When measles erupted in Clark County last year, it took a hefty response to stop the outbreak, which lasted nearly four months and recorded 71 cases.
Clark County spent more than $860,000 in response efforts, and more than 230 people took part in the response, with 89 staffers from Clark County Public Health, 57 staffers from the Washington Department of Health, 50 volunteers from the Medical Reserve Corps and three staffers from the Centers for Disease Control and Prevention.
Clark County Public Health put in close to 13,000 hours of outbreak work, and contacted more than 4,100 people who were potentially exposed.
Another outbreak might soon consume Clark County if COVID-19 cases continue to increase in the coming weeks; but unlike last time, the state and federal government won’t focus their energy specifically on Clark County.
“It feels like deja vu,” said Clark County Public Health Officer Dr. Alan Melnick. “But this time around, we won’t have those kind of resources.”
Clark County Public Health, along with thousands of health departments across the country, will have to face a rapidly escalating pandemic with staffs and budgets that have dramatically decreased since the 2008 recession, said Adriane Casalotti, chief of government and public affairs with the National Association of County and City Health Officials.
“We know what to do and how to intervene,” Casalotti said. “It’s that we don’t have the people and the resources to do it.”
Local health departments are the first responders to disease outbreaks. They inform and educate medical providers and the public, actively monitor confirmed cases, investigate disease transmission and conduct outreach to close contacts of confirmed cases.
NACCHO represents nearly 3,000 local health departments across the country, and Casalotti said local public health agencies have lost close to a quarter of their overall workforce since 2008, which amounts to close to 60,000 workers.
Small health departments have lost about 11 percent of their funding in the same time frame, Casalotti said; medium-sized health departments are barely breaking even, and large health departments have seen about a third of their budgets cut.
The Washington Post reported that since 2003, the Centers for Disease Control and Prevention has seen its emergency preparedness budget cut by 30 percent, and President Donald Trump is recommending deeper cuts in the future.
This week, Washington approved a $200 million funding package for COVID-19, and the federal government is chipping in $11 million in aid to Washington. But this kind of reaction has become all too familiar to health departments in the U.S.
Legislators shirk or underfund public health when things are going well, and then they amp up dollars and resources when an emergency emerges.
“Every time we have a crisis, we recognize it and we put more money into it, but we have yet to commit to some kind of plan for sustainable funding,” Melnick said. “You’re seeing the results of it when we continue to go from one crisis to another.”
During the measles outbreak, Clark County Public Health shifted staff from their regular positions into outbreak response roles, which decreased the usual services that Public Health provides, such as food inspections and visits for their nurse-family partnership, which helps low-income first-time parents navigate parenthood.
From January to Feb. 20, 2018, Public Health conducted 261 routine food inspections. During the same time period last year, Public Health conducted only 122 routine food inspections.
Casalotti said that when health departments have to shift staff for outbreaks, that leaves other important services in jeopardy. And with decreased staffs, health departments already “have fewer bodies to pull from.” One area that usually gets hit hardest by those shifts is the communicable disease staff, who also work on preventing sexually transmitted diseases, which are on the rise across the U.S.
“It’s not as if these other issues stop,” Casalotti said.
A 2019 legislative decision package from the Department of Health, outlined how Washington needs $450 million per biennium to fill gaps in services for foundational public health, which involves communicable disease work. In the package, the department of health complained of having to “put out fires,” rather than focus on prevention, as the Seattle Times first reported.
“The local, tribal, and state governmental public health system is failing to provide the most basic, core public health services necessary to adequately protect and promote the health of all Washingtonians,” the package reads. “This makes all Washingtonians vulnerable to communicable diseases (both new and old), environmental health threats, chronic diseases (diabetes, heart disease, stroke, and cancer), and unhealthy births and childhoods.”
From 2003 to 2018, Clark County Public Health’s biennial revenue has dropped by close to $7 million, while the county’s population has risen by about 80,000 people. State foundational support has mostly flatlined at around $3.5 million over the last decade, and total funding from the state, which can include grants and other funding streams, has fallen by more than $3 million.
While health jurisdictions and tribes across the state saw a need for $450 million in foundational public health services, Gov. Inslee’s biennial budget eventually approved $22 million.
About $12 million of that funding was supposed to come from the state’s vape tax, but a decrease in vaping means public health will receive less funding than originally allotted.
Casalotti said once disaster strikes, you can see where investment has been lacking. With reduced funding and staff, cracks start to emerge throughout the public health system. Areas that should be prioritized receive triage treatment, or get neglected because staff can’t spend the needed time on them.
The problem with procuring more funding for public health work, Melnick and Casalotti said, is that when public health departments do good work, there work goes unnoticed because they prevented a problem. As Melnick likes to say, “there’s no advocacy group for people who don’t get sick.”
But as the department of health outlined in their decision package last year, consequences will arrive eventually if funding doesn’t.
“The results of a deteriorating public health system are increased health care costs, reduced productivity in our economy, and needless suffering from preventable disease and death.”