The Shape of Things to Come: COVID's Organizational Impact

It's no great secret that epidemics have an impact on society. In addition to their immediate toll of death and suffering, history records multiple examples of their ability to alter our patterns of behavior, to affect local and national economies, to influence the laws that we pass, and to bring about changes in the way that organizations operate, among other effects. The ongoing epidemic of SARS-CoV-2 is no exception to this observation.1–3 And while COVID-19's immense death toll4 may be its most obvious and immediately relevant impact, public health managers and practitioners should also pay close attention to the pandemic's influence on organizations within our public health system and the ways in which it has and will continue to influence the delivery of public health services.

Recognizing the variety of organizations that constitute America's public health system,5 and understanding how these organizations function and interact with one another, is critical to achieving many of the stated core competencies of public health professionals.6 And this understanding must encompass much more than an awareness of lines of authority or a detailing of who performs what function and when. Why? Because increasingly, theories explaining how organizations are structured and the contextual factors that influence their performance and interactions with one another are being used to better understand the factors that can affect the successful delivery of clinical and community health services.7,8

Traditional models of health care delivery, including the delivery of population health services, envision a linear “pipeline” extending from the researchers who develop and test new methods and technologies through to the practitioners who implement these new interventions in clinical or public health settings. This “build it and they will come” philosophy assumes that advances in curative and preventive health technology will be readily adopted, resulting in improved health outcomes, and tends to minimize the many internal and external contextual factors—political, cultural, and economic—that can influence the implementation and sustainability of scientifically proven interventions.9 However, more and more, complex system models are being advanced as a framework to better understand population health challenges, including the stubborn persistence of many health disparities, even in the face of effective interventions.10,11

Like other complex systems, the US public health system comprises numerous, interdependent components that interact in ways that are highly dynamic and often not predictable.12 For example, when public health leaders attempt to address the growing prevalence of obesity, they must consider many interrelated factors that contribute to obesity including industry's role in promoting fast food, the increased availability of high calorie foods, reductions in leisure-time physical activity, and barriers to walking and other physical activities posed by the built environment.13 Given this complex, interactive array of variables, it is unlikely that any one single intervention will be successful in reducing the prevalence of obesity. Furthermore, complex systems are characterized by the presence of feedback loops that are responsible for either amplifying (positive feedback) or dampening (negative feedback) variables in the system.14 Feedback loops can arise from a number of sources, including laws and policies, economic pressures, community norms, public perceptions, or environmental circumstances. Consider the issue of vaccine acceptance, highly relevant to our efforts to end the COVID-19 pandemic and prevent other life-threatening infectious diseases. Research reveals that the attitudes and practices of one's social circle can serve to either promote (positive feedback) or impede (negative feedback) vaccine uptake.15 This finding underscores the fact that tackling vaccine promotion from a complex system perspective requires not only an adequate supply of vaccine and an effective delivery system but also proactive efforts to build vaccine acceptance through substantial community engagement.16

Complex systems are also adaptive, that is, they can change in response to system pressures.12 Two recent examples confirm the power of exigent circumstances (in this instance, America's SARS-CoV-2 epidemic) to catalyze changes in the way that organizations within a system are structured and how they interact with one another. On August 17, 2022, the Director of the US Centers for Disease Control and Prevention (CDC) announced efforts to restructure the agency in response to “structural and systemic operational challenges which were exacerbated during the COVID-19 pandemic.”17 Several weeks earlier, The Commonwealth Fund released a report criticizing the current, “haphazard” approach to public health in the United States and cited the “tragedy” of the coronavirus pandemic as a “starting point” for reforming and strengthening America's public health system.18

Given widespread criticism that a lack of timely, comprehensive data blunted the US response to the COVID-19 pandemic,19 it's not surprising that both the CDC plan and the Commonwealth report call for changes that would promote the rapid collection, analysis, and dissemination of public health data. This is a good thing. Whether we're talking about SARS-CoV-2, hepatitis C virus infections, drug overdose deaths, or newly diagnosed cases of diabetes, surveillance is the starting point of public health action—providing the “when” and the “where” necessary to help guide intervention efforts. Unfortunately, surveillance does not always provide the “why” of underlying factors contributing to disease exacerbations or necessarily point to the “how” of what combination of strategies will be most effective in returning the balance of health. That's why it's critical that we avoid relying solely on linear constructs of action to address population health challenges. Even when we have effective vaccines to prevent serious illnesses such as COVID-19 or treatments to cure chronic infections such as hepatitis C, we cannot assume that these “silver bullets” will bring about an epidemic's end. Why? Because there are many interacting factors and diverse stakeholder communities that can influence the valuing and uptake of interventions, even if said interventions have been proven by rigorous scientific research to be highly effective.

What does this reality mean for public health organizations such as the CDC and the broader public health system, and how should it inform any proposed restructuring or reorganization? First, that efforts to improve the effectiveness of a public health organization must be simultaneously inward and outward looking. By all means, address internal operational shortcomings but don't ignore the policies, processes, and procedures that affect interaction with other entities within the public health system, be they governmental, public, or private. Stated another way, a reinvigorated CDC may still fall short of its goals in the context of a weak public health system.20 Second, invest in strengthening connections, both formal and informal, with the wide array of entities that compose the public health system. The CDC plan calls for strengthened collaboration with “its customers,” and the Commonwealth report challenges the Department of Health and Human Services (HHS) to commit to community engagement and to promote stronger multisector partnerships. Without question, these are positive statements, but they must be followed up with tangible and sustainable actions.

Although cross-sector collaborations and partnerships are now widely recognized as critical steps to ensuring population health,21 gaps in workforce capacity and shortfalls in funding are frequent barriers to initiating and sustaining these collaborations.22 An analysis of data from the 2016 National Profile of Local Health Departments found that “information exchange” was the most frequent way in which local health departments collaborated with public, private, and governmental partners; other, more intensive forms of collaboration were far less frequent.23 This situation has not changed much in recent times. The 2019 National Profile of Local Health Departments also found that local health departments were “less likely to collaborate in ways beyond exchanging information.”24 While information sharing is useful, responding effectively to population health challenges requires more intensive and sustainable collaborations in which planning, implementation, and evaluation are collective efforts, touching upon all of the varied system elements that can affect health outcomes.

A recent, COVID-19–specific example involving 44 organizations in North Carolina across 9 different sectors (public health, health care, education, business, nonprofit organizations, religious organizations, transportation, county government, and public safety) substantiates the importance of collaboration between organizations and stakeholders when responding to public health challenges.25 Leaders who were interviewed for this study confirmed that robust collaboration extending beyond information sharing helped to prevent “blind spots” in pandemic decision making, to translate public health guidance so as to make it locally relevant, and to identify and plan for social service needs resulting from “downstream” pandemic impacts. Furthermore, after conducting a network analysis, these researchers found that local health departments had the most direct and indirect connections to other organizations in the network map—providing credence to the recommendation that local public health leaders work in collaboration with all relevant partners to bring about improvements in community health.26

There is little doubt that the COVID-19 pandemic will bring about changes in our public health system. It's up to public health leaders and practitioners to make sure that these changes are meaningful and long-lasting, not superficial and transitory. What, then, is the take-home message when it comes to understanding COVID-19's potential impact on the US public health system? Simply this: Investment in building a stronger public health system in the United States must nurture all 10 of the essential public health services,27 understanding that, like the organ systems of the human body, the whole will not function effectively if even one of the systems is deficient. Nor can our focus be limited solely to improvements at the federal level. Public health capacity at the community level must be every bit as robust as it is at the federal level. Failure to invest in those elements of the system that are in closest reach of the populations we serve disregards everything we now understand about the workings of complex systems.