Public Health Post COVID-19: Predicting and Addressing the Needs of the Future

Although public health will change post COVID-19, four key areas are already undergoing reinvigoration: (1) workforce development and infrastructure; (2) bolstering training, partnerships, and communication; (3) technology and data collection modernization; and (4) the prioritization of health equity.

Workforce Development and Infrastructure

The public health workforce has traditionally been comprised of governmental authorities at the federal, state, and local levels. It encompasses most of what is considered to be the public health infrastructure, which has been on crutches for several years before the pandemic:

Since 2010, spending for state public health departments has dropped by 16% per capita and spending for local health departments has fallen by 18%, according to a KHN and Associated Press analysis of government spending on public health….At least 38,000 state and local public health jobs have disappeared since the 2008 recession, leaving a skeletal workforce for what was once viewed as one of the world’s top public health systems.¹

Additionally, increased funding to public health departments to address an emergency is often later reapportioned elsewhere with changes of legislative priorities, such as the reduced funding of the Public Health Emergency Preparedness program after September 11, 2001 and the Patient Protection and Affordable Care Act’s depleted Prevention and Public Health Fund.² Most state and local departments receive little funding and spend less than $100 per resident.³ This lack of funding has led to a reduction in the public health workforce by diminishing the size of state and local health departments every year, totaling to a $4.5 billion gap.⁴ The reduction in size of the workforce has been caused by the retirement and resignation of public health staff, citing pay as their top reason in the 2017 Public Health Workforce Interest and Needs Survey (PH WINS).⁵ Interestingly, a 2018 poll found that 89 percent of registered voters sampled felt that public health played a key role in their communities and 57 percent were willing to pay higher taxes to ensure better access.⁶

The pandemic has shed new light on the problem. According to the National Association of County and City Health Officials (NACCHO), the stressors of operating within a weak public health system during the pandemic, including little funding and being heavily burdened by a lack of staff, have led to the loss of over 70 top public health officers nationwide.⁷ Director Robert Redfield, head of the Centers for Disease Control and Prevention (CDC) has testified before Congress that public health infrastructure has been underfunded, which hampered the federal government response to the pandemic, and needs re-investment.⁸ COVID-19 relief bills such as the HEROES Act and the enacted CARES Act have included some infrastructure relief.⁹ Ultimately, the post-pandemic public health workforce must be continuously funded and grown to address future emergency health threats, improve social determinants of health, and address ongoing health disparities.

Bolstering Skills and Training: Partnerships, Policy Engagement and Communication

Several skills gaps in the public health workforce were identified before the pandemic and have been highlighted throughout the pandemic. Strategic skills and systems thinking were listed as a top need for workforce training in 2017’s PH WINS.¹⁰ That same year, the de Beaumont Foundation and its National Consortium for Public Health Workforce Development — public health leaders from more than 30 national public health membership associations, federal agencies, and public health workforce peer networks — released their “Call to Action” for a more strategic public health workforce.¹¹ That report listed the use of strategic skills, skills that look beyond strict public health practice to meet the needs of the public through interdisciplinary lenses, to be a priority for the workforce.  The report also included systems thinking, persuasive communication, and policy engagement as a few of its eight indispensable, high-performance strategic workplace skills and included recommendations for more effective training in academia, public health agencies, and other partners.¹² With the public more public health “aware” during and due to the pandemic, it will become increasingly important for academic programs, agencies, and employers to emphasize training and use of strategic skills.¹³ 

Systems thinking, such as building collaborative partnerships, includes creating outcome-based relationships to achieve shared goals.¹⁴ Public-private partnerships are key collaborations and have aided in the pandemic response, such as personal protective equipment production and vaccine development and distribution. Most notably, the public-private partnership Operation Warp Speed (OWS) raised funding for research and development for vaccine candidates in record time while using federal agencies for regulatory guidance, including partnerships with large pharmacies to administer vaccines to vulnerable populations.¹⁵ UPS and FedEx have also partnered with OWS for the logistical delivery of the vaccine by developing new technologies, training, and transport methods during the pandemic response.¹⁶ The future of the public health workforce will likely include the incorporation of public health roles in other sectors and facilitating these public-private partnerships for the long term.¹⁷ The pandemic has shown that almost every field, outside of public health and healthcare, can be invested in public health outcomes. Building collaborative partnerships will tackle future public health emergencies and disparities by facilitating action through increasing resources and expanding capacity.

This pandemic has also emphasized the importance of public health law and policy analysis and robust policy engagement, and the need for these skills will only increase post-pandemic. Before the pandemic, policy engagement was identified as a top skill needed for the workforce, encompassing the ability to address and enforce public health needs throughout local, state and federal levels.¹⁸ The pandemic has underscored the need to understand the process, levels of authority, and enforcement mechanisms in emergency preparedness and response from all levels of government, allied health professions, and within the private sector. Further, public health students and professionals will need to be trained, within academic programs and employment settings, to address public health needs by considering a systemic approach to solving the most pressing concerns — from research to practice and policy.¹⁹ The importance of law and policy has been highlighted, as public health actions have been unable to disassociate from enforcement actions, including local mask policies, state stay-at-home declarations, and federal guidance. This pandemic has shown that public health professionals need the ability to understand, use, and explain public health law and policy, and that this needs to be part of their training and development.

Strengthening effective communication skills is necessary to translate important policy decisions and crucial public health measures. The need to better communicate roles and enforcement mechanisms has proven central during the pandemic, as the public remains politically divided regarding the pandemic response efforts and the government experiences difficulties retaining public trust. A recent Pew Research study found that the public’s trust in the federal government has hovered at near-record lows and “effectively handling threats to public health” has fallen to 42 percent.²⁰ One example of a result of this lack of trust and effective communication has been vaccine hesitancy. According to the Kaiser Family Foundation’s COVID-19 Vaccine Monitor, which tracks public opinion about the COVID-19 vaccine, 71 percent of the public surveyed in December 2020  would “definitely or probably” get a vaccine.²¹ Of those who would not take the vaccine, 55 percent said they would not because of their lack of trust in the government to ensure a safe and effective vaccine, the second-highest reason cited.²² To address these challenges, OWS and the Department of Health and Human Services have allocated funding for state and local communication programs to reassure the public and promote vaccination.²³ Health literacy in the general public is commonly low, amplified during a time where unverified information is easy to access through the internet and social media, and requires investing in communication initiatives and skill-building in order to reduce misinformation and loss of public trust.²⁴

Technology and Data Collection Modernization

One of the most discussed areas of growth during the pandemic has been the integration of and reliance on technology. For example, early in the pandemic many healthcare providers relied on telehealth services to deliver care during stay-at-home orders, resulting in the exponential growth of telehealth services, with a 154 percent increase in telehealth visits during the last week of March 2020.²⁵ Federal agencies and states have taken quick legislative, regulatory, and executive actions to increase access to telehealth as part of their COVID-19 response.²⁶

However, the lack of existing technological proficiency and efficient data collection systems for the public health workforce has shown to have dire consequences during the pandemic.  Data modernization, data collection, and the use of technological services will become key tools in future public health practice for surveillance and decision making, especially since the pandemic has highlighted technological issues. Outdated systems due to workforce gaps, paperwork backlogs, and lack of interoperability have caused delays in obtaining data during the pandemic and overall reduces the efficacy of the public health system. Ultimately, these delays can accumulate and even lead to loss of life.²⁷

Another technological problem involves inadequacies with electronic health records (EHRs). Eighty-five percent of all health data is electronic, including data shared by hospital EHR systems, and public health surveillance relies on data from 3,000 federal, state, and local agency partners.²⁸ Electronic data has facilitated the management of patient data within certain healthcare organizations, but the use of different EHR systems in the healthcare industry has led to fragmentation and lack of interoperability among providers, payors, and public health agencies.²⁹ The current decentralized system has led to incredible difficulty tracking millions of diagnostic tests, hospital reports, and upcoming vaccinations, which could be better addressed through a centralized public health data collection system.³⁰

The CDC has proposed one such system to report among healthcare entities, surveillance systems, and local health departments, using $500 million CARES Act funding to launch its Data Modernization Initiative (DMI). The DMI will “begin to expand its public health and surveillance infrastructure by helping improve public health’s ability to inform the public, evaluate health outcomes, and inform evidence-based decision-making, policy, and public health response.”³¹ The CDC’s DMI plans to bring together state, tribal, local and territorial partners as well as advance its existing public-private partnerships to create a system that will align to the U.S. Public Health Surveillance Enterprise.³² The DMI focuses on three priority areas: seamless multi-directional data sharing across the public health ecosystem; implementing new workforce standards and approaches for public health reporting; and enhancing CDC services and systems for ongoing data infrastructure modernization.³³ The CDC, within its DMI, has already launched pilot program plans for its Pandemic‐Ready Interoperability Modernization Effort (PRIME).³⁴ PRIME is a multi-year collaboration with the U.S. Digital Service (USDS) which will focus on COVID-19 and potential future pandemics by creating a cloud-based system that will support hospital, laboratory, and public health department data.³⁵  Post COVID-19 public health will include technological advancements and services that will expand and facilitate the role of public health throughout the larger health ecosystem./p>

Prioritization of Health Equity

The U.S. healthcare and public health systems have long been affected by racial discrimination and policies that have advanced disenfranchisement.³⁶ The COVID-19 pandemic has drawn attention to the health disparities across the country and systemic barriers that are still affecting Americans every day. Overall, people of color continue to face increased risks and die at a much higher rate during this pandemic.³⁷ The CDC has stated that racial and ethnic health disparities have been a result of a history of discrimination in systems including healthcare and education, wealth gaps, occupation and labor, and housing conditions.³⁸ Further, the public’s focus on the pandemic’s worsening of racial and ethnic disparities has deepened since George Floyd’s death in police custody — as organizations, states, and localities began to declare racism as an official public health issue.³⁹

Although increasing diversity and inclusion has been identified as a key workforce priority, identifying health equity as the main goal has been a recent advancement.⁴⁰  “Health equity” can be defined as everyone having equal access to resources that could give people the opportunity to be as healthy as possible.⁴¹ The CDC’s 10 Essential Public Health Services (EPHS) has long been recognized to encompass the mission of public health and was updated in 2020 to reflect this commitment to promote the health of all people in all communities.⁴² The EPHS has been reimagined with health equity at the very center, where previously “research” was in place, an action that has set the tone for the future of public health and its priorities.⁴³ Viewing public health as a tool for social justice and inclusive health policy will be crucial to address persistent structural health disparities.

Additionally, addressing racial and ethnic health disparities requires a commitment to action from both public and private organizations. The American Public Health Association (APHA) lists health equity as one of its core values and the following key principles for its advancement, including being explicit when addressing and identifying health equity needs; identifying racism and racial bias; implementing a “health in all policies” approach to address social determinants of health; respecting and including communities in initiatives; creating an internal culture of health equity within organizations; and measuring progress made towards health disparities.⁴⁴ After the COVID-19 pandemic, public health will likely be more focused on meeting these goals and reducing these disparities as organizations begin to shift their priorities to ensure progress towards an equitable nation.

Conclusion

The future of public health post COVID-19 will involve reformation and reinvigoration. The four topics highlighted in this article are some of the key action areas of a post-pandemic public health system. The COVID-19 pandemic has highlighted the importance of having a robust public health system that can actively respond to the next public health emergency and ongoing health disparities. Increasing workforce development through skill-building and infrastructure, strengthening and improving technology, and prioritizing health equity are fundamental areas that will likely be developed and further implemented to create an innovative and efficient public health system. 

Endnotes

1. Ungar, L., Weber, L., Smith, M., The Associated Press, Recht, H., & Barry-Jester, A.M., Hollowed-Out Public Health System Faces More Cuts Amid Virus (Aug. 24, 2020), available at https://khn.org/news/us-public-health-system-underfunded-under-threat-faces-more-cuts-amid-covid-pandemic/.
2. Id.
3. Id.
4. The Impact of Chronic Underfunding of America’s Public Health System: Trends, Risks, and Recommendations, 2019, available at https://www.tfah.org/report-details/2019-funding-report/.
5. De Beaumont Foundation, KEY FINDINGS OF PH WINS 2017: Explore the Data, available at https://www.debeaumont.org/phwins-signup/ph-wins-explore-the-data/.
6. De Beaumont Foundation, National Survey Reveals Strong Bipartisan Support for Public Health, 2018 (January 2019), available at https://www.debeaumont.org/national-survey-reveals-strong-bipartisan-support-for-public-health. 
7. King, A., Embattled Public Health Workers Leaving At 'Steady And Alarming' Rate (Nov. 25, 2020), available at  https://www.npr.org/2020/11/25/938873547/embattled-public-health-workers-leaving-at-steady-and-alarming-rate.
8. Hirsch, L. & Dzhanova, Y., Coronavirus response hurt by lack of funding for public health labs, CDC director tells Congress, (Mar. 10, 2020), available at  https://www.cnbc.com/2020/03/10/coronavirus-testing-delays-caused-in-part-by-underfunding-cdc-director-says.html.
9. The HEROES Act, passed by the House of Representatives, included $75 billion for developing and implementing a national system for COVID-19 testing, contact tracing, surveillance, containment and mitigation; $2.1 billion for the Centers for Disease Control and Prevention’s (CDC) Public Health Emergency Preparedness cooperative agreements, core public health infrastructure activities and data system modernization; and $7.6 billion for the Health Resources and Services Administration to expand capacity for testing and care through community health centers. See https://apha.org/news-and-media/news-releases/apha-news-releases/2020/heroes-act; https://www.congress.gov/bill/116th-congress/house-bill/6800. The CARES Act, which became law, included $4.5 billion to the CDC to remain available from Fiscal Years 2020-2022 for public health preparedness and response. Of that amount, $3 billion is designated for public health, including $1.5 billion in designated funding for state and local preparedness and response grants, and $500 million for public health data surveillance and infrastructure modernization. See https://www.congress.gov/bill/116th-congress/house-bill/748.
10. See supra n. 5.
11. De Beaumont Foundation, Building Skills for a More Strategic Public Health Workforce: A Call to Action (July 18, 2017), available at  https://www.debeaumont.org/wp-content/uploads/2019/04/Building-Skills-for-a-More-Strategic-Public-Health-Workforce.pdf.
12. Id.
13. Brisolara, K.F. & Smith, D.G., Preparing Students for a More Public Health–Aware Market in Response to COVID-19, Prev Chronic Dis 2020;17:200251 (July 9, 2020), DOI: http://dx.doi.org/10.5888/pcd17.200251. 
14. Id.
15. Ho, R., Warp-Speed Covid-19 Vaccine Development: Beneficiaries of Maturation in Biopharmaceutical Technologies and Public-Private Partnerships (Nov. 17, 2020), available at  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671640/.
16. Frieden, J., FedEx, UPS Reassure Senators About COVID Vax Distribution (Dec. 10, 2020), available at  https://www.medpagetoday.com/infectiousdisease/covid19/90143; See also Sekar, K., Congressional Research Service (CRS), Funding for COVID-19 Vaccines: An Overview (Dec. 15, 2020), available at  https://crsreports.congress.gov/product/pdf/IN/IN11556.
17. Tolchinsky, A., Why Public-Private Partnerships Strengthen Our Public Health Response, (July 1, 2020), available at  https://www.cdcfoundation.org/blog/why-public-private-partnerships-strengthen-our-public-health-response.
18. See supra n. 11.
19. See supra n. 13.
20. Americans' Views of Government: Low Trust, but Some Positive Performance Ratings, Pew Research (Sept. 17, 2020), available at  https://www.pewresearch.org/politics/2020/09/14/americans-views-of-government-low-trust-but-some-positive-performance-ratings/.
21. Hamel, L., Kirzinger, A., Muñana, C., & Brodie, M.,  KFF COVID-19 Vaccine Monitor: December 2020 (Dec. 22, 2020), available at https://www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/.
22. Id.   The most cited reason for hesitancy in obtaining the vaccine (59% of respondents) was concern about the vaccine’s side effects.
23. U.S. Department of Health and Human Services, Answers to National Governors Association Questions on Vaccine Distribution and Planning (2020), available at  https://www.hhs.gov/sites/default/files/national-governors-association-questions-on-vaccine-distribution-planning.pdf.
24. Wang, H., Cleary, P.D., Little, J., & Auffray, C., Communicating in a public health crisis - The Lancet (Aug. 10, 2020), available at https://www.thelancet.com/journals/landig/article/PIIS2589-7500(20)30197-7/fulltext.
25. Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic - United States, January–March 2020 (Oct. 30, 2020), available at  https://www.cdc.gov/mmwr/volumes/69/wr/mm6943a3.htm.
26. Burris, S., de Guia, S., Gable, L., Levin, D.E., Parmet, W.E. & Terry, N.P. (Eds.), Assessing Legal Responses to COVID-19, Boston: Public Health Law Watch (2020), available at  https://static1.squarespace.com/static/5956e16e6b8f5b8c45f1c216/t/5f4d6578225705285562d0f0/1598908033901/COVID19PolicyPlaybook_Aug2020+Full.pdf.
27. The Council of State and Territorial Epidemiologists (CSTE), Driving Public Health in the Fast Lane: The Urgent Need for a 21st Century Data Superhighway (2019), available at  https://resources.cste.org/data-superhighway/mobile/index.html.
28. Data Modernization Initiative (Nov. 19, 2020), available at https://www.cdc.gov/surveillance/surveillance-data-strategies/data-IT-transformation.html.
29. O’Neill, A., Accelerating Data Infrastructure For COVID-19 Surveillance And Management: Health Affairs Blog, (Apr. 14, 2020), available at  https://www.healthaffairs.org/do/10.1377/hblog20200413.644614/full/.
30. Id.
31. Data Modernization Initiative (Nov. 18, 2020), available at https://www.cdc.gov/surveillance/surveillance-data-strategies/dmi-investments.html.
32. See supra n. 28; see also Public Health Enterprise: the CDC’s system of relying on the collection and reporting of data from state and local partners; Richards, C., Lademarco, M., & Anderson, T., A new strategy for public health surveillance at CDC: Improving national surveillance activities and outcomes (2014), available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4187298/.
33. See supra n. 28.
34. See supra n. 27; see also https://www.cdc.gov/surveillance/pdfs/PRIME_1-sheet_single-page.pdf.
35. See supra n. 27.
36. Johnson, S.R., To battle racism, experts say make health equity a central principle, Modern Healthcare (June 6, 2020), available at https://www.modernhealthcare.com/safety/battle-racism-experts-say-make-health-equity-central-principle.
37. Health Equity Considerations and Racial and Ethnic Minority Groups (n.d.), available at  https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html.
38. Id.
39. Declarations of Racism as a Public Health Issue (n.d.), available at https://www.apha.org/topics-and-issues/health-equity/racism-and-health/racism-declarations.
40. See supra n. 11.
41. See supra n. 36; see also COVID-19 Racial and Ethnic Disparities (cdc.gov),   https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/index.html (updated Dec. 10, 2020).
42. The 10 Essential Public Health Services, released in 1994, has been used as a framework for the key public health activities within the acknowledged definition of public health practice. See supra n. 36.
43. CDC - 10 Essential Public Health Services - CSTLTS (Sept. 22, 2020), available at https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html.
44. APHA, Health Equity, available at  https://www.apha.org/topics-and-issues/health-equity; See also https://www.apha.org/-/media/files/pdf/factsheets/advancing_health_equity.ashx?la=en&hash=9144021FDA33B4E7E02447CB28CA3F9D4BE5EF18.