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Can 50 Separate Public Health Systems Contain a Pandemic?

Years of budget cuts and lack of political support left public health officials without the resources to rapidly contain COVID-19. Brian Castrucci, CEO of the de Beaumont Foundation, discusses what needs to happen now.

Three exhausted workers at a drive-through COVID-19 testing site in Austin, Texas.
Exhausted workers at a COVID-19 drive-through testing site in Austin, Texas.
Packed football stadiums, concerts and bars give an impression that the U.S. has left the COVID-19 pandemic behind. But as of Oct. 9, the seven-day new case average was over 100,000, about 10 times what was seen in June.

The country may be making headway, but Centers for Disease Control and Prevention (CDC) Director Dr. Rochelle Walensky warns that collective action is essential to preventing future surges. This includes overcoming resistance to public health efforts in parts of the country where vaccination rates remain low. “The virus isn’t stupid. It’s going to go there,” she told CNN.

Elected officials may have stopped short of declaring victory over COVID-19, but many are ready to move on to other issues. This shift in focus is not what public health workers need, says Brian Castrucci, chief executive officer of the de Beaumont Foundation, a public health policy nonprofit.

“We’ve hit what I call the Popeye moment, the point where you’ve had all you can stand and you can’t stand no more,” he says. “Just because COVID is not on the front page doesn’t mean that we don’t still need to take precautions or that there aren’t still hospitals that are filled.”

The de Beaumont Foundation has just released a report, Staffing Up, that takes a hard look at what it will take to make up for years of budget cuts to state and local public health departments. Its conclusion: they need 80,000 additional full-time employees.

This estimate is based on data from 2017-2019, and doesn’t encompass new needs resulting from the pandemic. It’s meant as a starting point for a national discussion, says Castrucci.
A graph showing the de Beaumont Foundation’s estimate that state and local public health departments need 80,000 additional full-time employees (FTEs) to adequately serve citizens.
The de Beaumont Foundation has estimated that state and local public health departments need 80,000 additional full-time employees (FTEs) to adequately serve citizens. (de Beaumont Foundation)
This is one more big investment at a time when other sectors of the government ecosystem also need support. But a recent paper in the Journal of the American Medical Association estimates that taking into account lost GDP, premature death and other health impacts, the pandemic has cost the U.S. $16 trillion — an amount equal to 90 percent of the country’s annual GDP.

This is four times the output lost in the Great Recession, and comparable to the cost of damages caused by 50 years of climate change. Moreover, the $16 trillion figure is based on an assumption that the pandemic will be contained by fall 2021.

“The immense financial loss from COVID-19 suggests a fundamental rethinking of government’s role in pandemic preparation,” say the authors.

Appraising the true cost of preparedness includes confronting the reality that factors including climate change, human incursion into animal habitat, a culture of global travel and commerce and the unceasing drive of microbes to adapt and change mean that COVID-19 is not the last — or even the worst — pandemic the country could face.

In an interview with Governing, Castrucci describes steps that state and local governments can take to manage current public health challenges and be better prepared for the next pandemic. The interview has been edited for length and clarity.

Governing: How would you characterize America’s response to COVID-19?

Brian Castrucci: Our response has been extraordinarily ineffective. We have one of the higher death rates per 100,000 in the world.

I want to be very clear that responsibility for that does not lie with the public health system. The people in our state and local health departments threw everything they had at this pandemic response. What they didn’t have were the necessary resources. That’s a decision made by elected officials.
Dr. Brian Castrucci
Brian Castrucci: “We are trying to have a pandemic surge response, but that surge is on a broken foundation.” (de Beaumont Foundation)
Political rhetoric early in the pandemic made the job of public health even harder than it already was, seeding doubts about mask wearing, stay-at-home protocols and the vaccines. We have paid a price for that rhetoric throughout the entire pandemic. It came from both sides, with Kamala Harris saying she wouldn’t take a Trump vaccine.

The worst part is that we’re already losing the next pandemic before it’s even started because 26 states are limiting public health authority. We are undermining our public health system while still in the throes of the pandemic, and that’s a very bad recipe for the future safety, security and economic prosperity of our nation.

Governing: What weaknesses need to be addressed at the state and local level?

Brian Castrucci: We are trying to have a pandemic surge response, but that surge is on a broken foundation. We need 80,000 more FTEs just to repair and rebuild the basic public health services that we need, that every American deserves.

It’s not just the people, it’s the systems. If you believe in a “U.S. public health system,” you probably also believe in unicorns because neither exists. We have 50 individual, separately operated public health systems, investing different amounts of money per capita, prioritizing different things.

With more than 700,000 Americans dead from COVID-19, we should have the political will to rethink the system and act now. The mortality rate, though consequential, was low this time. Could you imagine if this played out against a five or 10 percent mortality rate? Or maybe the infection rate and severity of disease is much higher, breaking our health-care system.

Governing: What needs to happen at state and local levels to contain the pandemic?

Brian Castrucci: We missed that bus early on. We’re still just trying to mitigate it. As long as people are not going to get vaccinated, we are going to not be able to fully mitigate the virus.

At this point, we’re on a path to it being endemic. There will be outbreaks, and hopefully vaccines will limit the toll. But when you’re in mitigation, that’s when you have to use cruder measures like community-wide stay-at-home orders.

You would think from the media narrative that public health officials have been waiting all of their careers for a chance to shut down their counties. No one wanted to do that, but it had to be done to stop the spread of the virus. The fact that public health practitioners have been bullied, harassed and assaulted for it is really demoralizing.

Governing: Is there anything that can be done to shift that dynamic?

We have to prioritize the health of our society over the objections of a few individuals. People have argued that this is about individual rights. But if you believe strongly in individual rights, you would have to agree that exercising your individual rights should not prohibit me from exercising mine.

If you don’t want to take this vaccine, that’s fine. But don’t put me in peril because of that choice. Don’t make my workplace more risky to me. Don’t make my schools more risky for my children. When you impugn the rights of others under the guise of individual rights, that’s selfishness.

One thing we can do if we have the political will to do so, and I think Joe Biden has started, is to say “no.” No is the most powerful thing we have — no, you can’t go to that football game. No, you can’t get on that flight. No, you can’t be at my workplace if you’re not vaccinated or can’t show results of a test.

Governing: What should state and local governments do now to be better prepared for a future pandemic?

Brian Castrucci: The first thing is that we need to figure out how to combat disinformation. I don’t think anyone is anti-science; anti-science, I could fix. The problem is that people have found scientists that agree with them.

People say: “This doctor said this virus isn’t real, it’s not that bad and we shouldn’t take the vaccine, and this doctor says it is bad, and we should take the vaccine. They’re both doctors — who should I believe?” That is the greatest threat, that we don’t have a person who can speak in a trustworthy way about the threats of viruses that are in the future.
Castrucci is an author of a new book exploring the impact of recent policy on the health of Americans. The book is published by the American Public Health Association, and his co-authors include AHPA Executive DirectorGeorges Benjamin. (de Beaumont Foundation)
State and local governments need to bring everyone together and have honest and crucial conversations about what happened, what went wrong and how we will defeat viruses in the future. We need to have nationwide resilience building, but you can’t build resilience while you’re yelling and screaming hateful things at each other.

This pandemic has been politicized like no other previous public health crisis. The question is whether that is a one-off or the start of a trend. If it’s the start of a trend, we are in desperate, desperate trouble.

Governing: Your brief reveals a need to greatly expand the public health workforce. What do we need these workers to be doing?

Brian Castrucci: They need to be monitoring disease threats, doing epidemiology, providing the basic public health services that keep us safe.

If you were a trapeze artist and there were holes in your net, how comfortable would you feel flying through the air? With each cut, with each reduction to public health, we cut another hole in that net. And when we needed it, when we fell from the trapeze, that net was not strong enough to catch us.

We have to rebuild that net. This is about infrastructure, about lasting investment. This is the time for businesses and other sectors to come forward to government and say, “We don’t want our safety to be imperiled by bad decisions that you’re making about public health.”

It is also unequivocally on public health to help people understand what we do. We have to do a better job of articulating our value proposition in a clear, concise, repetitive way.

Governing: How quickly do we need more workers on the job?

Brian Castrucci: How long do you want to be on the trapeze with no net?

Governing: Are discussions about increasing public health funding confronting the economic risks of under-investment?

Brian Castrucci: No. The problem is that COVID-19 may have cost the U.S. $16 trillion, but the locus of control with public health sits with individual governors.

Part of the challenge is that there are any number of governors who have engaged in behavior that is antagonistic to public health guidance. Those will be the same governors trying to rebuild their public health systems with federal dollars.

How confident are we that a governor who opted to not enact, but to ban, mask mandates will have the public’s interest at the forefront in repairing this public health system?
A cartoon depicting a match labeled "COVID-19" about to set fire to a pile of logs labeled with other public health concerns such as "racism," "sexism" and lack of access to health care."
The spread of COVID-19 was fueled by factors well beyond struggles with policies around masking or business closures. (de Beaumont Foundation)
Governing: Some of the worst impacts of the pandemic were due to social inequities. Does the public health sector need to have a bigger role in addressing social determinants of health?

Brian Castrucci: I would point you to something called CityHealth. We’re a sponsor of this project, along with Kaiser Permanente. It’s a nine-policy package, and these are policies that we believe every city should have, everything from clean indoor air to paid sick leave and early pre-K.

When we started this project in 2017, fewer than half of the 40 largest cities in the U.S. had even four of these policies. Today, over 90 percent do.

This needs to be more ubiquitous, but it’s hard for public health officials to get into a policy space when 200 have been terminated or forced to resign or retire for the mere act of doing their job.

Governing: What kinds of changes are needed at the federal level?

Brian Castrucci: The federal government can give money to the states with restrictions. The federal government, tomorrow, could choose to have a federal data system for public health and say to each of the states, “If you put in 5 percent, we’ll put in the other 95 percent, and here are the rules.”

They could go to the states with a Medicaid-type model, where the states have to put up a certain match. We may need to try, in partnership with the states, to federalize public health.

Some states will not choose to participate today but over time they will, and America will be safer. If we continue to have 50 different public health systems with 50 different priorities, then we are always going to be at risk.
Carl Smith is a senior staff writer for Governing and covers a broad range of issues affecting states and localities. He can be reached at or on Twitter at @governingwriter.
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