BCHC Urges Subcommittee on the Coronavirus Crisis to Help Rebuild Public Health Infrastructure

RE: September 29 Hearing – Upgrading Public Health Infrastructure: The Need to Protect, Rebuild, and Strengthen State and Local Public Health Departments

Dear Chairman Clyburn and Ranking Member Scalise:

I write today on behalf of the Big Cities Health Coalition (BCHC), a forum for leaders of America’s largest metropolitan health departments to exchange strategies and jointly address issues to promote and protect the health and safety of the nearly 62 million people they serve. We laud you for holding this important hearing in the U.S. House Select Subcommittee on the Coronavirus Crisis and appreciate the opportunity to submit a letter for the record. Our members have not only been on the frontlines of the pandemic response for nearly two years now, but have also experienced firsthand public health’s long-standing resource challenges. We very much appreciate the increased focus on public health preparedness and response, including thinking beyond the current public health emergency.

Dr. Mysheika Roberts, Health Commissioner for Columbus, Ohio, is a hearing witness and our Chair-Elect. We support her testimony and suggest that the experiences she shares with the Committee are likely reflective of many of our members’ experiences as well.

As the Committee recognizes, being a public health official throughout the pandemic has been challenging. The workforce is exhausted, overwhelmed, and overworked. Nearly every day I get calls from members discussing when, not if, they are going to retire or move on from their positions because of the relentlessness of the pandemic response. In a similar vein, I get calls from recruiters at least weekly asking me for names of people to fill open vacancies. More and more I have to tell them the bench is empty.

This is catastrophic for our nation’s health. While many knew this was coming, the pandemic has exacerbated the speed at which the “brain drain” is occurring.

At the same time, the public health field as a whole is dealing with unprecedented levels of mis- and dis-information that makes the job of health officials harder and erodes trust not just in the public health system, but also in government as an institution that can do good in people’s lives. Public health leaders across the country, even “on the coasts,” where trust in government and science tends to be more steadfast, have been physically threatened and politically scapegoated throughout the COVID-19 response. One of our BCHC members has had a county sheriff protecting her entire family for more than a year. Putting aside the absurdity of it all, such protection can also be a drain on scarce resources in an emergency. And, this has an impact on the workforce’s own health: as reported in CDC’s Morbidity and Mortality Weekly Report in June 2021, public health workers are at risk for negative mental health consequences because of the prolonged demand during the pandemic response and an unprecedented vaccination campaign.[1]  

While we’ve fought harassment, anti-public health sentiments, preemption, and misinformation, which has challenged the response, we also know that much of the death and disease could have been avoided if we had truly built a robust, well-resourced governmental public health system before the pandemic. An effective response requires a strong preexisting public health infrastructure across all levels of government and all programs, so that we can be prepared for any emergency and can continue to operate all necessary (i.e. “routine”) public health programs. Building the plane while we were flying it, i.e. staffing up in the middle of a crisis, was not ideal – and something we can and must fix.

For future responses, there must be a comprehensive federally led and resourced detection and response infrastructure, developed and carried out in tandem with local and state governments. It is critically important that states and locals are seen as true partners, to provide situational awareness of what is happening on-the-ground and to inform what is needed for the response. Information provided through state and local updates should feed into an all-of -government approach. The lack of comprehensive national guidance and messaging during the early days of the COVID-19 pandemic led to a patchwork of activities across jurisdictions, which remain confusing and inefficient today.

Below we share observations and recommendations to improve the nation’s preparedness and response infrastructure, and our public health system as a whole, based on BCHC members’ experiences over the course of the response. These areas include funding, workforce, data, and equity.

Funding 

The lack of consistent funding over time for public health and emergency preparedness, and even more so in big cities and other local jurisdictions, has necessitated Congress to repeatedly provide emergency supplemental funding to state and local health departments to stand up a response when major outbreaks occur, as was the case with H1N1, Ebola, and Zika. This also occurred after 9/11 when we built systems with large influxes of money and then rolled back those investments after each emergency. How and at what level the federal government supports public health must change.

Local, state, and federal governmental public health must have reliable, consistent funding. This funding should be discretionary and more cross-cutting (non-categorical disease) in nature to support foundational public health work. This would allow health departments to increase cross-sector and root causes work, as well as have more flexible resources for emerging public health issues.

Sustained, direct funding to local health departments for preventing epidemics and other future crises, not just responding to them, is a missing piece of our public health infrastructure. In order to better prevent such outbreaks, federal resources must support data infrastructure and workforce development.  

New funding opportunities for large local health departments in 2021, such as CDC’sNational Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved Communities, Including Racial and Ethnic Minority Populations and Rural Communities, are greatly appreciated and should serve as a model for future funding opportunities to ensure local jurisdictions are well-resourced. As increasing investments are provided to the CDC, we urge you to work with its leaders and those at the Department of Health and Human Services (HHS) to ensure that resources are allocated locally and those dollars are tracked for accountability purposes. Currently, there is little transparency about dollars that flow through states to the local level.

Finally, federal guidelines around permissible expenditures are often too restrictive, creating barriers to acquiring new equipment or space, for example. Small changes, such as permitting federal funds to be used for construction or to buy additional computers, would make a huge difference in the next emergency. The support of Congress is critical to keeping some of this progress in place.

Workforce

Health departments face significant workforce challenges to maintain robust staffing levels and recruit and retain needed professionals. Local and state health departments have lost nearly a quarter (23%) of their workforce since 2008, shedding over 50,000 jobs.[2] The deficiency is compounded by the age of the public health workforce – nearly 55% of public health professionals are over the age of 45 and almost a quarter of health department staff are eligible for retirement.[3] Between those who plan to retire and those who plan to pursue opportunities in the private sector (often due to low wages in the public sector), nearly half of the local and state health department workforce is likely to leave the field over the next several years.[4] Already, we are seeing turnover among BCHC membership: 10 to 15% of our health officials have decided to retire or move on since the pandemic started. Some of this is due to age and tenure, but no doubt also related to the tireless work of the last year plus.

The Biden Administration’s recent workforce initiatives investing $7.4 billion of the Congressionally-allocated American Rescue Plan (ARP) funding is an important step in building the necessary workforce and the pipeline. BCHC strongly supports the House passed FY2022 Labor-HHS-Education Appropriations bill that includes funding for the public health workforce and new funding to support public health infrastructure and capacity. We also support the Public Health Workforce Loan Repayment Act (H.R. 3297), authored by Representatives Jason Crow (D-CO) and Michael Burgess (R-TX), which would create a loan repayment program that would provide up to $35,000 per year per health professional in exchange for a two-year commitment to serve in a local, state, or tribal health department. As new staff are brought into the COVID-19 response, this is an incentive to keep them long term, ensuring their valuable experience is harnessed and remains available for the next crisis.  

Data 

The governmental public health system’s data infrastructure, particularly at the state and local level, is antiquated and inefficient. While the Health Information Technology for Economic and Clinical Health Act (HITECH) supported health care providers in modernizing their data systems, no such federal resources were made available for governmental public health to modernize their electronic records systems. BCHC is appreciative of the COVID supplemental funding provided for CDC’s Data Modernization Initiative. A continued investment over the next decade at the CDC that provides funding to directly support state, local, tribal, and territorial health departments would transform today’s public health surveillance into a state of the art, secure, and fully interoperable system. This investment should support the updating and upgrading of technology, as well as even more basic articulated needs like laptops to enable telework. Federal guidelines must direct the states to be as flexible as possible when distributing dollars to locals, and mandate a detailed accounting of how dollars are allocated and in what time frame(s).  Again, we need more transparency on where federal dollars are being deployed.

There are five core data systems that support the public health surveillance enterprise: National Notifiable Disease Surveillance System (NNDSS), Electronic Case Reporting (ECR), Syndromic Surveillance, Electronic Vital Records System, and Laboratory Information Systems (LIS). These systems need modernization now to protect the health security of all Americans. It took CDC a very long time to stand up syndromic surveillance during this outbreak, using their flu and other similar surveillance systems. Even so, the capacity to do this kind of surveillance at the state and local level varies greatly across the country. Sufficient information exchange between local health departments and health systems/hospitals is also still lacking. The Congress should instruct the CDC to evaluate the current electronic lab reporting system, including with a report on the status of these systems, and dollars should be provided to upgrade the systems as necessary. 

Federal entities need to take both federal capacity and local health department experiences into account when making future recommendations in order to accurately detect emerging infectious diseases. For example, many large local jurisdictions are in favor of a centralized data collection tool and technology systems with standardized capacity metrics, immunization records, and definitions, and would be eager to collaborate with the CDC and partners to ensure this tool is created in such a way that its uptake will be swift and effective.  

Structural Barriers to Equity

Health disparities and inequities in the United States are neither new nor unique to COVID-19, but instead are driven by structural inequities and social determinants of health, including hundreds of years of systemic racism. In order to adequately address the disproportionate impact of COVID-19 on communities of color, we must act now to ensure those most impacted are reached and resourced. 

Achieving equity and good health for future generations, BCHC’s mission, will not be easy. Acting on racism through a public health lens may help to reframe the conversation and illustrate that we are all only as healthy as the least healthy among us. Doing so will mean rebuilding our communities, and in some cases, the systems within which we operate, so that each and every person, no matter where they live, the color of their skin, or where they were born, has the opportunity to live a healthy, full, and productive life. 

The federal government can do small things to move the needle, such as ensuring that CDC produce guidance documents and other content in multiple languages to increase reach to vulnerable populations and alleviate burden on local jurisdictions. Thinking more long-term, in order to actually address disparities, we must commit to investment in communities in order to rebuild trust in medical and public health systems. 

As the pandemic continues, and hopefully soon subsides, public health leaders will continue to encounter the challenges of burnout, politicization, and harassment and job-related threats to them and their staff. We urge leaders at the Federal level to lead, affirming the mandate for public health, raising awareness of the system, and the workforce that supports it. We also urge Congress to learn from the events of the past two years in building back a better, stronger, well-resourced public health system for the next emergency as well as the routine challenges our communities face every day.

Again, we thank you for your foresight, leadership, and service in working to promote and protect the public’s health. The spotlight the Select Subcommittee on the Coronavirus Crisis is placing on public health infrastructure, workforce, and capacity is timely and needed. We appreciate the opportunity to share these recommendations and welcome the opportunity to discuss them with you further. Please do not hesitate to contact me at 202-557-6507 or juliano@bigcitieshealth.org.

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[1] See https://www.cdc.gov/mmwr/volumes/70/wr/mm7026e1.htm

[2] National Association of County and City Health Officials (NACCHO). Keep Communities Healthy by Investing in the Public Health Workforce. August 2020.

[3] Public Health Workforce Interests and Needs Survey, 2017.

[4] Ibid.