A New Normal for Public Health Agencies

May 19, 2020|10:55 a.m.| Marcus Plescia MD, MPH | ASTHO Chief Medical Officer

Marcus PlesciaAs states and territories prepare to reopen many of the functions of their economies and communities, it is also time to pivot to a new normal at health departments nationwide. COVID-19 has been the most substantive threat facing public health in decades and required an urgent mobilization and redirection of resources for all public health programs. A crisis of this proportion would stress any agency, but following a steady decrease in workforce over the past decade, public health has been hit particularly hard. We cannot expect health departments to continue pre-COVID work and continue to sustain the COVID-19 response without adequately scaling up our resources.

Many vital public health functions such as immunizations, chronic disease prevention, STI/HIV prevention, and the opioid overdose response have had to be scaled back in response to COVID-19. If this continues, it will soon have profound effects on the public’s health, even in areas where we have previously been successful, such as tobacco cessation and childhood immunizations. The new normal in public health must be an adaptation to the need to contain and control COVID-19 while simultaneously addressing the many other public health needs in a jurisdiction. We need to adapt to the new normal, but we cannot continue to do more with less.

Scale Up Vaccination Campaigns
The threat of other infectious disease outbreaks is an immediate concern for public health. As we desperately seek a vaccination for COVID-19, it should remind us of the important function of health departments in assuring access to existing vaccination schedules. Under current "stay at home" orders, many families have not participated in well-child visits. According to the Association of Immunization Managers, activities involving going out in the field have been suspended in most health departments. As a result, studies have estimated that the administration of the MMR vaccine has dropped substantially.

The new normal means we must address this issue prior to the likely resumption of the school season this fall. Adult and child influenza vaccinations will also be far more important. If a predicted second wave of COVID-19 this fall is accompanied by a serious flu outbreak, the impact on the medical system could be catastrophic. Our vaccination efforts need to resume soon and go beyond traditional public health campaigns—like increased opportunities for large-scale immunization in non-clinical settings like parking lots, summer camps and workplaces.

Prevent a Resurgence of Other Chronic Diseases
It is never useful to pit one public health problem against another. But it is important to recognize that despite the substantial death toll of COVID-19 over a short period, heart disease and cancer continue to be the top killers in America. Last year there were 269,000 cancer deaths and 525,000 deaths from heart disease. State and local tobacco control programs have had a profound effect on reducing the incidence of these diseases, but tobacco-use trends that were concerning prior to the pandemic have worsened. COVID-19 has shifted public health’s attention from the concerning implications of the EVALI outbreak, and efforts to address e-cigarette use have been undermined in the last three months. The Food and Drug Administration (FDA) has now delayed the premarket review deadline for e-cigarettes because of COVID-19, and significant reductions in charitable giving have diminished the capacity of important tobacco control advocacy groups.

Refocus on Diseases of Despair
This pandemic came during an existing epidemic of addiction and opioid misuse that provided many indications of the strains on the fabric of our society that have now become so evident with COVID-19. Often referred to as "diseases of despair," the opioid epidemic, suicide, alcohol addiction, and domestic violence continue to rage across our society, and have worsened as a result of the stress and hardship of COVID-19. Some efforts to address behavioral health have been hampered by the challenges of continuing effective interventions and therapy during a pandemic. Recent reports of suicides among medical providers treating COVID-19 patients and soaring rates of calls to mental health crisis lines highlight the alarming national suicide trends we continue to experience, and addressing stigma and providing mental health first aid programs are important now more than ever.

Protect the Most Vulnerable
As we think about a new normal in public health, the core work of promoting and protecting the health of those at risk is particularly acute given the devastating toll of COVID-19 among the elderly and people of color. Social distancing rules have exacerbated social isolation among those who are physically debilitated or suffer cognitive impairment, a situation that will not improve as our plans to reopen America place significant emphasis on the need for continued mitigation strategies for groups at greatest risk. Mitigation strategies must shift from "social" isolation to physical isolation, and public health should help pursue policy and environmental interventions that provide resources and stimulation for those who have been "shut in" by the pandemic. In this new normal, public health needs to continue to look for ways to partner with clinical providers to encourage different forms of preventive services that address a wide range of both medical and social problems.

Create a New Normal
Public health plays an important role as a convener in addressing many population, medical and social issues. That role is critically important moving forward. The recently updated Healthy People 2030 objectives, which will launch in August are a way to reset our efforts and lead the new normal. They provide a shared vision for public health across sectors and regions, and the developmental and research objectives which are designed to address areas of substantial disparity between populations are particularly important to our experience with COVID-19.

It is a challenging time in public health. COVID-19 has made it difficult to meet needs and still attend to longstanding issues. After decades of neglect, public health has little surge capacity. While public health practitioners are good at finding ways to do two things at once, this is not a sustainable model for health improvement. New funding streams are emerging for public health through testing and contact tracing that may provide resources for agency expansion. We must insist that this expansion of the public health workforce is long overdue and must be sustained. Once the pandemic is controlled, these contact tracers should stay in the workforce and expand public health capacity to control core infectious diseases like HIV and other STIs. Their focus should be expanded to engage creatively in other issues like violence prevention and better control of chronic disease risk factors like diabetes, hypertension, and tobacco use—all highly relevant to COVID-19 outcomes.

Good leadership requires the ability to look ahead and get creative. That future will be with us before we know it, and if we are not attentive to it, the implications of the COVID-19 pandemic could ultimately be overshadowed by a resurgence of the public health issues that have plagued us in the past. The new normal means adjusting to the threat of COVID-19 while also sustaining the core work of public health. We can do two things at once, and always have, but sustained resources that will expand public health agency capacity have to be part of the high expectations of governmental public health to protect and promote the nation’s health. The new normal does not mean doing more with less. It means doing more with more. The success of our nation’s reopening depends on it.

Marcus Plescia is the chief medical officer at ASTHO