Lessons for Public Health Excellence from the COVID-19 Pandemic: A Perspective from New York City

By Hannah Byrnes-Enoch, Nellie Afshar, Jesse Singer, Hannah Helmy, Emiko Otsubo, Kimberly Jocelyn, and Dave A. Chokshi

February 5, 2024 | Discussion Paper

At the beginning of the COVID-19 pandemic, public health leadership in New York City and their response to the emerging pandemic were in the public eye. Immediately, the New York City Department of Health and Mental Hygiene (NYC DOHMH) and other local health departments (LHDs) were expected to be a voice of calm, equitable, data-based guidance amid a maelstrom of information and misinformation—as well as the hub for organizing mass testing, vaccination, and treatment operations. LHDs strove to deliver on these imperatives, often through herculean efforts by dedicated public health workers. However, years of disinvestment—and some cultural attributes associated with the field of public health, described in detail below—meant that many LHDs struggled to scale up to respond to the exigencies of the COVID-19 pandemic (Trust for America’s Health, 2021).

In this paper, the authors consider key lessons from the early stages of the pandemic based on their experiences at NYC DOHMH, seeking to understand how the historical and current context of public health affected the department’s ability to meet the demands of the moment and to assess strategies to pursue excellence in public health practice for COVID-19 response and beyond. Key practice domains of operational excellence, customer service excellence, and data and research excellence are explored and illustrated with real-world examples. Based on this explication, the authors propose a larger-scale re-envisioning of the field of public health and its role in our society, centering around the root causes of inequities and poor health outcomes. Reorienting around a culture of service and action would align our collective priorities with the changes needed to reinvigorate public health for a new era.

Background: Public Health in the United States

Historically, public health advances have led to major improvements in lifespan and overall health around the world, from the development of sanitation systems in the 1800s to the public health interventions spanning milk pasteurization, water chlorination, vaccination, and much more that collectively halved the infant mortality rate in the United States in the early years of the 20th century (CDC, 1999a; Institute of Medicine, 1988). In parallel with the rise of the medical establishment in the United States and the transition into an era in which morbidity and mortality were increasingly due to noncommunicable diseases, public health underwent a major shift (Fairchild et al., 2010). Over the early 20th century, public health as a field moved away from the broad perspective on health and social welfare that had been the hallmark of these and other early successes. The field began to transition away from an operational or boots-on-the-ground approach within a broadly environmental concept of health to a more academic perspective that de-prioritized action in favor of understanding and assessing behavior, risks, and outcomes with a retrospective lens (Fairchild et al., 2010).

In contrast, with the tangible advances of the medical establishment, public health advances in much of the 20th century, such as the progress in sanitation that reduced the incidence of waterborne disease, were relatively intangible to the public and to the politicians who controlled funding and resources. In the well-known paradox of disease prevention, treatment of disease took priority over the difficult, slow, and often unsung work of preventing disease (Fineberg, 2013). In addition to the broader erosion of the ethos of service observed in American culture as a whole, LHDs were positioned poorly for operational excellence at the beginning of the COVID-19 pandemic in 2020—and this further cemented the conception of public health as an invisible, administrative, politically unpopular field (Goldberg, 2012).

Excellence in LHDs has too often translated to public servants executing an array of primarily administrative and retrospective functions competently. Extensive efforts throughout the 20th century to define and develop frameworks of key public health functions resulted most notably in the Ten Essential Public Health Services Framework developed by the Centers for Disease Control and Prevention (CDC), which outlined three types of services: assessment (e.g., data collection and analysis), assurance (active provision of services directed at improving health), and policy development (creation of regulations or standards to guide understanding and action around public health priorities) (CDC, 2021). Over the past decades, funding and political constraints have led most health departments to concentrate on “assessment” and “policy development” services, while the “assurance” services—primarily those focused on actual service delivery—have atrophied (CDC, 2021).

This is not to say that LHDs have renounced larger-scale efforts to improve the health of their communities. Rather, such efforts—and successes—have more often been invisible to the layperson or even been accompanied by negative publicity. Recent efforts within LHDs to influence broader societal factors have received widespread attention—including NYC’s efforts to limit smoking, sodium, and trans fats, as well as its recent declaration of racism as a public health crisis—and have borne fruit in several cases (New York City Board of Health, 2021; Frieden et al., 2008). Such worthwhile initiatives have also, however, redoubled external efforts to frame governmental policy action on public health issues as overreach and, in many cases, have sparked backlash (Chokshi and Stine, 2013). In the case of NYC’s ultimately unsuccessful effort to implement a portion cap on serving sizes of sugar-sweetened beverages during Mayor Michael Bloomberg’s administration, legislators in Mississippi succeeded in passing an “anti-Bloomberg” bill that forbade implementation of equivalent policies by local authorities (Neporent, 2013). Increasingly, these important and necessary efforts to improve public health can require significant political will and capital, particularly in the wake of COVID-19 policies that brought about controversy and divisiveness (Hodge, 2022). A review has found that since the COVID-19 pandemic began, over 26 states have passed laws limiting public health powers and must address these factors as part of their larger-scale efforts (Weber and Barry-Jester, 2021).

Challenges for Local Public Health Departments in Responding to COVID-19

As one of the oldest, largest, and most well-resourced LHDs in the country, NYC DOHMH was relatively well-placed to meet the demands of the pandemic. As of 2021, the agency’s budget is over $2.2 billion, primarily derived from tax dollars, with over 7,000 staff. Yet, it is dwarfed by the medical sector, which employs between half and three-quarters of a million individuals, and overall health spending, estimated at around $86 billion from all sources in NYC alone (Teirlinck, n.d.; U.S. Census Bureau, n.d.; Martiniano and Moore, 2018; Kaiser Family Foundation, 2017). Such disproportionality is common across the country and is one of several major challenges LHDs face in responding to the COVID-19 pandemic.

Budgetary Limitations

Public health budgets and staffing in the United States are not just minuscule compared to the health care sector; they are substantially below the levels needed to deliver routine public health services adequately and equitably. State and local public health departments, on average, require an 80% increase in staffing to provide a minimum set of public health services, deemed the Foundational Public Health Services (FPHS), to their constituents (de Beaumont Foundation, 2021). FPHS were developed by the Public Health National Center for Innovations in 2013 as a framework for the minimum set of capabilities and services that the American public deserves from their LHD. In 2022, the FPHS were revised to include Equity (PHNCI, 2023). The current set is shown in Figure 1. Furthermore, the de Beaumont analysis clarifies that their estimates pertain to routine services and do not include estimates of additional staffing required in public health emergencies. Through the COVID-19 pandemic, it has become clear that under-funded LHDs are required to fill gaps left by the American health care system, including providing access to testing, treatment, and vaccination for people who lack access to traditional medical establishments (DeSalvo et al., 2021).

Over the past several decades, the scope of services expected from LHDs has increased, while efforts to secure consistent, sufficient funding continue to lag (Chokshi and Jarrah, 2021). While funding opportunities may spike following a disease outbreak or other public health event, any new dollars are typically short term, with restrictions ensuring that they can only be used to fill specific gaps or enhance specific services directly tied to the causal event. Such short-term, restricted dollars don’t allow for the long-term strategic planning necessary to plug holes left by decades of disinvestment exemplified in the latest debt-ceiling negotiations that include a rescission of $27 billion in unspent COVID-appropriated funding, with $10 billion of that coming from the Public Health and Social Services Emergency Fund, and another $1.5 billion from the CDC (Rovner, 2023).

Systemic disinvestment in and de-prioritization of public health has left LHDs without the data, technology, infrastructure, and robust community-based workforce, among other resources, that were essential to respond to COVID-19 (Varma, 2022). In the absence of a robust data and technology infrastructure, conducting the complex and rapid analyses needed to guide pandemic response required enormously time-consuming workarounds, further exacerbated by a lack of standardization in approaches to data use, storage, and management across LHDs, national public health bodies, and health care institutions. Similarly, while engagement with community partners has long been a priority, LHDs generally lacked the staffing to go directly into neighborhoods to bring resources, share knowledge, and conduct mass testing and large-scale contact tracing (Castrucci et al., 2021). The lack of a collective understanding of public health as having the duty to address any of the broader aspects of a health crisis, including the existing inequities within society, resulted in public health leadership being boxed in, disregarded, and ill-prepared to take decisive action (Castrucci et al., 2021).

With the advent of effective COVID-19 vaccines and treatments, LHDs, including NYC DOHMH, have increasingly returned to business as usual. And yet the coronavirus pandemic continues, with new variants emerging, long-term health effects of infection becoming apparent, and other viruses, like mpox and RSV (respiratory syncytial virus), threatening and re-emerging dangers—requiring both continued vigilance and continued activity from LHDs and an overstretched workforce exhausted from years of attempting to provide a full spectrum of services while severely under-resourced.

Operational Capacity

The legacy of decades of comparatively intangible and relatively routine work is a national leadership and operational ethos that, while fitted to the typical work of most LHDs, may lack the capacity to pivot to the management of an exceptionally visible, high-urgency emergency response. The COVID-19 pandemic response required an all-hands response, with individuals and teams throughout the government reorienting from routine work. In NYC, for example, a manager of restaurant inspectors (a routine public health function) might suddenly find that they had been reassigned to oversee quality assurance for COVID-19 testing sites; data analysts were reassigned from routine finance reporting to tracking personal protective equipment (PPE) logistics. In light of the need, the NYC DOHMH transitioned large numbers of staff from routine work to full-time emergency response work, with more than half of its staff spending at least some time dedicated to emergency response work.

Yet the routine reality of LHD work meant that the NYC DOHMH did not have the volume of experienced operational and logistical experts, data analysts, and other experts vital to functioning at peak performance in an emergency for a sustained period. Within an LHD of over 7,000 staff, a team of dedicated emergency response logistic and operations experts served as the core of expert field operations staff throughout the response, to the point of burnout and exhaustion due to the lack of available alternates to rotate through these vital emergency response roles. Furthermore, the administrative infrastructure of a large city bureaucracy creates well-documented challenges for rapid approval of contracts, movement of money, large-scale hiring, reassignment of duties, and other necessary components of a rapid response operation. In NYC, among the many challenges caused by this reality was the impact on the NYC DOHMH’s ability to offer, coordinate, and scale testing and vaccination. The ability to meet implementation demands was hampered by staffing shortages and challenges with establishing contracts—and early in the pandemic was also marked by difficulty demonstrating operational capacity, particularly to political leaders. This operational capacity was required to rapidly identify and secure dozens of new sites for offering testing and vaccination in as many accessible locations as possible across the city, such as museums, shopping centers, and tourist destinations, which required teams of logistical experts to assess sites and make necessary accommodations, in addition to developing and negotiating new partnerships, establishing contracts, and outfitting locations for services.

Example: Contact tracing COVID-19 at scale. In June 2020, NYC launched a contact tracing program housed in the city’s public hospital system, NYC Health + Hospitals. While contact tracing for infectious diseases was typically a public health function run by NYC DOHMH, the hospital system’s demonstrably faster contracting and hiring mechanisms and existing operational capacity allowed for the rapid scaling required to meet the demands at that time.

Building Trust

The NYC COVID-19 response put the NYC DOHMH in the position of providing services and information to various audiences—from PPE coordinators at hospitals or community-based organizations to policy makers, elected officials, and beyond—while the situation and data were changing rapidly. These interactions are, fundamentally, a form of customer service. The ability of any LHD, including the NYC DOHMH, to provide such service and information in trustworthy, useful, and responsive ways is a major factor in building—or eroding—trust, and this work undoubtedly impacts how both the public and decision makers perceive and interact with their LHD. In 2009, 43% of Americans viewed the nation’s public health system positively. During the pandemic, this figure fell to 34 percent (Robert Wood Johnson Foundation and Harvard T.H. Chan School of Public Health, 2021). The Global Health Security Index, which ranked countries on pandemic preparedness, ranked the United States lowest on a measure of public confidence in government (GHS Index, 2021). Developing trust with the constituents who use services and better political understanding with the elected officials who facilitate their use is an important factor in health equity more broadly and has been the subject of intense attention over the past year in particular for public health, though not isolated to this discipline (Warren et al., 2020). Without a foundation of trust, public health leaders cannot expect the public or policy makers to pay attention when making recommendations or requests.

Positioning Data to Facilitate Decision Making

Public health professionals tend to prioritize scientific accuracy and rigor, ensuring that chains of evidence are complete and robust before taking action. Yet throughout the COVID-19 pandemic, public health leaders have been in the position of advising policy makers and addressing problems based on woefully incomplete information. Political leaders’ lack of experience and comfort with prioritizing a harm reduction mindset—one in which the course of action most likely to reduce harms for the greatest number was prioritized—contributed to confusion and indecision. In this context, harm reduction meant acting based on incomplete data because the benefit of timely action was more likely to reduce harm than waiting for a complete picture. Public health is a practical pursuit at its core, but it is closely tied to scientific research in that the framework and rigor of scientific research are often applied in public health contexts. The use of public health and epidemiologic data for rapid-cycle policy making differs in important ways from the retrospective analyses, conducted with little expectation of immediate action, that are the typical focus of LHDs.

From the outset of the COVID-19 pandemic, NYC DOHMH leadership had to reframe the decision-making process and work with data teams to rethink how data were visualized and communicated. This required careful understanding of the end-users, balancing the burden of proof with the need to take action and the costs of inaction, and designing different data communication products for different users—using technology, design, and web resources to create products that served the needs for policy makers, media, researchers, and the general public. This required different tools that focused on the most appropriate metrics for the question at hand and new partnerships among various data teams who specialized in different types of data, visualization, and messaging.

Example: Basing decisions on data. From the start of the COVID-19 pandemic, public health leaders fought to base decisions regarding governmental COVID-19 response on data, aiming to set clear thresholds and goals for implementing or lifting interventions and investment in resources. However, directly basing day-by-day policy action on rapidly changing health data was not something LHDs—or politicians—had much experience in. For example, even for something as fundamental as reporting COVID-19 case numbers, there was a tension between conveying the data using specimen collection date (the established epidemiologic method) or using the date a test result was reported. Because political leaders were not accustomed to the lag time associated with reporting such data, it undermined the goal of basing decisions on data. In NYC, it took multiple iterations and collaborations to reach the point where political leadership was comfortable with public health analyses and willing to lean on NYC DOHMH data to justify or explain policy action. Key advancements included investing in data visualization, evidence-based data communication techniques, and web usability, as well as using “nowcasting” methods—which extrapolated real-time results to try to surmount data lag—as much as possible (Greene et al., 2021). Similar efforts to improve real-time data-driven outbreak responses are also occurring at the national level, such as the creation of the Center for Forecasting and Outbreak Analytics at the CDC, established in 2021, now providing resources and analytics expertise through partnerships at the local level.

Toward Public Health Excellence During a Pandemic

The fact that LHDs such as the NYC DOHMH were able to stand up extensive programs providing vital services during a pandemic—from home methadone delivery, in-home vaccination, public health detailing programs, mass vaccination sites, a world-class COVID-19 data website, and tailored educational materials—is testament to the commitment of thousands of public health professionals (Montesano et al., 2021). At the same time, NYC DOHMH struggled internally with balancing tradeoffs, including around spending political capital, a tendency to “admire the problem” (through analysis and re-analysis) rather than focus on the most effective solutions, and a deeply engrained scarcity mindset that led to thinking too small, asking for too little, and not moving quickly enough (Varma et al., 2021). Excellence in public health practice requires practitioners to situate these challenges, and the real-time learnings and adaptations described above, in the context of existing frameworks for public health scope and excellence.

The field of public health has been envisioned and re-envisioned many times (Frieden, 2015; Fairchild, 2010). Two landmark Institute of Medicine reports in 1988 and 2003, The Future of Public Health and The Future of the Public’s Health in the 21^st Century, summarized the efforts of leaders in the field to develop a shared understanding of public health’s role in civil society and the activities that public health entities must undertake to assure health at a population level (Institute of Medicine, 2003; 1988). These reports represent a collective understanding of the duties of public health entities, including LHDs, described in frameworks such as the Ten Essential Public Health Services (see Box 1) (CDC, 2021). Other frameworks tend to offer similar minimum sets of capabilities or responsibilities for government public health (CDC, n.d.; PHNCI, 2023; National Association of County and City Health Officials, 2005; Handler et al., 2001).

Two frameworks in frequent use today, the Public Health Accreditation Board’s national accreditation program standards and measures and the Baldrige Performance Excellence Program, offer detailed criteria for assessing the performance of a health-focused organization (Public Health Foundation, n.d.). The Public Health Accreditation Board explicitly bases its standards on the Ten Essential Public Health Services and provides an excellent description of what public health entities—including LHDs—are tasked with doing (CDC, n.d.; Public Health Accreditation Board, 2013). However, there is little mention of how these tasks should be approached to develop trust or ensure efficient and speedy responses. In contrast, the Baldrige Performance Excellence Program dives deeply into the importance and interconnection of people and process, providing detailed criteria for achieving performance excellence (NIST, 2023). While the Baldrige framework has sometimes been used in health departments, its criteria are generally more oriented toward health care institutions and do not speak directly to many of the challenges and priorities of LHDs, such as public communication (Roberts et al., 2020).

As the early months of COVID-19 played out, previous public health frameworks were insufficient, in the authors’ experience, for achieving practical excellence in the context of new realities of pandemic response, the demands of routine work, and an increasingly fraught relationship with both the public and politicians. Instead, NYC DOHMH pursued new models of practice directly from the lessons of the pandemic and the challenges highlighted. The authors considered what excellence in several areas would look like beyond the COVID-19 pandemic if NYC DOHMH were to maintain the focus on clarity, action, and problem solving that characterized the best of its efforts during the pandemic.

New York City DOHMH “Excellence” Efforts

Programmatic and Operational Excellence

LHD operations span an enormously broad scope, from the foundational services and capabilities succinctly described in the FPHS, to hyper-local and grant-funded priorities, all requiring staffing across numerous skill sets. For example, in just one division of the NYC DOHMH, the staff offers Rat Academy training on how to prevent rodent infestation in neighborhoods, conduct restaurant inspections, analyze environmental policy, and develop community-oriented data stories to spread awareness of the role of the built environment in health. As NYC DOHMH leadership sought to better understand the scale and impact of COVID-19 response operations and how to pivot and assess tradeoffs when competing demands arose, the authors developed a simple set of questions under a structured framework that set the standard for programmatic and operational excellence. Using a consistent, structured framework helped uncover problems, focus on solutions, and enable NYC DOHMH leadership to communicate key aspects of health department programs more efficiently. These questions were embedded into quality performance management systems and used as a framework for evaluating and assessing extant and nascent programs and services.

Fundamentally, these questions were derived from the experience of the commissioner of health (one of the authors, DAC) during his time in service, particularly when he was asked to review program design and operations (see Box 2). Proposed operational changes or new service options were often presented without a clear articulation of the problem, intervention, timeline, potential roadblocks, and risks, leading to the cluster of “what” questions shown in Box 2. Operational accountability was often diffuse, the population served was not well enough elucidated, and teams had not developed the reflex to look to other jurisdictions for lessons we could build upon, leading to the “who” cluster shown in Box 2. Key management and communications questions—particularly around evaluation, funding, and scaling—were the focus of the “how” cluster, also shown in Box 2.

The effect of establishing a simple but clear and complete framework for operational excellence became apparent through several examples:

Restructuring a large, multifaceted suite of programs. The NYC DOHMH New Family Home Visiting program, originally slated to launch in February 2020, was programmed to bring together multiplehome-visiting services toprovide critical support for new parents, including breastfeeding support, education on creating a safe home, mental health screenings, and doula services. However, theorganizational and structural changes required to integrate existing, distinct services and new resources were highly complex, and the leadership capacity necessary for such an undertaking was subsequently subsumed by the COVID-19 pandemic. An organizing framework was needed to help disaggregate the issues into their distinct, solvable components. Using a deliberate and systematic approach supported bythe questions shown in Box 2, this program successfully launched in December 2021, providing much-needed support and services to new parents who needed those
Chartering a special operations team. At the beginning of his tenure, the commissioner of health chartered a “special operations” team reporting directly to him to add rapid-response capacity and to help drive operational excellence. The special operations team incubated new projects, supported fledgling efforts like the Misinformation Response Unit, and provided expertise on key priorities such as improving data visualization efforts. While the team operated out of the commissioner’s office, members also embedded into existing organizational structures where needed, including the incident command system for COVID-19 response.
Enhancing partners’ operational capacity. In several instances, operational excellence meant extending beyond the agency to figure out the right way to support partners’ efforts. In one example, NYC DOHMH undertook a novel collaboration with health plans to pay for provider-initiated outreach for COVID-19 vaccine counseling for unvaccinated people (Gallego et al., 2022). The collective effort, spanning seven insurance companies covering more than 90% of the Medicaid market, and the use of emergency contracting allowed for an idea-to-execution period of six weeks. Another example marshaled NYC DOHMH’s advocacy, legal, communications, and community engagement expertise to help steward the launch of the nation’s first Overdose Prevention Centers, operated by OnPoint NYC (Giglio et al., 2023).

Trust Through Customer Service Excellence

The ultimate mission of an LHD is to serve the public, but much of the daily work is invisible to the public. An average member of the public interacts with the LHD only at certain touchpoints, like when obtaining a birth or death certificate in some jurisdictions, obtaining a dog license, visiting an immunization clinic, or being contacted as part of a case investigation for an infectious disease outbreak in others. But such interactions can reverberate far beyond the original service, affecting how that person perceives the LHD and its work, such as messaging on important public health issues. Distrust in health care providers and the government has been correlated with barriers to care and poorer health outcomes. Trust in government and public institutions has even been correlated with variation in COVID-19 infection and fatality rates, with countries that scored higher in measures of trust having lower infection and fatality rates (Bollyky et al., 2022; Adamecz-Völgyi and Szabó-Morvai, 2021; Wesson et al., 2019; Whetten et al., 2006). Public trust also affects how staff understand their own work, reinforcing a sense of pride and internal motivation in daily activities.

Vital to this effort is the realization that public health and medical institutions are not inherently trustworthy—the history of racial discrimination in medicine alone demonstrates countless examples of institutions betraying the trust of those who sought care (Institute of Medicine, 2003b). And simply increasing the flow of messaging toward a particular group or community is not a way to demonstrate trustworthiness. Instead, creating space for conversations, with careful attention to the medium, format, and timing of communication, is the first step toward building a bidirectional relationship that offers space for developing trust (Holtgrave et al., 2020). Over the past two years, the NYC DOHMH held hundreds of community conversations, established a community advisory board, and supported community organizations to create bidirectional dialogue around COVID-19. The agency spearheaded a citywide Public Health Corps, a cadre of community health workers hired from the neighborhoods they serve to serve as trusted liaisons among New Yorkers, the health system, and community-based organizations (City of New York, 2021). For the longer process of building relationships and demonstrating trustworthiness, we identified the pivotal role of routine interactions in building—or eroding—trust and developed a set of four Customer Service Excellence Principles (Respect, Trust, Empathy, Accountability; see Box 3) as a framework to guide us in reframing our relationships with those we serve, leading to efforts such as:

Reassessing website navigability. Broadening our definition of customer service led to a reassessment of strategies that can be applied to improve navigability of LHD websites and services. After developing the customer service excellence framework, NYC DOHMH developed two new landing pages to help guide users who landed on the main website looking for clinical and public health services. Engaging in iterative website improvements to expand accessibility and ensure user-friendliness touches on each Customer Service Excellence Principle.
Investing in mystery shoppers. NYC DOHMH launched a mystery shopper initiative to assess customer experience with the birth and death certificate workflows, core services that are one of the most common ways individuals interact with the agency. Obtaining birth and death certificates was framed by agency leadership as one of the many small opportunities the NYC DOHMH has to gain or lose the trust of the people we serve. Historically, there have been logistical difficulties with navigating birth and death certificate processes; as such, assessing experience with these processes was seen as a useful sentinel for overall customer experience. Using mystery shoppers, who use a service or process as if they were a typical customer and then share a detailed report on the experience, is common in customer service-oriented industries like retail and restaurants but can be extremely useful in understanding any type of customer service experience. Trialing a mystery shopper initiative for these core services was a first step toward incorporating more explicit accountability while monitoring current-state customer assessments of Respect, Trust, and Empathy.

Data and Research Excellence

Collecting, understanding, and using data for action is a priority for NYC DOHMH. Science for the sake of science, without attention to how it will better people’s lives, is not public health (Lange, 2021). The authors believe that ensuring that data are useful for action and accessible to stakeholders, including the public, should be considered a core LHD service. Centering this priority in the NYC DOHMH’s work required adjustments to how data were managed and used internally and shared externally, and how leadership decided what analyses and dissemination pathways to prioritize. Examples included:

Investing in our commitment to sharing data publicly. At the beginning of the COVID-19 pandemic, NYC DOHMH data and communications teams collaborated to develop actionable, accessible data visualizations, made back-end datasets available for free download on the internet, and ensured that its website evolved to meet the needs of the public, journalists, researchers, and policy makers (Montesano et al., 2021). This commitment to making data easy to access, understand, and use was vital to attempts to ensure that data could be influential. However, the authors realized that there was a need to “go further” and ensure that public health data, research findings, and knowledge were as accessible as possible to the public. Therefore, NYC DOHMH has committed to ensuring all research products are published “open access” with no paywall through our new policy for all agency authors, Ensuring Transparency in Health Through Open Scholarship (ETHOS).
Sharing rapid-turnaround, actionable analyses. Building on lessons from early in the COVID-19 pandemic around the need to make relevant, timely, and actionable data available to broad audiences, a “variant report” for the general public was shared in near real-time during the omicron wave to provide an in-depth understanding of how the omicron variant was changing the landscape of COVID-19 in NYC (NYC DOHMH, 2022a). Another rapid report built on a finding from the variant report showing that the hospitalization rate for Black New Yorkers was more than twice as high as compared with White New Yorkers during the omicron wave, digging into the drivers of the observed inequities and identifying strategies to take action to address structural inequities driving the observed outcomes, including investment in priority neighborhoods and improvements in access to health care (NYC DOHMH, 2022b).
Committing to building an internal, cross-cutting data infrastructure. Early in the COVID-19 pandemic response, an Integrated Data Team was launched as part of the emergency response operations to coordinate across numerous data teams and sources and serve as the central hub for complex data analyses. This team proved to be a critical pillar in nearly every decision throughout the COVID-19 response and offers many strengths and lessons for how to enhance and strengthen overall data infrastructure for cross-functional analysis for ongoing work. Building on the lessons learned, the team identified major objectives for building out supportive, flexible infrastructure for the long term, including data infrastructure modernization; establishing more standardized approaches to data collection, processing, management, and visualization; and building cross-functional analysis expertise. Another example of a more nimble data infrastructure was adapting an existing surveillance system to monitor the collateral impacts of the COVID-19 pandemic on health outcomes such as sexual health and food insecurity (Davies et al., 2023).
Conducting a rigorous internal analysis of recent research outputs to understand which teams within NYC DOHMH publish, what types of research and content areas are being shared, and where gaps exist in pursuit of a more robust, rigorous, and agency-wide data culture. Findings from the analysis identified opportunities to maximize our effectiveness and impact: Half of the NYC DOHMH’s peer-reviewed publications and professional meeting submissions at the time of the analysis came from a single division, and almost half of the studies submitted for agency review employed observational study designs, rather than more rigorous experimental or quasi-experimental designs. Few of the studies measured cost-effectiveness or return on investment of interventions. Furthering this work would require building a framework for research excellence modeled after the work done in the areas of customer service and operational excellence and creating a set of recommendations to strengthen the agency’s research infrastructure based on existing unmet needs, gaps, and challenges.

Conclusion

As public health systems contend with the realities of an ongoing pandemic and other imminent crises—and the simultaneous movement by government and business entities toward business as usual—the greatest risks are those of omission. Failing to capitalize on this moment, when public health is in the spotlight, and the costs of long-term disinvestment are most apparent, would be a tragedy (The Commonwealth Fund, 2022).

Responsibility for investment in LHDs lies with the government, and there is ample evidence that massive investment in public health would yield an equally massive return (Chokshi and Jarrah, 2021). But it is also the responsibility of individual and collective public health entities of the country and, indeed, the world to seize the moment to revisit our conception of the field of public health. This is the opportunity to think boldly about how to turn toward a model in which the people served by public health are viewed as customers, deserving of an LHD that makes an effort to earn—and deserve—trust, in which swift, efficient, and rapidly scalable operations are prioritized. The need for operational capacity is likely to grow as the frequency and intensity of public health emergencies increase, in part due to population migration, shifting human behaviors, and climate change. We have witnessed a glimpse of these changing dynamics during the global mpox outbreak. By investing in operational excellence, we will also invest in long-term staff morale and public trust.

As a starting point for re-conceptualizing the modern role of public health in American life, we can look to shared models of public health excellence, assessing existing tools like the Public Health Accreditation Board’s standards to identify areas where we have collective gaps in our conception of what public health must do and be to achieve excellence. This work is already well underway, with the 2022 revision led by the Public Health National Center for Innovations making substantial progress in re-envisioning the FPHS with a core of equity and a greater focus on the roles of data, technology, and fundamental infrastructure. But the magnitude of the situation calls for more. The authors propose a larger-scale re-envisioning of the field of public health and its role in our society, centering around the root causes of inequities and poor health outcomes, with a focus on service and action. Public health leaders must learn from the challenges and successes of the COVID-19 era and together craft a future for the field that will ensure that we are never again left so ill-equipped in a time of need.

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Authors of a new #NAMPerspectives consider key lessons from the early stages of the pandemic based on their experiences at @nychealthy. Learn more at https://doi.org/10.31478/20242a

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Lessons for Public Health Excellence from the COVID-19 Pandemic: A Perspective from New York City - National Academy of Medicine (2024)