“Despite many, many years of advocacy, funding for local public health has absolutely been stagnant at the state level, and/or been diminished,” said Kertanis, who directs the Farmington Valley Health Department. “We have been exceedingly challenged to really help people understand the full breadth and depth and scope of what public health is and the value and importance of it.”
Kertanis and others in the public health field hope the COVID-19 pandemic has permanently altered that dynamic. As Connecticut manages this crisis and considers how to better prepare for the next one, some officials and experts have a simple suggestion: Invest in the state’s public health infrastructure.
“One of the silver linings of the pandemic is that now everybody knows what public health does, and hopefully everybody sees the value and the relevance to their daily lives of public health,” said Dr. Deidre Gifford, the state’s acting public health commissioner.
“Public health infrastructure in the United States has been dwindling, and people are starting to realize when times are good, public health can function in the background, but it’s very important that there’s a very strong infrastructure in place for the next time there’s a public health emergency, because we all know there will be another one.”
Nationally, per capita public health spending decreased 9.3% between 2008 and 2016, according to a study published in the National Journal of Public Health, and Connecticut hasn’t been an exception.
“That is very acute here in Connecticut, where public health surveillance and certain components of the Department of Public Health have been critically underfunded for decades,” said Dr. Albert Ko, chair of the Department of Epidemiology of Microbial Diseases at the Yale School of Public Health. “This isn’t a problem from the last year or the last administration or even the last 10 years.”
Those in public health hope the pandemic will provide a wake-up call about the need to invest in their field. Already, the Biden administration has pledged to spent $7.4 billion in American Rescue Plan funds to hire and train public health workers — both to bolster the response to the ongoing pandemic and to prepare for similar crises in the future.
In Connecticut, Gov. Ned Lamont has proposed using federal funds for personal protective equipment, financial assistance to local health departments, the modernization of DPH data collection and other infrastructure, access to contraception and more. Altogether, the investment would total more than $92.5 million over the next four years, according to an allocation plan submitted to the legislature.
“I think everybody has a new appreciation of Department of Public Health, don’t they?” Lamont said.
‘Flat-footed and unprepared’
In Connecticut, public health is overseen at the state level by the Department of Public Health and at the local level by 65 local health departments. In non-pandemic times, those agencies are responsible for contact tracing, disease investigation, infectious disease prevention, chronic disease education and more.
The pandemic has brought public health into public view — garnering greater appreciation for the field but also exposing holes in the infrastructure of both the state’s and the nation’s public health systems. Kertanis said the local departments in Connecticut lack necessary expertise in epidemiology, nursing and communication, as well as proper data systems.
Early in the pandemic, for example, the state was forced to build a contact-tracing tool “on the fly,” Kertanis said.
“Unfortunately at both the state and the local level, because of historic disinvestment in public health, we have not been able to keep pace with information technology to the extent we needed to,” she said. “That’s another area where we were flat-footed and unprepared.”
Ko emphasized the “fragmentation” of health care in the United States and said the system often struggles to collect and integrate data. For example, he said, that there’s no easy way to track demographic information about people who are hospitalized due to COVID-19.
“The informatics has just been not up to what we would expect from a robust public health system and not up to what other countries are doing,” Ko said.
Because local health departments are often crucial for reaching vulnerable communities, these issues may help explain why COVID-19 disproportionally affected Black and Latino residents in Connecticut and elsewhere.
“Going into this pandemic, if you asked public health professionals, we knew we were going to see these inequities,” Kertanis said, “because we have not had the liberty of investing in the resources that it takes to really best support those communities and their needs.”
Mark Masselli, the founder of the Community Health Center, said underfunded public health infrastructure left Connecticut with a reactive response to COVID-19, rather than a proactive one.
“You may not have a fire in town, but you still fund the fire department,” Masselli said. “What we learned is nobody was prepared for this pandemic, but our public health infrastructure was woeful in terms of its ability to be prepared.”
Like other states that lacked adequate public health infrastructure, Connecticut relied on private entities — including CHC as well as hospital systems such as Hartford HealthCare, Trinity Health of New England and Yale New Haven Health — to provide coronavirus testing and vaccination.
But Masselli questioned whether that approach can work long term as a comprehensive solution to the state’s public health needs. He said he’d like the state to not only fund a stronger public health system but also plan intentionally for how to utilize that system.
“Obviously money helps, but a strategic plan needs to be put in place,” Masselli said. “This is the state-level — [it] needs to be out of the governor’s office — of a strategic plan about how the public health system is shaped up in Connecticut.’'
‘They need more support’
After decades of underfunding, public health workers hope the last year’s intense focus on their field could finally lead to proactive investment.
So far, the results seem promising. Biden’s $1.9 trillion relief plan signed in March directed funds toward public health schools and programs, as well as the hiring of 100,000 public health workers, which would nearly triple the public health workforce.
According to the White House, these workers were to focus initially on COVD-19 contact tracing and vaccination, then transition into more permanent roles “to build our long-term public health capacity that will help improve quality of care and reduce hospitalization for low-income and underserved communities.”
In Connecticut, Lamont has similarly framed public health investment as a way to fight health disparities. The governor on May 24 outlined a plan to use federal money for universal home visiting, more community health care workers, bolstered mental and behavioral health services, improved data systems and greater support for local health departments.
“[Local health departments] were thrust right into the front lines of this battle against COVID,” Lamont said. “They performed heroically, but they need more support.”
Meanwhile, Lamont said he plans to hire not only a full-time public health commissioner to replace Gifford, who is currently serving as both the acting public health commissioner and the commissioner of the state Department of Social Services — but also someone to oversee health care more generally, including the Department of Public Health, the Department of Social Services and more, possibly as a “supercabinet” position.
“I just think we have too many pieces to the puzzle right now, and sometimes we’re not integrating,” the governor said.
But those who desire greater public health funding still have concerns. What happens when funds from the federal American Rescue Plan eventually dry up? What about as memory of COVID-19 begins to fade? Will state and local officials resume trimming public health budgets just as they have in the past?
Kertanis said the current wave of public health investment won’t matter much if this burst of funding doesn’t translate to sustained investment.
“This can’t be a one-and-done,” she said. “This can’t be a one-time infusion of money and then it goes away. We need to figure out how we sustain that.”
Alex Putterman can be reached at aputterman@courant.com.
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