The coronavirus disease, COVID-19, has held the world at ransom just as the beginning of a new decade. Labelled a pandemic by the World Health Organization, the virus quickly spread around the world despite lockdown efforts by governments, which unfortunately came a little too late.

As the disease gripped the U.S., testing efforts fell short due to a lack of access to diagnostic tests. In subsequent days, Congress passed the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (P.L. 116-123), a $8.3 billion emergency funding package of which about $6.7 billion were allocated to the Department of Health and Human Services (HHS), with specific amounts earmarked for the Office of the Secretary – Public Health and Social Services Emergency Fund, the CDC, the FDA and the National Institute of Allergy and Infectious Diseases (part of NIH, National Institutes of Health). 

Could we have done better to prevent this? Could we have been better prepared?

State Preparedness for a Public Health Crisis

A non-partisan public health policy research and advocacy organization, Trust for America’s Health, released a report in February 2020 that measured the level of readiness of U.S. states for widespread health emergencies to ensure protection for all individuals:

  • High tier performers, per the report included 25 states and DC (9 up from last year)
  • There were 12 middle performers, down from 30 in 2018
  • 13 were low tier 

The report stated that states are better prepared to face emergencies, such as nurse licensure compact, which allows nurses to practice in multiple jurisdictions during an emergency. Accreditations to ensure emergency prevention and response systems are in place and staffed by qualified care providers. Flu vaccination rates are low — 42 during 2017-2018 and 49 during 2018-2019 — well below the 70% target.

Access to paid time off is low, however, which can exacerbate infectious disease outbreaks. This is very relevant to the current COVID-19 epidemic, where many workers might continue to work even if sick to avoid losing pay, which could accelerate the spread of infection. As a fix, Congress passed the Families First Coronavirus Response Act that imposes paid family and sick leave obligations on small employers (<500 employees).

In its report, Trust for America’s Health recommends:

  • Providing stable and sufficient funding for domestic and global public health security
  • Preventing outbreaks and pandemics
  • Building resilient communities and promoting health equity in preparedness
  • Supporting the public health workforce and ensuring effective leadership and coordination
  • Accelerating development and distribution, including last mile distribution, of medical countermeasures
  • Readying the healthcare system to respond and recover

Public Health Budget Cuts

Between 2018 and 2019, 11 states have slashed their public health funding, including Alabama, New York and North Carolina. This has resulted in a higher turnover in public health departments and a drop in personnel, especially epidemiologists. Experts and local officials have noted deficiencies such as lack of sufficient ventilators and ICU beds. The call to ‘flatten the curve’ is therefore two-pronged: it helps keep you and your family safe and it also prevents our hospital systems from being overwhelmed. 

“If we stay below a certain threshold, we can try not to overwhelm our health care system. So, we need to take aggressive measures now,” Amy Acton, MD, who heads the Ohio Department of Health, told Politico in an interview. The coronavirus epidemic is going to stress a system that is already stressed under the weight of the flu season.  

Following release of the budget for fiscal year 2020, the American Public Health Association (APHA) warned that the proposed cuts to our public health system in the budget would hinder the health system’s ability to stem health care challenges that our nation will face. The current COVID-19 epidemic is an ideal example. The 2020 budget had proposed a 12% cut to the HHS, with over $750 million in cuts to the CDC and $1 billion to the Health Resources and Services Administrator programs. 

“This budget, put simply, kicks the can of worsening American health down the road. It’s possible for us to improve public health by increasing our investment in immunizations, preventing chronic disease, reducing injuries, protecting the public from environmental health threats and improving access to other critical health services,” said Georges Benjamin, MD, Executive Director of APHA. 

The situation has not been any different over the years. A 2018 report by Trust for America’s Health stated that the CDC’s core budget has remained flat over the years and any form of budget cuts have a direct impact at the state and local levels. It turns out 12% of CDC’s budget is for Prevention and Public Health Fund; the 15-year period from 2013 to 2027 is expected to see a $12 billion decrease in preventive funding than the intended allocation. Public health budgets have seen cuts across 31 states from 2015-2016 to 2016-2017: state public health spending was lower in 2016-2017 than it was in 2008-2009. Local health departments have seen massive job losses since 2008 as staff were laid off, along with much smaller budgets over the years.

Going Forward

The government’s 2021 budget has reduced funding allocations for the NIH (7%) and the CDC (9%), which can directly impact our nation’s response to public health crises. Emily Conron,  U.S. policy and advocacy officer at Global Health Technologies Coalition, told Healio in an interview that these cuts could significantly impact the development of newer vaccines, diagnostics and treatments, which can lead to greater loss of life.

Crystal Watson, DrPH, MPH, who works with the Johns Hopkins Center for Health Security, shared her concerns about the nation’s ability to prepare for infectious disease epidemics:

  • $25 million less for CDC’s public health preparedness and response means less money for state and local health departments to responds to a public health crisis
  • $85 million cut for emerging and zoonotic infectious diseases, including a $33 million cut to CDC’s antibiotic resistance initiative.
  • $18 million funding reduction for the Hospital Preparedness Program can hamper the readiness of hospitals to prepare for outbreaks like the COVID-19 epidemic

 Funding Ask

Leaders from public health organizations across the U.S. — the Association of State and Territorial Health Officials, National Association of County and City Health Officials and others — requested a supplemental appropriations bill that could support federal, state, tribal and local capacity to respond to the COVID-19 outbreak by allocating resources for:

  • New equipment that will allow timely diagnoses
  • Additional staffing for testing, including clinic visits or mobile home testing teams for the uninsured and underinsured individuals
  • Obtaining and maintaining quarantine isolation
  • Data analytics and surveillance systems for detection and prompt response
  • Transport for uninsured and underinsured persons who have symptoms for medical evaluation

As we continue to follow stories about how symptomatic individuals were turned away from testing sites due to rationing of diagnostic tests, how hospitals and clinics are running short of personal protective equipment for staff or that there aren’t enough hospital beds or ventilators to keep up with the influx of seriously ill patients with COVID-19, federal and state governments need to rethink our current investment in public health. Going forward, funds should be allocated, and policies developed that will allow a strong and steadfast response from public health officials in the face of a future epidemic or pandemic.