Leslie Hoglund, PhD, Clinical Assistant Professor in the School of Community & Environmental Health at Old Dominion University, recently worked with legislators and colleagues in Virginia to pass SB 192, which amended and expanded qualification requirements for local health directors, redesigning a restrictive policy that left nearly one-quarter of districts without permanent leadership. We spoke with Dr. Hoglund to learn more about how this transpired, any lessons learned in advocacy and policy support, and what’s next.

CPHLR: Can you tell us why you were focused on this issue and how this effort came about?

LH: The origin of this is really about frustrations with how health policy is made in the Commonwealth of Virginia. It’s not historically been a system that was rooted in research and evidence. I was the division director for population health data at the Virginia Department of Health in 2019 and the process there was that when there was legislation proposed to committees, it would get ferreted out to whatever agencies would do the work. So, we would often get bills — proposals — that might ask to add data fields to a registry or look at collecting new data sources, but I felt like it was kind of backward. We should be the ones driving our data collection to promote health, not being responsive to legislators who don’t know the evidence. I took a certificate in legal epidemiology and went into the course to learn how we might flip this around to be more proactive in terms of health policy.

I also at the time was noticing a large number of vacancies in our local health districts. On any given day there was about 20%-25% of our districts without permanent leadership. The reason why was because one specific law required a medical doctor to be in leadership. And I’m thinking, we’ve got PhDs, MPHs, we have people with long histories in public health who know the laws who know how to do community work, they know population health. Why aren’t we hiring them? There was this void of leadership, and it was unsustainable. It was a revolving door in many districts because medical doctors aren’t inherently in public health.

CPHLR: And they’re also not necessarily trained to do health policy …

LH: Right. And just the way public health is shifting away from direct clinical care. It’s policies, it’s systems, it’s environments, its networks, it’s connections. And our law doesn’t always reflect that.

I left the health department (serendipitously) in December 2019 to join academia. Prior to that I had met with my local senator, Mamie Locke, and had presented her with the backstory on the law related to who’s eligible to be a state health director and she was like, let’s do it. So that was session 2020. Obviously there was a multitude of things happening at that time. It made it through the senate, 40-0, but then died in the house committee. On the first go, on a bill like that, I thought that was a huge win.

Then in 2021 we didn’t feel like it was a good idea to bring it back, so we left it.

CPHLR: How did the pandemic shift this? The interest in the issue shifted, there was much more interest in public health authority…

LH: It did! The organization around the public health response in Virginia was initially not led by the local health department; it was local government that really stepped in to establish these things. I tend to be a little bit of a public health purist, so in my mind it was, why isn’t the health department doing this, it’s what we’re trained for!

In 2023, I reached out again to Senator Locke to see if we could bring the bill back and she told me that Senator Monty Mason had already proposed the bill again. He remembered it and wanted to bring it forward because of the lack of competencies he’d see in the local health departments during the pandemic. Having an OBGYN, for example, come in to manage a pandemic response was huge learning curve. He had gone to visit testing clinics and vaccination clinics and he would talk to the people and there would be an MPH volunteer, medical reserve corps doing registrations and that didn’t make sense to him. So, he proposed it again. It passed and was signed by Governor Youngkin.

The experience of the pandemic and the response by public health is what shifted the interest in hiring individuals for health department director positions who had training in public health specifically. They expanded the criteria to include those who had training in public health.

CPHLR: It seems like that shift because of the pandemic created an invaluable opportunity. Can you talk a little about how you worked with Senators Locke and Mason?

LH: I had known Senator Locke as a parent, through my children, who were part of a senate page program. When I approached her in 2020, I provided her with all the evidence and information. I had done additional analysis looking at other states and what their eligibility criteria were for local health department directors, their infrastructure and set up. I provided her talking points and things like that.

When it was proposed again, there were a lot of things that clicked into place. There is a new health commissioner at the state level who has a different mindset around public health. She had a new perspective and didn’t like that there were so many vacancies either.

Things led to each other, and it worked out.

CPHLR: There was momentum.

LH: Yes, there were concerns about feasibility originally, but as it happens, one of my colleagues who I had mentored for her MPH practicum became the first non-MD local health director in 2023. So, they have implemented whatever systems they needed to do.

As of early January, there were maybe one or two vacancies. Out of 30-some health districts, they’ve definitely hired non-MDs and I think they’re finding that it’s a good thing to have that permanent leadership in place.

CPHLR: Can you speak to the load of supporting this process? As an academic, how did that play out for you?

LH: Around 2022-2023, the Virginia Public Health Association realigned itself with APHA and it started an advocacy and policy committee, which I am a part of. When that bill came around, they made that their top priority legislation that they championed. Their advocacy was a huge component of the passing of that bill.

With Senator Mason, I had provided him with similar information that I’d provided to Senator Locke. His staff and VPHA took the background of what I’d created and really ran with it.

CPHLR: Building alliances and partnerships to increase capacity for this effort — so it’s not all on you — is important. APHA and VPHA have all of those resources.

LH: There was no way I could have done this on my own to carry this forward. VPHA saw this as a great “first win” and they’ve now focused on other ideas based on this inventory that I had done of the Virginia laws.  

CPHLR: How do you feel legal epidemiology and policy surveillance support this work?

LH: I cataloged and made an inventory of the health law, and I saw the gaps in code and what is happening in practice and the disconnect. As well as what is happening in practice and environment that isn’t confined in law, that should be for sustainability reasons.

There is an active role for public health to say that we need a policy in place, or we need to propose a bill without limitations on how we do that. Health is ambiguous, health is for all, and the more we play into this idea that it’s political, the less impact and efficacy we’re going to have in creating healthy communities. VPHA has really taken on this idea of advancing and achieving health equity and doing that through policy and health systems.

I do think I have more impact as a citizen than being inside of the infrastructure of public health, specifically at the state level. In the last four years I’ve had more impact teaching public health and advocating for certain policies.

CPHLR: As an academic, do you feel like your administration was also supportive of this?

LH: Through my clinical track, I had the opportunity and time to use my scholarship in service to the community. I’ve been asked to provide leadership on programs for the community, because I have the experience of working in governmental health and academia gives me the space to continue that work. My main research focus is mostly focused on food security and creating food security for communities.

CPHLR: For any researcher out there who wants to have an impact, how would you recommend positioning themselves to have the ability to do that?

LH: Engaging in this type of work, there must be a mechanism, passion, or desire to improve that interest. Do your homework. My homework was creating a catalog database of the laws and noting when they were last amended, creating comments, looking into other research literatures say about this, what is being done. Start doing analysis of the status of your interest. Be willing to advance some changes and propose ideas, because legislators are always looking for ways to improve the quality of life. If they don’t have to do the homework, and you can do it for them, they will be happy.

I’m happy to be at a university that cherishes academic freedom and promotes action for change. At times publishing becomes the priority, but what is it leading towards or helping to advance. Don’t let it die in the journal; let it come to real life and have an impact.

CPHLR: Is there anything else you would like to add?

LH: I’ll say this one thing, when I first decided to take on this legal epidemiology policy surveillance course, it was for my own professional development. I wasn’t expecting it to lead to legislation change at the state level, but knowing that it is possible, helps me to become a better public health professional and researcher. I hope to bring a legal epidemiology course to our MPH program. My experience has taught me that we can advocate, we can educate, we can get people to see, with just a small little change, that we are able to create a better system that leads to the outcomes we desire – more physical, mental, and social wellbeing.