As the coronavirus began spreading into America last winter, Baltimore Health Commissioner Letitia Dzirasa was busy working on a new strategic plan for her department. Planning for an emergency quickly gave way to actually fighting one.
The city needed to ramp up testing, contact tracing and other measures, she said, but it soon became clear that the health department didn’t have all the resources it needed, starting with staff that numbered about 900.
”For a city of our size, we should be double that,” Dzirasa said. “We were overworked and underpaid when this pandemic started. And when this started, we didn’t have the adequate infrastructure that was warranted.”
What experts say is underinvestment in public health now shows in the lagging percentage of residents vaccinated across the state, especially among the most vulnerable populations. Higher proportions of white people have been given a shot compared with Black and Latino people. And city officials have clashed with Maryland Gov. Larry Hogan over how Baltimore is handling its share of still-scarce vaccine.
Public health officials and experts say the rocky vaccine rollout reflects both major policy failures and leadership problems. But a core issue is the tattered state of public health at all levels of government, under-resourced and understaffed for years, as people grew less interested and sometimes less trustful and decision-makers followed suit.
In Baltimore and across the country, officials say it was not a single decision to divert funds and attention, but years of disinvestment. That left limited lab capacity to identify threats and meager stockpiles of supplies needed for everything from protecting workers and filling vaccine vials. It diminished the workforce needed for effective testing, surveillance, outreach and vaccinations.
As the coronavirus battered the country, the lack of resources, coupled with uneven cooperation and leadership across the country, has had some “tragic” consequences for life and the economy.
“It’s been a very unfortunate learning experience about how important it is to have a strong public health system,” said Dr. Joshua Sharfstein, a vice dean of the Johns Hopkins Bloomberg School of Public Health who has worked in local, state and federal public health positions.
“At every step, the country struggled,” the former Baltimore health commissioner said, “starting with testing and communications and now with the vaccine rollout.”
In Baltimore, Dzirasa turned to public-private partnerships to beef up community health and contact tracing staffing.
Once vaccines started to become available, she collaborated with local hospitals to help deliver doses throughout the city. The department lacked enough clinicians to do so quickly, and Dzirasa said she wanted to focus on reaching smaller pockets of the most at risk for severe disease, such as seniors and the homebound.
The move sparked criticism from at least one City Council member who said it allowed the department to avoid accountability. The Hogan administration later accused the city of turning away extra doses and receiving more than it was “entitled to,” accounts that city officials dispute.
Meanwhile, the city still trails all but two other state jurisdictions in getting vaccines to its residents, state data shows.
Public health experts say that once the pandemic ends they need to consider such episodes and determine what worked well and what didn’t to help prepare for the next outbreak or pandemic.
That process has begun, including by officials at the health policy group Trust for America’s Health. The group produces a yearly assessment, and the latest found a $4.5 billion annual investment shortfall in public health agencies.
The list of needs is long and includes funding to prepare for an emergency and how to respond to one. Hospitals and health systems need proper surge plans and systems to coordinate resources, as do all levels of government. The report also found that other preparation was needed to shore up the health of communities beforehand, with increased access to health insurance and care.
The group said public health investment did go up from 2019 to 2020 in 43 states by an average of about 12%, with Maryland increasing its investment about 4%.
Congress, under the new Biden administration, also recently passed billions of dollars in emergency funding as part of the American Rescue Plan for such things as vaccine distribution, communications, supplies and protective equipment, as well as the development of new vaccines, data modernization and workforce development.
But small annual increases and one-time emergency funding are insufficient, said Dara Lieberman, a report author and director of government relations for the Trust for America’s Health.
“A lot of public health experts warned we’d be able to weather small-scale emergencies or outbreaks or local or regional emergencies,” she said. “But we were not ready for the surge capacity needed for a major disease outbreak or pandemic.”
Officials at the U.S. Centers for Disease Control and Prevention noted the shortcomings in a statement released March 11 in observance of the first year of the pandemic that has led to more than 536,000 deaths in the United States.
“Through the near-blinding spotlight of this crisis, we now clearly see what we should have addressed before,” said the statement about long-standing health inequities, neglect of infrastructure and a reactive rather than preventive posture on public health. “To move past this pandemic, we must resolutely face these challenges head on.”
Some in public health expressed concerns that attention will wane, as happened after other infectious disease outbreaks that killed or injured thousands: the H1N1 flu in 2009; Ebola from 2014 to 2016; and Zika beginning in 2015.
Attention could evaporate soon after vaccines become more widely available and restrictions are lifted, said Brian Castrucci, president and CEO of the de Beaumont Foundation, a health-focused charitable group.
Local and national leaders may be unwilling to direct resources at the next threat that doesn’t yet exist.
“In some ways, the vaccine works against us, because once we can go back to normal, then there are a lot of things that are much more important,” at least in the eyes of politicians, Castrucci said.
Dr. Georges Benjamin, executive director of the American Public Health Association, said it can be tough to quantify the role of the local public health agency for elected leaders and the public. It’s behind-the-scenes work that stops bad things from happening, such as contaminated water, unsanitary restaurants and disease outbreaks.
He said a bigger problem, however, may be mistrust of government and the politicization of once-mundane guidance. In this case, mask-wearing, quarantining and sharing of information with the public health system, which made controlling the pandemic harder.
“In many ways this response aligns with the anti-government mindset that has been developing in the country for some time,” Benjamin said. “We even have elected leaders who understand poorly why an investment has been or should be made over the years.”
Much has been made of vaccine hesitancy by minority groups, he noted, but surveys now show those identifying as conservative have a higher rate of rejection. And, he said, there is inconsistent messaging to counter misinformation.
Lack of coordination and consistent leadership also made the vaccine rollout tougher.
The federal government pumped billions of dollars into vaccine development and manufacturing, leading to three authorized vaccines in less than a year. Then federal authorities left distribution largely to states, which passed much of the work on to localities.
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“They had a bad hand,” Dr. Eric Toner, a senior scholar with the Johns Hopkins Center for Health Security, said of local public health agencies. “They did not have enough staff or funding.”
Though Maryland health leaders increasingly diverted doses to pharmacies and mass centers operated by hospitals and others they view as more efficient to deploy vaccines, local health leaders argue they know their communities best and should manage doses until supplies vastly increase.
Dr. Nilesh Kalyanaraman, Anne Arundel County’s health officer, said he can divert attention from other community health initiatives to manage pandemic-related needs such as contact tracing and vaccine distribution. To free resources, he moved funds from programs related to sexually transmitted infections and behavioral and environmental health.
He said the moves have been tough, but he’s hampered mostly by what he doesn’t control. Anne Arundel is the state’s fifth-most populous jurisdiction but has received the lowest number of doses per person from the state.
“We do everything we can with limited funding, but when these kinds of events occur, we don’t have the infrastructure to respond as quickly,” he said. “We’re stretching staffs at levels that are really challenging.”
Dzirasa, meanwhile, is examining how to change policy and budgets to ensure a healthier and more equitable landscape going into the next crisis. She hopes the agency soon can take a proactive, rather than reactive, approach to community health.
“We have hopefully learned a lot of lessons from this pandemic,” she said, “such as a need of supporting public health for the long haul.”