Are Health Departments Outdated?

The summer of 2020 was to be Jacksonville, Florida’s spotlight moment. The Bold New City of the South had been selected as the alternate site of the Republican National Convention. This was going to be fun; the last time Northeast Florida hosted a large event (Super Bowl 2005), cruise ships were anchored in the St. John’s River for extra hotel rooms, restaurants, and nightclubs.¹ But just like Milwaukee, Wisconsin’s plans for the Democrats, COVID-19 shut us down.

Looking from the outside, it is hard to know what obstacles the Florida Department of Health in Duval County might have faced as they prepared for the GOP. But it is likely that their challenges, both before and in the midst of the pandemic, were similar to those described by Jeanette Kowalik in the City of Milwaukee. I suspect that our two cities are not isolated cases. The challenges of disinvestment so well described in her editorial (p. 602)—fractured jurisdictions, inert organizational structures, outdated technology, inadequate funding—are similar to those that plague public health everywhere. Where local problems differ, it is not by nature but by degree.

Kowalik’s description of what has been drives consideration of two larger thoughts. First, we need to identify what public health will look like in the wake of the pandemic. This is not an original idea; the November 2020 issue of AJPH devoted a special section to this very topic.² But there will be no unanimous “gold standard” vision, as what public health looks like in each community will differ with that community’s interests and needs. To resolve issues such as those highlighted by the Wisconsin experience, it is key to focus our national advocacy on the benefits of a robust public health infrastructure and not on a specific format or system. Hopefully, we have learned that such advocacy must encompass an empathetic appreciation for concerns other than those of strictly scientific value.

But even if we are able to advocate effectively on our behalf, who is left to take up the cause? While our professional mojo may be flowing in response to the acute need, this is not a good time to be a health official. Some health agencies have been silenced; and when we speak, our advice may be ridiculed or stapled to the conspiracy of the day. State and local health officers themselves have been subject to withering criticism and physical threat simply for doing their jobs. Lee Norman, the Kansas State health officer occupying my former seat, has been assigned a security detail.³ (Kansans disagree, of course, but we generally do so with a healthy dose of “Midwestern nice.”) Outside the pandemic, health officials are being subject to criminal prosecution for public health incidents that may be beyond their control.⁴

Given all this, who would want the job? Perhaps a few brave (or foolhardy) souls will continue to venture into the shark-infested waters. But they will do so with a lack of institutional knowledge. Since the start of the pandemic, in Kansas alone 27 health officials have left their posts, and one in eight Americans lives in a community that has lost the leader of its local department of public health.^5,6 It seems clear that experience and expertise are no longer the primary requirements for public health leaders. The ability to build relationships with policymakers, the media, and the public to secure one’s relevance and resilience may be more predictive of success.

It has been said that in life, it is not what you know but who you know. Our community must quickly identify those who will take up the challenge of guiding public health into the new decade.