public Health
Public health experts say focusing on these disparities is crucial for helping
communities respond to the virus effectively — so everyone is safer. "I think it's
incumbent on all of us to realize that the health of all of us depends on the health
of each of us," says Dr. Alicia Fernandez.
43
Copyright © Jon Comola, 2020
Ancillary to Public Health
44
Copyright © Jon Comola, 2020
ongoing chronic disease care. The public health and epidemiologic consequences
are not clear but should be anticipated and planned for.
Ancillary to Public Health
“The single most influential action Texas could take for significant progress
across all three sections of these recommendations is to enable all Texans
to carry health insurance. Covered Texans maintain personal responsibility
for their own wellness and contribute to our ability to detect, prevent,
respond and recover from a public health crisis. Texas could achieve a
simple coverage matrix by implementing currently available federal
Medicaid and coverage waiver opportunities, establishing its own state-
based health
insurance exchange, and enacting savings incentives for businesses to offer
more coverage choices. When Texans carry health insurance, they help fund
the workforce, contribute crucial health statistics for surveillance, and
strengthen our public health infrastructure.”
These are challenging times for municipalities, counties, states and the nation and
the world but the value of population-based health interventions and the need
for vibrant public health enterprises is an imperative. In many respects we should
consider a system redesign.
The DSHS supports city and county health departments and serves an important
role in collaboration, fostering the growth of healthy communities resulting in
greater prosperity. One important component to fostering healthier communities
is taking time to improve health literacy. Our Advisory members suggest building
curriculum in public schools for things like ‘germ spread theory’ for example.
45
Copyright © Jon Comola, 2020
46
Copyright © Jon Comola, 2020
Ancillary to Public Health
47
Copyright © Jon Comola, 2020
Ancillary to Public Health
Recommendation 10: Build the system that can “know” in real time the health
status of individuals to enable appropriate mobilization of health and health
care resources. (NOTE: We are researching this topic further and will be issuing
a supplement this Winter.)
The virus has managed to shine a glaring light on some of public health’s and
health care’s most foundational cracks. Gaps in care, data, and IT systems have
become more visible in the midst of the confusion and uncertainty of the
pandemic. Issues around data access, sharing, and quality have adversely
impacted public health’s ability to understand, predict and manage the crisis.
Scientists are faced with analyzing which public policy strategies work best. In this
process they are contending with problems related to compiling data, merging
distinct reporting systems and methods among cities, states, and regions and
standardizing information collected from a mix of health systems, public agencies,
private health insurance plans, and providers. What is needed is interoperability -
the ability of different information systems devices or applications to connect, in a
coordinated manner, within and across organizational boundaries to access,
exchange and cooperatively use data amongst stakeholders. We should consider
deploying something similar to a Universal Patient Identifier (UPI), creating a base
standard for all health systems to operate upon. Knowing each person’s health
status during a public health crisis allows public health professionals to triage who
to test and treat first. Having real time information saves lives and helps ensure
our health systems do not exceed capacity. Today more than 30 countries use
some form of a UPI. Our Advisors recognize that Texas does not have a statewide
Health Information Exchange (HIE) and the lack of a mechanism to exchange
information has further compounded the problem.
48
Copyright © Jon Comola, 2020
Ancillary to Public Health
“I would like to echo Dr. Cigarroa’s statement; ‘It is critical to the future
health of Texas that we appropriately invest in public health to help prevent
disease and to be able to respond swiftly and accurately to a public health
crisis whether it be a pandemic or not. This requires a public health surge
capacity, innovative ways of educating more public health professionals
and the appropriate Information Technology infrastructure to be able to
acquire reliable data, metrics and enhance communication among
Departments of Public Health.’”
Greg Hartman, Texas A&M University, Chief Operating Officer & Senior Vice
President | Health Science Center, Vice Chancellor | Texas A&M University
System
49
Copyright © Jon Comola, 2020
Ancillary to Public Health
“If we learn anything from the COVID-19 crisis is the need to take a
dramatically different approach to preparing for a wide variety of public
health crises. We’re lucky that the virulence of the virus, in its current
manifestation, is not more lethal nor more easily spread. The next epidemic
or iteration of COVID-19 may be much worse and that is the scenario we
must be prepared to confront.”
This digital ID can easily be used to screen travelers for diseases when traveling
from country to country thereby limiting the number of travelers exposed to a
disease. This information can help public health authorities collect vital data for
tracking diseases. With no need to exchange physical documents, a digital ID
provides a kind of touchless system when people are maintaining social distancing
and avoiding potentially contaminated/infected surfaces. Biometrics such as face
recognition help ensure privacy is maintained.
To make them useful to public health, they need to contain current immunization
records and travel histories at a minimum while being mindful of individual
privacy. Finding the right solutions to put in place before another infectious
spread across borders is important to our success in preventing another
pandemic. Our Advisory believes that as a first step toward having vital tracking
information, Texas needs to improve its immunization registry.
50
Copyright © Jon Comola, 2020
Ancillary to Public Health
51
Copyright © Jon Comola, 2020
Ancillary to Public Health
George T. Roberts, Jr. FACHE, Chief Executive Officer, Northeast Texas Public
Health District
52
Copyright © Jon Comola, 2020
References
American Public Health Association. “Centers for Disease Control and Prevention and the Health Resources and
Services Administration.”
https://www.apha.org/-/media/files/pdf/advocacy/speak/200611_cdc_hrsa.ashx?
la=en&hash=9AF3A3AA2BC352199D7BCAB16DBB0C139C858896.
Anderson, Roy M. et. al. How will country-based mitigation measures influence the course of the COVID-19
epidemic? The Lancet 395. no. 10228 (March 21, 2020): 931-934. https://doi.org/10.1016/S0140-
6736(20)30567-5.
Apa, James. “Introducing Scan: The Greater Seattle Coronavirus Assessment Network.” Public Health Insides,
March 23, 2020. https://publichealthinsider.com/2020/03/23/introducing-scan-the-greater-seattle-
coronavirus-assessment-network/.
Association of State and Territorial Health Officials. “Coronavirus Disease 2019 (COVID-19) Response Hub.” ASTHO.
https://coronavirus-astho.hub.arcgis.com.
Association of State and Territorial Health Officials. “National Public Health Performance Standards.” Accreditation
and Performance, 2020. https://www.astho.org/Programs/Accreditation-and-Performance/National-
Public-Health-Performance-Standards/.
ASTHO Staff. “16 Key Considerations for Drive-Through or Mobile Testing.” ASTHO Experts Blog, Association of
State and Territorial Health Officials, March 19, 2020. https://astho.org/StatePublicHealth/16-Key-
Considerations-for-Drive-Through-or-Mobile-Testing/03-19-20/.
Bates, Jonathan. “Drones Aiding Fight Against COVID-19.” NCSL Blog, National Conference of State Legislatures,
May 7, 2020. https://www.ncsl.org/blog/2020/05/07/drones-aiding-fight-against-covid-19.aspx.
Benjamin, Georges C. “Ensuring health equity during the COVID-19 pandemic: the role of public health
infrastructure.” Pan American Journal of Public Health, Rev Panam Salud Publica 44, June 2020.
https://doi.org/10.26633/RPSP.2020.70.
Bicharra Garcia, Ana Cristina, et. al. “Collaboration and Decision Making in Crisis Situations.” (February 2016). DOI:
10.1145/2818052.2855520.
Blanford, Emily. “How States Are Leveraging Their Medicaid Programs to Respond to COVID-19.” NCSL Blog,
National Conference of State Legislatures, April 9, 2020. https://www.ncsl.org/blog/2020/04/09/how-
states-are-leveraging-their-medicaid-programs-to-respond-to-covid-19.aspx.
53
Copyright © Jon Comola, 2020
Boland-Krouse, Scott and Lawrence Burka. “After Coronavirus, E-Passports Could Help Prevent The Next
Pandemic.” Forbes, June 5, 2020. https://www.forbes.com/sites/oliverwyman/2020/06/05/after-covid-
19-how-e-passports-could-help-prevent-the-next-pandemic/#1f7d41cb1d5f.
Carr, Brendan G. and Judd E. Hollander. “Virtually Perfect? Telemedicine for Covid-19” New England Journal of
Medicine 382, no. 18 (April 30, 2020). https://doi.org/10.1056/NEJMp2003539.
Center for Disease Control and Prevention. “10 Essential Public Health Services.” Public Health Professionals
Gateway, U.S. Department of Health and Human Services.
https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html.
Center for Disease Control and Prevention. “National Public Health Performance Standards.” Public Health
Professionals Gateway, U.S. Department of Health and Human Services.
https://www.cdc.gov/publichealthgateway/nphps/index.html.
Centers for Disease Control and Prevention. “Sending Early Warning Signals from Emergency Departments to
Public Health.” National Syndromic Surveillance Program (NSSP). Last modified August 12, 2020.
https://www.cdc.gov/nssp/index.html.
Centers for Disease Control and Prevention. “Ten Essential Public Health Services and How They Can Include
Addressing Social Determinants of Health Inequities.” U.S. Department of Health and Human Services.
https://www.cdc.gov/publichealthgateway/publichealthservices/pdf/Ten_Essential_Services_and_SDOH.
pdf.
Changoiwala, Puja. “Covid-19 Threatens to Overwhelm India’s Health Care System.” Undark, April 14, 2020.
https://undark.org/2020/04/14/covid-19-india/.
Colombo, Francesca. Resilient Health Systems: What we are learning from the COVID-19 crisis. Paris: OECD, April 2,
2020. https://www.oecd-forum.org/posts/64973-resilient-health-systems-what-we-are-learning-from-
the-covid-19-crisis.
“Coronavirus emphasizes challenges for rural communities.” Texas Agriculture Daily, Texas Farm Bureau, March
13, 2020. https://texasfarmbureau.org/coronavirus-emphasizes-challenges-for-rural-communities/.
“COVID-19: Impact on Employment and Labor.” NCSL Blog, National Conference of State Legislatures, May 13,
2020. https://www.ncsl.org/research/labor-and-employment/covid-19-impact-on-employment-and-
labor.aspx.
Crisis and Emergency Risk Communication, 2nd ed. Atlanta: Centers for Disease Control and Prevention, 2018.
https://emergency.cdc.gov/cerc/ppt/cerc_2014edition_Copy.pdf.
Criss, Tamara, Celia N. Hagan, and Emily J. Holubowich. Driving Public Health in the Fast Lane: The Urgent Need for
a 21st Century Superhighway. Atlanta, Georgia: Council of State and Territorial Epidemiologists, 2019.
https://resources.cste.org/data-superhighway/mobile/index.html.
Crock Bauerly, Brittney et. al. “Broadband Access as a Public Health Issue: The Role of Law in Expanding Broadband
Access and Connecting Underserved Communities for Better Health Outcomes.” Journal of Law, Medicine
& Ethics, Sage Journals (July 12, 2019). https://doi.org/10.1177/1073110519857314.
De Visser, Edwart J. et al. “AREA: A Mobile Application for Rapid Epidemiology Assessment.” Procedia Engineering
107, (2015): 357-365. https://doi.org/10.1016/j.proeng.2015.06.092.
54
Copyright © Jon Comola, 2020
Dorsett, Jennifer, “FCC grants temporary broadband access to help rural communities.” Texas Agriculture Daily,
Texas Farm Bureau, April 2, 2020. https://texasfarmbureau.org/fcc-grants-temporary-broadband-access-
to-help-rural-communities/.
Elflein, John. “Total number of U.S. coronavirus (COVID-19) cases and deaths as of August 20, 2020.” Statista, Aug
21, 2020. https://www.statista.com/statistics/1101932/coronavirus-covid19-cases-and-deaths-number-
us-americans/.
Emmanuel, Zeke. et. al. “A National and State Plan to End the Coronavirus Crisis.” Center for American Progress,
August 3, 2020.
https://www.americanprogress.org/issues/healthcare/news/2020/04/03/482613/national-state-plan-
end-coronavirus-crisis/.
Enlund, Sydne and Iris Hentze. “Mitigating Health Workforce Barriers During the COVID-19 Pandemic.” NCSL Blog,
National Conference of State Legislatures, March 27, 2020.
https://www.ncsl.org/blog/2020/03/27/mitigating-health-workforce-barriers-during-the-covid-19-
pandemic.aspx.
Ensuring Integrity in Governments' Response to COVID-19 (English). Washington, D.C. : World Bank Group.
http://documents.worldbank.org/curated/en/801501588782665210/Ensuring-Integrity-in-Governments-
Response-to-COVID-19.
Executive Director Bill McBride to Governors’ Offices, March 18, 2020, National Governors Association.
https://www.nga.org/wp-content/uploads/2020/03/MedSurgMemo_FINAL.pdf.
Executive Director Bill McBride to Governors’ Offices, March 27, 2020, National Governors Association.
https://www.nga.org/wp-content/uploads/2020/05/EO-CARES-Act_Workforce_Summary_032520.pdf.
Executive Director Bill McBride to Governors’ Offices, April 3, 2020, National Governors Association.
https://www.nga.org/wp-content/uploads/2020/04/Memo-on-Older-Adults-and-Disabled-Final-
formatted.pdf.
Executive Director Bill McBride to Governors’ Offices, April 6, 2020, National Governors Association.
https://www.nga.org/wp-content/uploads/2020/03/NGA-Health-Workforce-and-Facility-Memo-Final-
formatted.pdf.
Executive Director Bill McBride to Governors, April 27, 2020, National Governors Association.
https://www.nga.org/wp-content/uploads/2020/03/COVID-19-Telehealth-Memo-20200320450pm.pdf.
Fishbane, Lara and Adie Tomer. “Broadband is too important for this many in the US to be disconnected.” The
Avenue. Brookings, August 14, 2019. https://www.brookings.edu/blog/the-
avenue/2019/08/14/broadband-is-too-important-for-this-many-in-the-us-to-be-disconnected/.
Flahive, Paul. “Texas Legislature Poised For Biggest Broadband Push In State History But Still Catching Up.” Texas
Public Radio, May 14 2019. https://www.tpr.org/post/texas-legislature-poised-biggest-broadband-push-
state-history-still-catching.
Galea, Sandro and Nason Maani. “COVID-19 and Underinvestment in the Public Health Infrastructure of the United
States.” Milbank Quarterly, vol. 98, no. 2 (June 2020): 250-259. https://doi.org/10.1111/1468-
0009.12463.
55
Copyright © Jon Comola, 2020
Gardner, Heidi K. and Marviak, Ivan. “7 Strategies for Promoting Collaboration in a Crisis.” Harvard Business
Review, July 08, 2020. https://hbr.org/2020/07/7-strategies-for-promoting-collaboration-in-a-crisis.
Glik, Deborah C. “Risk Communication for Public Health Emergencies.” Annu. Rev. Public Health, 2007.
https://doi.org/10.1146/annurev.publhealth.28.021406.144123
Google. “Texas.” Mobility Changes, COVID-19 Community Mobility Reports. May 9, 2020.
https://www.gstatic.com/covid19/mobility/2020-05-09_US_Texas_Mobility_Report_en.pdf.
Haaland, Connor and Brent Skorup. “How Drones Can Help Fight the Coronavirus.” COVID-19 Crisis Response,
Mercatus Center, March 30, 2020. https://www.mercatus.org/publications/covid-19-policy-brief-
series/how-drones-can-help-fight-coronavirus
Hentze, Iris. “COVID-19: Occupational Licensing During Public Emergencies.” NCSL Blog, National Conference of
State Legislatures, August 3, 2020. https://www.ncsl.org/research/labor-and-employment/covid-19-
occupational-licensing-in-public-emergencies.aspx.
Himmelstein, David U. and Steffie Woolhandler “Public Health’s Falling Share of US Health Spending.” American
Journal of Public Health 106, (January 2016): 56-57. doi: 10.2105/AJPH.2015.302908
Institute of Medicine. For the Public's Health Investing in a Healthier Future. Washington, DC: National Acad. Press,
2012. https://www.ncbi.nlm.nih.gov/books/NBK201023/.
Interlandi, Jeneen. “Why We’re Losing the Battle With Covid-19.” New York Times, July 14, 2020.
https://www.nytimes.com/2020/07/14/magazine/covid-19-public-health-texas.html.
Kaiser Family Foundation. “Medicaid Emergency Authority Tracker: Approved State Actions to Address COVID-19.”
Coronavirus (COVID-19). August 21, 2020. https://www.kff.org/medicaid/issue-brief/medicaid-
emergency-authority-tracker-approved-state-actions-to-address-covid-19/.
Kent, Jessica. “Could COVID-19 Help Refine AI, Data Analytics in Healthcare?” Health IT Analytics, April 24, 2020.
https://healthitanalytics.com/features/could-covid-19-help-refine-ai-data-analytics-in-healthcare.
Krishen, Anjala S. and Michelle Petrescu. “The importance of high-quality data and analytics during the pandemic.”
Journal of Marketing and Analytics 8, (2020): 43–44. https://doi.org/10.1057/s41270-020-00079-3.
Lacina, Linda. “COVID-19 reveals gaps in health systems: WHO Briefing.” World Economic Forum, May 6, 2020.
https://www.weforum.org/agenda/2020/05/covid-19-reveals-gaps-in-public-health-system-who-
briefing/.
Minton, Lisa, Liz Vela, and Bruce Wright. “Counting the Cost of Texas Health Care.” Texas Comptroller of Public
Accounts, March 2017. https://comptroller.texas.gov/economy/fiscal-notes/2017/march/health-
care.php#:~:text=%2443%20Billion%20and%20Rising&text=In%20fiscal%202015%2C%20Texas
%20spent,dedicated%20accounts%20within%20general%20revenue.
56
Copyright © Jon Comola, 2020
National Association for School Psychologists. “Need for Crisis Training in Schools.” 2019,
https://www.nasponline.org/professional-development/prepare-training-curriculum/need-for-crisis-
training-in-schools.
National Conference of State Legislatures. “State Fiscal Responses to Coronavirus (COVID-19).” September 4, 2020.
https://www.ncsl.org/research/fiscal-policy/state-fiscal-responses-to-covid-19.aspx.
National Governors Association. “Coronavirus Response.” NGA Center for Best Practices, 2020.
https://www.nga.org/bestpractices/.
National Governors Association. “Coronavirus State Action Chart.” May 12, 2020. https://www.nga.org/wp-
content/uploads/2020/05/CoronavirusStateActionsChart_12May2020.pdf.
National Governors Association. Roadmap to Recovery: A Public Health Guide for Governors. NGA, April 21, 2020.
https://www.nga.org/wp-content/uploads/2020/04/NGA-Report.pdf.
Oderkirk, Jillian. “Readiness of Electronic Health Record Systems to Contribute to National Health Information and
Research.” OECD Health Working Papers, No. 99, OECD Publishing, Paris (2017).
https://doi.org/10.1787/9e296bf3-en
OECD. “Beyond Containment: Health Systems Responses to COVID-19 in the OECD Countries.” April 16, 2020.
https://read.oecd-ilibrary.org/view/?ref=119_119689-
ud5comtf84&title=Beyond_Containment:Health_systems_responses_to_COVID-19_in_the_OECD.
OECD. “Flattening the COVID-19 Peak: Containment and Mitigation Policies.” March 24. 2020. https://read.oecd-
ilibrary.org/view/?ref=124_124999-yt5ggxirhc&title=Flattening_the_COVID-19_peak-
Containment_and_mitigation_policies.
OECD. “Health at a Glance 2019: OECD Indicators.” OECD Publishing, Paris (2019).
https://doi.org/10.1787/19991312.
OECD. “Health for Everyone? Social Inequalities in Health and Health Systems.” OECD Health Policy Studies, OECD
Publishing, Paris (September 27, 2019). https://www.oecd.org/publications/health-for-everyone-
3c8385d0-en.htm.
OECD. “Public Integrity for an Effective COVID-19 Response and Recovery.” OECD Policy Responses to Coronavirus
(COVID-19), OECD, April 19, 2020. http://www.oecd.org/coronavirus/policy-responses/public-integrity-
for-an-effective-covid-19-response-and-recovery-a5c35d8c/.
OECD. “Recommendation of the Council on Health Data Governance.” OECD Legal Instruments (2019).
https://www.oecd.org/health/health-systems/Recommendation-of-OECD-Council-on-Health-Data-
Governance-Booklet.pdf.
Potter, Lloyd B., and Nazul Hoque. “Texas Population Projections, 2010 to 2050.” Office of the State Demographer.
Accessed April 10, 2020. https://demographics.texas.gov/Resources/Publications/2014/2014-
11_ProjectionBrief.pdf.
57
Copyright © Jon Comola, 2020
Public Health Accreditation Board. “Accreditation Snapshot.” Public Health Accreditation Board, 2019.
https://www.phabdata.org/data-portal.
Public Health Accreditation Board. “Benefits of PHAB Accreditation Reaching More Communities as Covered
Population Continues to Climb.” Public Health Accreditation Board, 2020.
https://phaboard.org/2019/09/03/benefits-of-phab-accreditation-reaching-more-communities-as-
covered-population-continues-to-climb/.
Ramsey, Ross. “Analysis: A digital divide with dire consequences for Texas.” Texas Tribune, April 1, 2020.
https://www.texastribune.org/2020/04/01/digital-divide-dire-consequences-texas/.
Ramsey, Ross. “Analysis: Funding for rural broadband in Texas is in trouble. The pandemic might save it.” Texas
Tribune, July 29, 2020. https://www.texastribune.org/2020/07/29/broadband-rural-texas-pandemic/.
Rippe, James M. “The Health Promoting Power of Daily Habits and Practices.” American Journal of Lifestyle
Medicine, (July 20, 2018). https://doi.org/10.1177/1559827618785554.
Robert Wood Johnson Foundation. “A New Way to Talk About the Social Determinants of Health.” Vulnerable
Populations Portfolio. Robert Wood Johnson Foundation, January 1, 2010.
http://www.rwjf.org/content/dam/farm/reports/reports/2010/rwjf63023.
Rovner, Julie. “Opinion: Always The Bridesmaid, Public Health Rarely Spotlighted Until It's Too Late.” NPR, May 1,
2020. https://www.npr.org/sections/health-shots/2020/05/01/848628724/opinion-always-the-
bridesmaid-public-health-rarely-spotlighted-until-its-too-lat.
Rowe, Karly. “The time is now for universal patient identifiers.” Digital Commerce 360, August 25, 2019.
https://www.digitalcommerce360.com/2019/08/25/the-time-is-now-for-universal-patient-identifiers/.
Texas Department of Health Services. “Texas Medical Reserve Corps.” Last updated January 11, 2018.
https://www.dshs.texas.gov/commprep/TexasMRC.aspx.
Texas Health and Human Services. “Public Health Regions.” Texas Department of State Health Service, 2020.
https://dshs.texas.gov/regions/default.shtm.
Texas Health and Human Services. “Texas Local Public Health Organizations.” Texas Department of State Health
Service, 2020. https://dshs.texas.gov/regions/lhds.shtm.
Texas Workforce Commission. “Occupational Employment Statistics (OES).” Texas Labor Market Information, 2020.
https://texaslmi.com/LMIbyCategory/Wages.
Thale. “The electronic passport in 2020 and beyond.” Thale Group, 2019.
https://www.thalesgroup.com/en/markets/digital-identity-and-security/government/passport/electronic-
passport-trends.
Thompson, Kelly and Nicholas Anderson. “Emergency Suspension Powers.” The Policy Surveillance Program. June
21, 2017. http://lawatlas.org/datasets/emergency-powers.
58
Copyright © Jon Comola, 2020
Tumpey, Abbigail J., David Daigle, and Glen Nowak. “Communicating During an Outbreak or Public Health
Investigation.” The CDC Field Epidemiology Manual, (2018). https://www.cdc.gov/eis/field-epi-
manual/chapters/Communicating-Investigation.html.
U.S. Bureau of Labor Statistics. “Epidemiologists.” Occupational Outlook Handbook, U.S. Department of Labor.
visited June 24, 2020. https://www.bls.gov/ooh/life-physical-and-social-science/epidemiologists.htm.
U.S. Bureau of Labor Statistics. “May 2019 State Occupational Employment and Wage Estimates.” Occupational
Employment Statistics, U.S. Department of Labor, 2019. https://www.bls.gov/oes/current/oessrcst.htm.
U.S. Bureau of Labor Statistics. “May 2019 State Occupational Employment and Wage Estimates Texas.”
Occupational Employment Statistics, U.S. Department of Labor, 2019.
https://www.bls.gov/oes/current/oes_tx.htm.
U.S. Bureau of Labor Statistics. “Occupational Employment and Wages, May 2019.” Occupational Employment
Statistics, U.S. Department of Labor, 2019. https://www.bls.gov/oes/current/oes191041.htm.
U.S. Census Bureau. “State Population Totals and Components of Change: 2010-2019.” Census.Gov, U.S.
Department of Commerce, December 30, 2019. https://www.census.gov/data/tables/time-
series/demo/popest/2010s-state-total.html#par_textimage_1574439295.
U.S. Department of Agriculture, 2020. USDA Invests $19 Million In Broadband For Rural Texas Communities.
February 28, 2020. https://www.usda.gov/media/press-releases/2020/02/28/usda-invests-19-million-
broadband-rural-texas-communities.
Washington State Department of Health. “National Accreditation.” Public Health System Resources and Services.
https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/PublicHealthSystemResourcesandServi
ces/NationalAccreditation.
World Health Organization. “Contact Tracing in the Context of COVID-19: Interim Guidance.” May 10, 2020.
https://apps.who.int/iris/handle/10665/332049.
World Health Organization. “Surveillance Strategies for COVID-19 Human Infection: Interim Guidance.”
Institutional Repository for Information Sharing, May 10, 2020.
https://apps.who.int/iris/handle/10665/332051.
59
Copyright © Jon Comola, 2020