The firing of former health officer Dr. Bob Lutz from the Spokane Regional Health District sparked questions of the role and structure of local public health boards.
Public health experts say his firing is just another example of how public health has become politicized during the pandemic.
A number of health officers in Washington – including in Yakima, Walla Walla, Lewis, Chelan-Douglas and Okanogan counties – have resigned or retired since the beginning of the pandemic. A petition in the Benton-Franklin health district is circulating to fire the current health officer. In Idaho, one Panhandle Health District board member refused to vote on a mask mandate a few weeks ago, citing “political pressure.”
With Washington state law requiring that elected officials make up the majority of local health boards, a lack of funding statewide and locally, and diverse rules nationally for public health boards, it’s not surprising to many officials how this politicization happened.
And while it is concerning, said Jeff Ketchel, executive director at the Washington State Public Health Association, it’s not anything new.
“The public health system is working exactly as it was designed to work,” he said.
Structure of public health boards
Public health is a broad area, Ketchel said, and people are just now starting to understand the complexity and authority health departments have to keep people safe.
While health departments have become a driving force in the fight against COVID-19, some also administer vaccines, inspect restaurants and certify birth and death records.
Nationwide, the structure and behavior of public health systems vary greatly. Some are centralized, meaning the state department of health makes most decisions. Others are decentralized, meaning they have local control and funding. Others have some sort of mixed control.
The diversity of public health systems often makes it difficult to document and compare public health around the country, said Michael Meit, director of research and programs at the East Tennessee State University Center for Rural Health Research.
Boards of health exist to provide oversight and direction for health departments, Meit said. Typically, the members are local elected officials, and in an ideal world, those people would have public health experience.
In Washington, local governments have the authority to directly address local health issues through local laws. Of the state’s 39 counties, there are 35 local health jurisdictions.
For counties with a home rule charter, the county legislative authority establishes a local board of health and its membership and selection process. For counties without a home rule charter, the board of county commissioners constitutes the local board of health, unless they are part of a multicounty health district.
Local health districts across the state are composed of either one, two or three counties. For example, the Spokane Regional Health District is composed only of Spokane County. But Ferry, Pend Oreille and Stevens counties make up the Northeast Tri County Health District.
In all health districts, elected officials must constitute the majority of the local health boards, according to state law.
In a district with one county, the county legislative authority may appoint both elected officials and non-elected officials as members of the board.
In Spokane, the 12-member board of health includes three Spokane County Commissioners, three Spokane City Council members, two Spokane Valley City Council members, one elected official representing small cities and three citizen representatives who are appointed by commissioners.
Two or more counties may join together to form a health district as long as the boards of county commissioners pass a resolution regarding the formation. The board for a multicounty district must include at least five members for those with two counties and seven members for those with three counties. The board must also include two county commissioners for each county in the district. County commissioners can also appoint members of the public.
Washington state law allows a health district to appoint an administrative officer, whose job is to administer the operations of the board, except for duties assigned to the health officer. It is not required that a health district appoint an administrative officer.
The Spokane Regional Health District currently does have an administrative officer, Amelia Clark, who started her role in September 2019. With the direction of the board of health, Clark’s job is to provide overall leadership for the successful operation of the district, according to the district’s website.
In the Northeast Tri County Health District, two county commissioners from each county and one elected official representing a town or city in each county serve on the board.
In Idaho, health districts look a little different. The state has seven health districts, each comprised of multiple counties.
For districts with fewer than eight counties, such as the Panhandle Health District, the board of health consists of seven members to be appointed by the boards of county commissioners within the district. Each board of county commissioners may appoint a board member if they choose. For districts with more than eight counties, the boards of county commissioners may appoint eight or nine members.
The Panhandle Health District Board of Health is made up of seven members, including a Shoshone County commissioner, a Boundary County commissioner, two representatives from Kootenai County, two representatives from Bonner County and one representative from Benewah County.
“Having boards entirely made up of elected officials is difficult because they have a certain oversight role to play of a health department,” said Betty Bekemeier, director of the Northwest Center for Public Health Practice at the School of Public Health at the University of Washington.
Role of public health boards
Ketchel, who has worked for three public health jurisdictions, said each public health district is different in how they operate.
“If you look at one jurisdiction, it will not necessarily inform you about another one,” he said.
The public health board often sees that the budget is being handled and proper services are being followed, Ketchel said. One of the primary roles of a local public health board is to appoint the health officer, who is required by state law to be an experienced physician licensed to practice medicine.
Ideally, the board would help facilitate the decision-making power but always have the backs of the local health department, Bekemeier said.
Multiple national organizations exist to provide support and guidance to local public health departments, despite their differences across the country.
The National Association of Local Boards of Health works to improve public health guidance by providing resources and support to local boards of health.
The association’s vision for boards of health is that they are appointed as a result of a well-informed selection process, comprised of individuals who have demonstrated knowledge and skills to serve, and effectively serve the public health needs of their community. The group also created a model of six functions of public health governance. Those include:
- Lead and contribute to the development of policies that protect and improve public health
- Assure the availability of adequate resources to perform public health services
- Exercise legal authority as applicable by law and understand the roles of the governing body
- Build community partnership to protect community health
- Routinely evaluate, monitor and set measurable outcomes for improving health
- Assume the ultimate responsibility for public health performance in the community
The Centers for Disease Control and Prevention also has guidance for public health departments, statewide and locally. Their 10 essential public health services include assessing and monitoring health status, investigating health problems, communicating effectively to inform and educate the public, and creating and implementing policies, plans and laws that affect health.
Proposed changes in local public health
In an effort to curb politicization, Rep. Marcus Riccelli, who has been outspoken about his disappointment in the firing of Lutz, is drafting legislation that would restructure local public health boards.
His proposal would change the composition of local boards so at least half of the board is non-elected officials. These people must either be health professionals with active or retired-active licenses or trained and employed epidemiologists.
The bill would also require counties whose board of county commissioners currently serve as the board of health to adopt a separate board of health. County commissioners in any county could still serve on the board as long as they don’t make up of the majority, Riccelli said.
“We’re in the midst of a pandemic, and we need leadership,” Riccelli said. “We need health care professionals to be weighing in.”
The Public Health Action Coalition Team of Spokane formed after Lutz’s firing with a goal of holding the health board accountable, member Jerrie Allard said.
The coalition plans to file complaints with appropriate state and local agencies and eventually develop language to address systemic public health issues, including censorship of the public health officer and makeup of the board. Members of the coalition include health care, labor and education groups, underrepresented communities, community activists and business associations.
Those who supported Lutz argued he should be able to make public health statements without risking censorship from the board or administrator.
Allard said she did not feel the firing of Lutz was done in the community’s best interests.
“We want to keep this topic alive,” Allard said.
Ketchel, who is also working with the coalition, plans to advocate for more funding for public health during this legislative session. It’s something he does every year, but this year it feels especially important.
When the pandemic hit, he said not a single public health agency was ready, but they did the best they could with the little resources they had.
“I don’t think this is the public health system our communities deserve,” he said. “We’re the richest country in the world.”
Meit said the country needs to get to a place where science is driving the decision-making, not politics.
Bekemeier agreed. She said a few months ago, she thought the pandemic would’ve emphasized the importance of public health officials and local boards. Now, she fears the pendulum has swung to the other side.
“That they’re being vilified for their work is unconscionable,” she said. “That has to change.”
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