Coronavirus poses new test for strained public health system

The emergence of the coronavirus could pose a tough test for a public health infrastructure that is fraying at the edges due to years of budget cuts and limited resources.

While the number of public health issues facing the U.S. has increased in recent years, funding has not, stretching thin local and state health departments that are responsible for tracking and containing outbreaks while also addressing other health needs in their communities.

“We have not had a year in our country where we’ve not had a public health emergency to address and we’re continuing to do it on a shoestring budget,” said Dr. Georges Benjamin, executive director of the American Public Health Association (APHA).

That situation has many worried as health workers begin grappling with the threat from the new virus.

Only five people have tested positive for the virus in the U.S. so far, and all had visited Wuhan, the Chinese city where it was first detected. The Centers for Disease Control and Prevention (CDC) says the virus has not spread from person-to-person contact in the U.S., but that is likely to happen as it did in previous outbreaks.

The CDC is monitoring 92 possible cases as of Wednesday afternoon but currently considers the risk to the general public to be low. Still, public health workers are already preparing for the worst as cases increase in China and other countries.

That attention to the coronavirus is likely to add to the strain on health workers and could pull the limited workforce away from other crucial issues, like the flu, which still kills thousands of individuals a year.

Local health departments have lost about 58,000 workers since 2008, and unlike other public sectors, did not rebound after the recession. And the industry is fraught with high staff turnover due to burnout from heavy workloads and low staffing levels, partly due to chronic underfunding of public health in the U.S., advocates say.

“Local health department officials and workers are incredibly dedicated to what they do and always finding ways to fill the gaps,” said Adriane Casalotti, chief of government and public affairs for the National Association of County and City Health Officials, which advocates for local health departments.

“What ends up happening is you end up pulling people off more day-to-day public health priorities when emergency strikes.”

A similar situation unfolded last year when public health workers found themselves dealing with an unexpected measles outbreak that infected more than 1,200 people across the country. In New York City alone, the outbreak cost $6 million.

State and local health departments are already addressing a variety of public health issues right now, including a widespread flu virus, the opioid epidemic, vaping illnesses, rising STD rates, record-high suicide rates and natural disasters.

But they haven’t seen funding increases from Congress or federal health agencies that keep pace with the increasing demands put on health departments.

That makes it hard to stay focused on those issues when another public health emergency arises, experts say.

“We need capacity at those agencies to handle more than one significant issue at the same time and now we just don’t have that level of support,” said John Auerbach, president and CEO of the Trust for America’s Health.

It’s building to be another bad flu season and health departments are working to increase vaccination rates while tracking illnesses and educating the public.

The CDC estimates there have been 15 million flu illnesses, including 140,000 hospitalizations and 8,200 deaths so far this season.

“What often happens in an emergency like coronavirus is you pull everybody who was working on something else and you just push them over to the issue that’s the most urgent and then other things don’t get attended to,” Auerbach said.

“It isn’t the optimal way to minimize risk to the public. You need to have the capacity to respond simultaneously to multiple health issues because, in fact, we face multiple health issues at the same time.”

Funding sources have not kept up with public health needs, experts said.

A key source of funding for state and local health departments is the public health emergency preparedness grants from the CDC.

The grant program, which helps health departments in all 50 states prepare for and respond to public health threats, has seen a 30 percent funding cut since it was first established in 2002, despite an increasing number of public health emergencies. It has been flat-funded for the past two years at $675,000.

The Prevention and Public Health Fund was established under the Affordable Care Act as the first mandatory funding stream for improving the nation’s public health system. In reality, it is often used to pay for other health care programs that aren’t solely focused on preventing diseases and illnesses. While the fund was initially supposed to be at $2 billion by fiscal 2015, cuts and offsets mean it likely won’t reach that number until fiscal 2028.

State governments are also cutting public health funds as they struggle to keep up with the increasing costs of health care.

While total state spending on public health increased by 2 percent in fiscal 2018, 17 states and D.C. cut their funding that year, according to the Trust for America’s Health.

Budget cuts at the federal and state levels often hit local health departments the hardest as they rely on funding from both.

“Some states are better prepared than others but overall the cuts have impacted our readiness, have impacted the number of people you can hire and impacted the number of people who can work in laboratories,” said Benjamin of the APHA.

Congress often approves extra funding for public health emergencies, as it did for Zika in 2016. But months of congressional infighting led to a delay in passing the funds, hampering prevention efforts in the states.

Congress recently created a fund that the Department of Health and Human Services (HHS) can dip into during public health emergencies without congressional approval.

HHS Secretary Alex Azar said Tuesday the CDC will use the money to respond to the coronavirus, but it’s not clear if any of it will trickle down to state and local health departments.

“CDC is currently utilizing these resources for immediate planning and response needs, including surge support for ports of entry, enhanced laboratory capacity, communication/education efforts, and CDC technical assistance,” said an HHS spokesperson.

Benjamin warned of the overall impact on public health if the outbreak persists.

“At the local level, those folks have been hurting from lost staff and resources,” he said.

“They’ll be able to handle this outbreak initially but over time it will become a burden and they’ll have to stop doing other things.”