The deadly consequences of the gutting of America’s public health infrastructure

According to University of California, Los Angeles (UCLA) public health professor Jonathan Fielding, chief of the Los Angeles Department of Public Health from 1998 to 2014, the decline of vital public health infrastructure, which included the loss of workforce staff and resources, perhaps began even prior to the start of his tenure in that office.

Politicians and media pundits have accepted that mass sickness and death are the inevitable product of the COVID-19 outbreak. Entirely absent from their lips are the words “eradication of disease.”

Along with the lack of COVID-19 tests, which remain lifesaving and vital, Dr. Fielding told the Los Angeles Times on March 20 that the biggest obstacle facing public health authorities is the inability to track every single new presenting case back to its origins for as many steps and persons as necessary to find the initial infection in a given community.

“That was one of the first things we needed to do, and it can make (and would have made) a huge difference,” Fielding told the Times. “It’s very disappointing how slow we were in the United States.”

Had this been done, each infected person would have been isolated immediately. In other circumstances, where the disease is treatable, therapy would start right away, such as when a new case of tuberculosis is diagnosed. All household and workplace contacts would have been urgently identified, quarantined and tested. If the newly quarantined individual became ill from a virus for which there was no primary front-line treatment, they would have received effective care as needed.

Successfully combating COVID-19 is a process wholly dependent on painstakingly testing, isolating and quarantining every single diagnosed person. There is no other way to halt a communicable disease, including in an era of vaccine availability.

These are long-established and elementary principles that have guided public health departments for generations, halting attacks by microbes and viruses, including smallpox, measles, tuberculosis, polio and many others. Why, then, have these principles been ignored with reckless abandon when it comes to the COVID-19 pandemic?

The Centers for Disease Control and Prevention (CDC) and the Department of Health and Human Services (HHS) are the funding agencies for the 50 states and the several thousands of local health departments in most of the over 3,000 counties in the US. Historically, the local departments have been variously staffed with a designated public health officer, testing laboratories, a public health nurse, access to trained epidemiologists, and a workforce to interview diagnosed disease cases to identify and locate other human contacts and exposures.

Last year, Public Health Director for Riverside County Kim Saruwatari warned California state lawmakers at a Senate and Assembly hearing in Sacramento that they were courting disaster when and if the populace encountered a pandemic, given the succession of budget cuts enacted over the previous 10 years.

She told the Times last week that her department was left with “fewer trained staff to conduct case investigations and contact tracing, fewer epidemiologists to assist with analysis, fewer lab staff and less funding for updated laboratory equipment.” Funding cuts of 30 to 40 percent by the CDC and HHS affected all but one of California’s 58 counties.

The executive director for the Health Officers Association of California, Kat DeBurgh, told the Times that budget cuts for public health closed 11 testing labs in as many counties in recent years. “We can definitely see that the public health workforce has drastically shrunk and never recovered,” she said. “That really shows at a time like today.”

States across the country faced similar cuts. Between 2008 and 2017, some 55,000 public health workers’ jobs were destroyed in over 3,000 public health departments.

“These cuts reduced the capacity for these health departments to prevent illness and loss of life,” John Auerbach, president of the public health advocacy group Trust for America’s Health (TFAH), told the Times. “Their impact is being illuminated in an all too real fashion by the novel coronavirus.”

The TFAH estimated last year that, at a minimum, US public health is underfunded by $4.5 billion. Cuts to public health infrastructure were carried out by both Democratic and Republican administrations.

In 2012, President Obama diverted $6 billion from public health funding to cover physician reimbursements that had been cut from Medicare. Another $450 million was taken from public health funding to set up the Affordable Health Care insurance markets.

In 2018, President Trump’s massive tax cut for the wealthy slashed $750 million from the CDC. That same year, the CDC’s monitoring of novel virus emergence in 49 countries was reduced to 10 nations, which excluded China.

From 2003 to 2019, the CDC’s funding for state and local preparedness for extreme weather events, epidemics, and the opioid crisis was cut by a third. Meanwhile, the Hospital Preparedness Program (HPP), which functions to stockpile equipment needed for health emergencies, was cut in half.

In 2017, there were 18 declared public health emergencies compared to 29 in the previous 10 years. Nonetheless, in 2018, 17 state governments cut public health funding, including Texas, Alaska and Maine, which all slashed their budgets by more than 12 percent, according to a 2019 report issued by the TFAH. Of the $3.5 trillion spent on health care in 2017, only 2.5 percent was spent on public health.

In the fall of 2018, Trump’s HHS secretary Alex Azar diverted $260 million in CDC funds so that they could be used to lock up immigrant children in the southwestern concentration camps, according to The Hill. Another $13 million used for the same project was taken from the National Cancer Institute, and $5.7 million from a CDC HIV prevention project.

The $750 million in cuts to the CDC funding for fiscal year 2019 included $236 million for chronic disease prevention, $146 million for the National Institute for Occupational Safety and Health, $102 million for emerging and zoonotic (infectious diseases jumping from species to species), $52 million for environmental health, such as lead poisoning prevention, $20 million from injury prevention and control, $30 million for public health and preparedness and response, and $78 million for immunizations.

“The disinvestment in public health programs will only cost this nation more in the end,” Laura Hanen, then interim director of government affairs for the National Association of County and City Health Officials, told The Nation’s Health, the publication for the American Public Health Association, in 2018.

“The budget makes deep cuts that will negatively impact the CDC and state and local health departments to do their job—which is to keep our communities healthy and safe,” she said.

The destruction of the country’s public health infrastructure over the last 30 years has left the country’s population disastrously exposed. As hundreds die every day, the political establishment has been more concerned with keeping the stock market afloat than protect workers from the onslaught of this deadly pandemic.

There was nothing inevitable about the current public health crisis. Rather, it is a predictable outcome of years of budget cuts to the nation’s public health infrastructure.