When Dr. David Bishai stepped into the role of Harford County health officer, he did so with an eye toward mitigating the coronavirus pandemic in the relatively conservative Baltimore suburb. He hoped to keep more people out of hospitals, prevent sickness from spreading and improve outcomes among residents of color.
In Bishai’s view, he did what he could over the next nine months with the powers he had. He navigated a complex COVID-19 vaccine rollout, advocated for sensible mask-wearing guidelines and helped oversee the process of county children returning to schools this fall.
So when Bishai received his termination notice Oct. 22, he reasoned that leading with science among a population known to skew to the political right cost him the job.
“They’ll say they do internet research and masks don’t work,” Bishai said Tuesday of his critics. “And this measure, according to internet research, is ineffective.”
Those responsible for Bishai’s termination — the Harford County Council, which recommended his removal in a closed-door meeting, and the Maryland Department of Health, which approved the measure — won’t talk publicly about what they call a confidential personnel matter.
To Bishai, the termination fit with a pattern of external pressures he faced on the job, including from at least one local politician who called on him in May to resign for advising unvaccinated students in a marching band to wear masks with slits and put covers on the bells of their wind and brass instruments. He said he faced discipline for mentoring public health students during his county workday (he’s an adjunct professor at Johns Hopkins Bloomberg School of Public Health) and a vague complaint about his leadership style.
Be it the message or the messenger, Bishai’s firing underscores the difficult nature of holding down a leadership post in the public health field during the pandemic. All the more so that it followed two other Maryland health officers stepping down in as many months, citing political hurdles, aspects of the situation that were beyond their control, and even threats against their lives.
There’s been a high rate of turnover industrywide as job duties have mounted and pressure looms large over those responsible for the life and death of residents.
Some 500 health officers have left their jobs since the pandemic started, with hundreds of resignations or departures taking place in the past few months alone, said Adriane Casalotti, chief of government and public affairs at the National Association of County and City Health Officials.
Casalotti said that doesn’t include other workers — the deputies, directors, nurses and community health organizers, for example — who have left for more sustainable and better-paying jobs. Each departure, she said, can have a ripple effect and destabilize an organization, particularly when an individual has multiple job titles or responsibilities.
“For some departments, losing one person could be losing 25% of the workforce,” Casalotti said. “It means folks that have now a year or a year-and-a-half’s experience in the greatest public health challenge of our lifetimes, won’t be in the system when the next crisis hits.”
Ed Singer, who led the Carroll County Health Department for six years, as well as heading the Maryland Association of County Health Officers, will move to an unrelated job in county government after Wednesday. Keeping the details of the resignation to himself, he said only that he was unhappy to leave.
Dr. Travis Gayles, who led Montgomery County’s health department for about four years, stepped down in September after experiencing what County Executive Marc Elrich described as a “torrent of hate and vitriol from segments of the public, including receiving threats on his safety, racist and homophobic emails, and social media attacks.”
Neither Singer nor Gayles responded Thursday to requests for comment. But Gayles, in a previous interview, described working against a “headwind.”
Gayles said one thing that helped was connecting with his Baltimore counterpart, city Health Commissioner Dr. Letitia Dzirasa. “We collectively talked through where we needed to go, and that’s something I value a lot, from a formal perspective. But selfishly, I have been very thankful for her friendship.”
Even in heavily left-leaning Maryland, where Democrats outnumber Republicans by large margins and tend to be more receptive toward public health guidance and vaccinations, opposition has arisen, said Dr. Peter Beilenson, a former Baltimore health commissioner and Howard County health officer who resigned in December as Sacramento, California’s health officer.
Beilenson said health leadership positions in government have become untenable, especially given the round-the-clock demands of the pandemic. Compared with private practice, they also don’t pay particularly well, he said, especially for those coming in with student debt.
Even in counties with more Democrats than Republicans, local health departments have come under fire for guidance perceived by some as too lax and by others as violations of their rights, Beilenson said.
“It’s been a very difficult time, and everything is so politicized and polarized, people get very, very angry ... if they’re being told to do something they don’t agree with,” Beilenson said.
“The problem with politicization is, you got close to half the population screaming, ‘This is not true, this is not the facts,’ when they are indeed facts. And you have to have people agree to a common set of facts to move forward.”
Decadeslong underinvestment in the field became apparent as COVID-19 gained strength in the U.S. early in 2020. Small budgets, limited staff and a flood of responsibility overwhelmed departments as they juggled routine duties with the demands of a novel emergency. Those included everything from distributing personal protective equipment, standing up testing and contact tracing operations, and establishing vaccination clinics.
Adjusting for inflation, federal preparedness funding for local departments fell by nearly half from 2003 to 2020, according to researchers from Trust for America’s Health, a Washington, D.C.-based health policy organization. With those cuts came steep declines in the public health workforce, with an estimated 55,000 jobs lost since the 2008 recession, according to scholars at Johns Hopkins Bloomberg School of Public Health and Georgetown University’s O’Neill Institute for National and Global Health Law.
For Dr. Nilesh Kalyanaraman in Anne Arundel County, who assumed the job of county health officer just months before the coronavirus surfaced, diminished resources meant scaling back programs related to behavioral health, sexually transmitted infections and environmental health to respond to the pandemic. He said a lack of federal funding in public health contributed to his county’s shortcomings.
A better operation, he said, would include funds for all programs to continue at full capacity during emergencies, as well as budgeted dollars for data and informatics systems to help officials track problems and understand their severity and scale.
“We’ll have another infectious disease in a decade, so building that resilience into public health will be key,” Kalyanaraman said earlier this year.
His personal resiliency was tested as he worked long hours alongside a tired staff, albeit one that grew as more funds became available during the pandemic. Then in January, as county and state officials focused on returning students to schools, Gov. Larry Hogan wrote to a constituent on Facebook that Kalyanaraman “doesn’t really know what he is talking about” when the health officer suggested schools stay closed until the case rate per 100,000 residents improved.
Kalyanaraman declined to discuss the criticism but acknowledged it as one of the many challenges health officers encounter during a routine day. It helps, he said, to have had the support of county government leaders, which not every health officer has.
“It’s absolutely a critical piece to have support from the county executive and leadership, and I can’t credit that enough for our ability to weather all of this,” he said.
In Howard County, health officer Dr. Maura Rossman, now interim chair of the county health officers association in the state, said she, too, benefits from the support of her local government.
The work is still hard, though, she said, and incentives to join the force may not be enough for the next generation of hires. Rossman said public health needs an overhaul in the way it’s funded, which usually involves compiling grants and targeting them for specific purposes. Such funds sometimes come too late to make a difference, she said, and often have strict deadlines.
“We don’t fund our police force like that, we don’t fund [emergency medical services] or fire like that, we don’t fund our education system like that,” Rossman said. “It comes too late, then it disappears.”
Casalotti, of NACCHO, said public health officers also need relief from the barrage of hateful and threatening messages they receive. The organization sent a letter to the U.S. Department of Justice this month that urged the agency to focus on attacks related to public health workers’ response to the pandemic. So far, NACCHO has not received a reply.
“How long people hang on, and keep fighting the good fight, is impacted by how much support they feel they have,” Casalotti said.