COVID-19—The Historical Lessons of the Pandemic Reinforce Systemic Flaws and Exacerbate Inequity

The COVID-19 pandemic demonstrates the complex layers of public health practice associated with widespread infectious disease strategies, including containment, mitigation, and medical countermeasures. Through each of these stages of disease intervention, the pandemic exposed deep chasms in our country’s ability to ensure that the opportunity to be healthy is an inalienable right for everyone at the highest level of our existence—as a human being—and without regard for one’s race, ethnicity, sexual orientation, or economic or social status. I address some of the many examples of how the pandemic further deepened health inequities in our country, how current public health systems failed to address systemic and structural racism rooted in social determinants of health, and how the Public Health 3.0 framework was inadequate in addressing these issues.

Inequities in COVID-19 testing emerged early in the pandemic: during containment efforts. Studies confirmed that Black and Hispanic populations had disproportionately higher rates of hospitalization and death from COVID-19 than did Whites.¹ In New York City, New York, for example, efforts were undertaken to study testing across the jurisdiction by race/ethnicity and neighborhood, showing that more tests were done in geographic areas with concentrations of White people although non-White areas had more positive tests.²

Public Health 3.0, introduced conceptually in 2016 by the US Department of Health and Human Services in listening sessions across the country, held much promise as a way to view the crucial role of public health leaders in their communities. Today, our nearly 3000 local health departments and their leadership are theoretically well positioned to be community health strategists. Every day, they must work collaboratively beyond traditional public health programs and across communities to use sector partnerships to collectively effect environment, policy, and systems-level change—all with the promise to address social determinants of health and eliminate inequities. The hope that Public Health 3.0 brought to many public health professionals a mere five years ago was not met. The reality has been much starker and more complex.

A year after the 2016 US Department of Health and Human Services listening sessions, a set of recommendations came forward based on feedback from the public health community.³ There are a host of reasons some of the recommendations did not result in lasting transformational changes to the public health system.

Although many public health leaders across the country wanted to position themselves as chief health strategists for their communities and embraced the role fully, siloed funding streams remained and hindered engagement in more cross-cutting initiatives to address health equity from a macroapproach across programs. Local health departments continued to experience significant consequences from overall disinvestment in public health, causing a 21% decline in the overall workforce over the past decade.⁴ The broader field of public health did not rally to develop the training, tools, resources, and supports necessary to retrain an existing workforce on how to implement the Public Health 3.0 framework tactically and realistically for their institutions.

The recommendation that every community be protected by a Public Health Accreditation Board (PHAB)-accredited health department was never supported through broad political will or investment. Although language was introduced into legislation that supports accrediting all health departments, efforts stalled amid changing administrations, ongoing politics, and the pandemic. According to PHAB, as of May 14, 2021, a total of 39 state, 276 local, 4 tribal, and 1 statewide (in Florida) integrated local public health department systems have achieved five-year initial accreditation or reaccreditation through the PHAB, bringing the benefits of PHAB accreditation to 88% of the US population. Comparatively, as of August 2016, when Public Health 3.0 was introduced, approximately 80% of the US population lived in the jurisdiction of 1 of the 324 local, state, and tribal health departments that was accredited or that PHAB was in the process of accrediting. Because one of the key outcomes of accreditation is improved cross-sectoral relationships in the community—also a primary recommendation for achieving Public Health 3.0—the lag in health department accreditation significantly affects the achievement of Public Health 3.0, especially in the current context of the pandemic.⁵

This pandemic has laid bare the complete lack of data infrastructure—another tenet of Public Health 3.0. The recommendation to ensure data accessibility for communities across the country has not been met, as local health departments still need access to data with as much detail (i.e., at the zip code level) and as quickly as possible. The lack of timely access to data has continued to plague local health departments during this pandemic, limiting full visibility of what is happening in their communities to make informed decisions on local public health measures. Visibility and transparency of data also apply to the public and help reinforce trust in the governmental public health system, including trust in guidance, mandates, and public health orders as well as support for policy change.

To this day, a majority of local health departments have limited access to and visibility of vaccine supply coming into their jurisdictions through the multiple federal government partnerships that are providing vaccines outside local public health (e.g., federal pharmacy programs). This lack of visibility of the vaccine supply across a community inhibits a local health department from, among other things, addressing health inequity related to vaccine distribution and administration; comprehensive vaccination planning, distribution, and logistics; using vaccination logistics to address accessibility; targeting vaccination efforts at the neighborhood level to improve uptake; and coordinating vaccination education efforts.

A robust, interoperable public health data system is the key to responding to any public health emergency, particularly a pandemic of the magnitude of COVID-19. Because of strong advocacy efforts, between fiscal year 2020 funding and the CARES Act (the Coronavirus Aid Relief and Economic Security Act), Congress has provided $550 million for the public health Data Modernization Initiative at the Centers for Disease Control and Prevention. Further efforts will be needed to ensure that these funds are available to strengthen all levels of the governmental public health system, including local health departments. Aside from pure data infrastructure, data collection is an imperative, and the underreporting and lagged reporting of racial and ethnic data during this pandemic has been a tragedy in itself.

General infrastructure funding to support public health beyond the traditional and siloed federal funding mechanisms and outside the boom-and-bust funding cycles related to public health emergencies has not been realized. Public Health 3.0 cannot be fully implemented without sustainable and long-term investment in the grossly deteriorated infrastructure of the governmental public health system at the federal, state, local, tribal, and territorial levels. Funding, whether it is temporary emergency relief funding for pandemic response or longer term investment in infrastructure, must also reach the ground to local health departments in support of the communities they serve. The flow of federal dollars to local health departments across the country remains inconsistent; there are vast differences in funding amounts, restrictions for use, and overall timeliness of receiving funds. And to date, there has been a marked lack of accountability, visibility, transparency, and reporting on how previous and current funding is reaching local health departments. This is not to mention a failure to properly account for and address the short- and long-term consequences and outcomes from these investments.

In an article highlighting the historical context of COVID-19, Amy Forbes suggests that “disease crises have acted as a sort of stress test on society, revealing, amplifying or widening existing social fissures and health disparities.”^(6p1) There are important lessons from past public health crises that foreshadowed the atrocious loss of life and inequitable effects of COVID-19. Arguably, these could have been anticipated, even planned for, throughout the federal, state, and local governmental public health system. This work cannot be achieved in a vacuum, and public health is one entity among many stakeholders and partners necessary to proactively address and prevent these outcomes in the future. It is imperative that deeper engagement and relationship building occur across the spectrum of stakeholders, including public health, education, housing, agriculture, labor, transportation, and health care, and the community itself so that each understands their role in contributing to population health and the effects of their policies and systems on the health of the people in our country.