~Torney Smith
Spokane Regional Health District Administrator  

Half of Spokane County, Washington’s youth experienced at least one violence-related incident in the past year, according to findings recently released by Spokane Regional Health District (SRHD). Those numbers only tell part of the story of violence in Spokane County - over 50,000 incidents of child abuse were verified in the last decade. For the most recent year of data available, black and Hispanic students were more likely to report being arrested; Native American/Alaska Native students were more likely to have been bullied; and there were over 4,000 victims of domestic violence, the new SRHD report says.  

“The increase in violence perpetuated among children and people of color in this community is especially abhorrent,” said SRHD Community and Family Services Director Sheila Masteller. “This landmark report paints a clear picture of the numerous and substantial impacts that violence has on human health and well-being in our community.” 

The report, Confronting Violence, and its predecessors that look at other determinants of health and well-being in Spokane County - race and ethnicity, neighborhood, housing, education, income and more - collectively pose an important question for local public health. With such complex issues affecting health and quality of life, what is the role and responsibility of the health department in this community?

Spokane Regional Health District is the public health agency in this eastern region of Washington state, with nearly 250 employees providing approximately 40 different programs and services to a population of more than 475,000. Like its peers across the U.S., SRHD champions public health as an essential set of services guaranteed to all citizens—a network of local, state and national professionals working together for a safer and healthier community for all. Yet, taking into account the aforementioned violence indicators, in concert with others like an 18-year gap in life expectancy between Spokane’s least- and most-affluent neighborhoods, it is easy to see that not all Spokanites are afforded the same safety and health protections.

Formed in 1970, SRHD made a name for itself for decades as a primary collector of population health information, a fountain of one-on-one intervention in the name of healthier mothers and babies, a staunch defender of safer and healthier foods, an educator of tobacco as a health hazard, and much more. Yet, the health care needs of Spokane’s population began changing—to the tune of unacceptably high rates of diabetes, heart disease and stroke.  The demographics of Spokane County began changing; a population that was aging, while also getting less white—a welcome change from 95 percent white in 1990 to 92 percent white in 2015¹. The Spokane community also began looking to SRHD as an interpreter and distributor of information, rather than its collector.  

Unless Spokane Regional Health District recognized these new circumstances and adapted accordingly, it ran the risk of not just being ineffective, but of becoming obsolete. As SRHD embarks on a new journey to meet the changing needs of its community, it is clear that confronting and addressing the determinants that lead to poor health, like violence, will be paramount. There is an immediate need to collaborate with non-traditional partners to address factors as diverse as youth arrests, transportation, lack of affordable housing, high school dropout rates, neighborhood safety and more, which contribute to elevated risk for illness, injury, and premature death in Spokane community. Encouragingly, partners in the area are elevating their approaches beyond education and direct intervene to focus on environmental, policy, and systems-level changes.

Working on these issues pushes many public health agencies out of their comfort zones, yet the National Association of County and City Health Officials commended SRHD for leading this charge proactively. Through the health district’s foresight, which was also fueled by stale funding in the state, SRHD was already exploring more impactful intervention strategies. These approaches also led to accreditation for SRHD through the Public Health Accreditation Board, among the first cohort accredited in 2013.  

SRHD’s cross-sectoral, multi-tier tactics in defeating determinants is an approach that is echoed in Public Health 3.0, an initiative led by the U.S. Department of Health and Human Services Office of the Assistant Secretary for Health, touted as a major upgrade in public health practice to emphasize actions that directly affect the social determinants of health and advance health equity. It represents a challenge to business leaders, community leaders, state lawmakers, and federal policymakers to incorporate health into all areas of governance. And bonus, Public Health 3.0 builds on the work of Healthy People 2020, which encourages collaborations across communities and sectors.

It is a transition that is also very much in line with Public Health Leadership Forum’s creation of a sweeping new role for public health, one they call the “chief health strategist” of a community. As SRHD embraces public health’s new identity, it continues to build upon its past and present functions, such as food safety and local source control; infectious disease control; all hazards preparedness and response, and other foundational services - yet it is deviating from its traditional approaches, while expanding on new skills and expertise.

  The health district’s leadership is no longer about one person at the top, it is an amalgamation of program leaders and agency representatives, in concert with coalitions of experts - both inside and outside public health - collaborating and working toward the same goals. As it works to engage with traditional and non-traditional stakeholders to actively address the social determinants of health inequity, Spokane Regional Health District is defined as being many leaders in the community.

To this end, staff are now more focused on designing policies than providing direct services. For instance, SRHD partners with Spokane Regional Transportation Council (SRTC) on active living and transportation design. Efforts include the Walk. Bike. Bus. [MJP1] program, which promotes alternative modes of transportation, and the Complete Streets program, which aims to create roads designed and operated with users’ health and safety in mind. SRHD supports SRTC in advocating for transportation policies that support physical activity and environmental health.

SRHD team members are busy convening coalitions rather than working in siloes. A prime example of this teamwork lies in Priority Spokane, a multi-disciplinary workgroup that serves as a catalyst and convener for focused improvements in economic vitality, education, the environment, health, and community safety. Priority Spokane received a Culture of Health Award from the Robert Wood Johnson Foundation (RWJF) in 2014.

Priority Spokane worked with Spokane’s largest public school district, Spokane Public Schools, to conduct a study over two years of 7,000 students to learn when students began to fall behind and when they subsequently dropped out. The findings revealed tipping points in three categories: attendance, behaviors, and course completion. Together with partners — including RWJF, community members, Gonzaga University, and lawmakers — Priority Spokane and Spokane Public Schools developed and implemented strategies to address each tipping point and increase educational attainment.

Looking to the future, staff are also setting the tone and pace for Spokane’s health promotion efforts in partnership with health care clinicians and leaders in widely diverse sectors, from social services to education to transportation to public safety and community development. For instance, there is SRHD’s community health worker[MJP1]  initiative, where staff partner with low-income housing providers to empower trained workers in these housing properties to provide education and coaching to residents to stop smoking, get more physical activity and eat healthier—all of which are steps proven to reduce hypertension, prediabetes, diabetes, heart disease, stroke and cancer. 

Despite these early collaborative successes, Spokane Regional Health District team members realize continued partnerships will happen only if they are made priorities. These partnerships also require further developing in-house and out-of-house experience and skills in how to effectively influence policy.

Yet this shift should not be seen as a deviation from SRHD’s core mission, which remains: to always work to protect and improve the public’s health. Leaders and staff are more aware than ever of their potential to impact all lives in Spokane County—especially its underserved populations, with a focus on health disparities. The aforementioned unfair distribution of violence in Spokane reaffirms why this shift is critically important.   

Additionally, SRHD’s Confronting Violence report acts as another prime example of how Spokane Regional Health District is becoming its community’s chief health strategist. The report is truly one of the community’s first looks at violence through not only a lens of inequity, but also a lens of prevention—a look toward the future and the challenges that lie ahead. It examines the risk and protective factors related to violence locally, as well as looking more closely at service gaps. Its strategies are segmented by environmental, policy, and systems-level changes.  

Said Masteller, “Our hope is that the information presented will serve as a vital tool to guide collaborative efforts among partners across Spokane County, and shape future funding and program initiatives to confront violence.”  

It requires that stakeholders consider where alignment and partnership with other organizations can be furthered in Spokane County, as it accepts that combating violence will take the collective efforts of many non-traditional partners, at many different levels, especially in changing policies and shifting cultural views. As SRHD’s attention to the factors contributing to poor health outcomes, like violence, increases, the role of non-health sectors in optimizing the health of the county has become critical.  

Spokane Regional Health District stands shoulder to shoulder with other local and state health departments as they work to adapt and evolve, to become their community’s chief health strategist, to address emerging health demands, minimize current as well as looming pitfalls, and take advantage of new and promising opportunities.

¹Source: Legacy: Washington State Department of Health and Krupski Consulting, 1990-2009 Population Estimates: Population Estimates for Public Health Assessment, 1990-2011, December 2012<br/></br>Revised: Washington State Office of Financial Management, Forecasting Division, single year intercensal estimates 2001-2015, June, 2015.