By Christine Vestal & Michael Ollove, Stateline
Four months into the pandemic, some governors and local officials are sidelining public health professionals in a rush to reboot their state economies, even as infections and hospitalizations increase in many areas of the country.
Shunted to the background, and often ignored, public health professionals at the state and local levels who have been working long hours with few breaks are starting to burn out and lose momentum. Many have left office; a number of them were pushed out, either by their bosses or in the face of vehement public opposition.
A recent analysis from Kaiser Health News and the Associated Press found that at least 27 state or local public health leaders across 13 states had resigned, retired or been fired since April.
For at least a century, state and local public health agencies in the United States have been charged with protecting residents’ health and safety by monitoring infectious diseases and other health hazards, informing the public and taking action in an outbreak.
That includes testing, disease surveillance, data gathering, contact tracing and education. It also entails support for the local medical community, including ensuring an adequate supply of personal protective equipment and other essential resources.
But in this pandemic, top federal, state and local elected officials have taken the lead in performing those functions, not public health agencies.
“It’s been a bit of an uncoordinated disaster,” said Lori Tremmel Freeman, CEO of the National Association of County and City Health Officials. “Now that we’re at the point of reopening communities — businesses, pools, summer camps — local health departments are back in the ballgame and left to enforce the governors’ [restrictive] orders, which basically villainizes them.
“It’s really hard to be a partner in that work when you haven’t been allowed into the group that informed the decision,” she said.
From the beginning of the pandemic, Freeman and other experts say, the White House set the tone for this unprecedented circumvention of public health agencies.
President Donald Trump in March gave responsibilities to his White House task force, the federal government’s emergency management leaders and health experts from other agencies, diluting the historic leadership role of the nation’s primary public health authority, the Centers for Disease Control and Prevention.
Later, as the nation grew weary of quarantine, Trump flagrantly dismissed even his own health experts’ precautions in favor of jumpstarting the stalled economy.
Similarly, governors, mayors and county executives in many parts of the country took the lead in the beginning of the crisis, setting up COVID-19 surveillance websites, outsourcing testing and contact tracing, and buying masks and other medical supplies from manufacturers.
When governors and local elected leaders decided to reopen, often encouraged by vehement residents and businessowners demanding an end to shutdown orders, many complied despite warnings from public health officials that infections were still rising.
“We would agree on the metrics, a 14-day decline in infections, and then they would choose to ignore them,” said Freeman, the public health association CEO.
Governors who relaxed some restrictions early insisted that keeping businesses closed for a prolonged time would cause too much economic suffering. Republican Georgia Gov. Brian Kemp was one of the first to begin allowing businesses to reopen in his state in April, without a 14-day decline in infections. At the time, he insisted the state could safely ease its lockdown, dismissing computer modeling showing that the peak had not yet arrived.
While local public health officials in Georgia have objected to quickly reopening some businesses, Kemp’s public health director, Dr. Kathleen Toomey, has backed his decisions. Media reports said Toomey’s department released confusing and sometimes misleading data in support of relaxing restrictions. The number of coronavirus cases now is rising in Georgia, according to state data.
“Georgia — go to the beach, lake or a state park!” Tim Fleming, Kemp’s chief of staff, wrote in a Facebook post after the governor lifted restrictions. “They are all open and despite what the media is reporting there have been no issues on Georgia beaches or lakes today.”
Arizona also was quick to ease restrictions; it now is seeing its highest increases in cases since the pandemic began, and hospitals are nearing capacity.
Republican Gov. Doug Ducey attributed that rise to increased testing, although Dr. Cara Christ, the state health director, conceded she didn’t know whether the rising numbers were the result of more testing or community spread of the disease.
Freeman’s group and the Big Cities Health Coalition this week issued a sharp warning that attacks on public health officials were compromising American safety.
Noting that public health officials have been “physically threatened and scapegoated” and some forced out of their positions, the groups said, “We are losing expertise, experience, and most importantly, leadership, at a time when we need it most.”
The groups said it is not individual attacks that are most damaging, but the sidelining of public health expertise in the midst of the most dangerous health crisis in more than a century.
“At the federal, state, and local health levels,” the groups said, “new task forces have been created to guide COVID-19 decision-making, which lack the critical input of the public health brain trust and ignore that this virus has been and continues to be the most difficult and costly public health challenge of our lifetime.”
While turnover of top health officials in federal and state government is normal, especially when administrations change, said Dr. Georges Benjamin, head of the American Public Health Association, “we’re seeing it happen at the local level, now.”
“It’s a manifestation of the politicization of public health that many of us have been concerned about.”
The divide between elected and public health officials has been further illustrated this week as Trump continued to insist on holding a maskless, indoor campaign rally in Tulsa this weekend, overruling the cautions of his own health advisers, including Dr. Anthony Fauci, who heads the National Institute of Allergy and Infectious Diseases, and the director of the Tulsa health department, Dr. Bruce Dart.
Noting that Tulsa and Oklahoma had been experiencing new highs in reported COVID-19 cases, Dart told the Tulsa World, “I wish we could postpone this to a time when the virus isn’t as large a concern as it is today.”
Trump dismissed the request, and his campaign is requiring attendees to sign waivers that they won’t sue should they become infected while at the rally.
Officials Quit, Fired
In Ohio, the state’s health director, Dr. Amy Acton, resigned from her post last week. Early in the pandemic, she was hailed in many quarters for her plainspoken explanations of state safety measures. As time went on, she drew vociferous attacks over the restrictions.
Businesses such as gyms and concert venues sued her, lawmakers pushed to limit her authority, and protesters, some of them conspicuously armed, demonstrated outside her Columbus home.
A Republican state representative called Acton a “globalist” on Facebook, which the Anti-Defamation League denounced as an anti-Semitic trope.
Acton’s governor, Republican Mike DeWine, had backed her and put her forward as the face of the state coronavirus response. She will continue to advise him.
In rural Colorado, Rio Grande county commissioners fired Emily Brown, director of the county public health department. They were at odds over the release of COVID-19 data and her resistance to quickly relaxing restrictions. She was threatened on social media.
In Orange County, California, Nichole Quick, the county’s health officer, abruptly quit last week after finding herself at odds with county commissioners over her COVID-19 policies, including a requirement that people use face masks as the county reopened. She had also been the target of public venom. At one public meeting, in which one participant mentioned Second Amendment rights during the pandemic, another revealed Quick’s home address. Protesters picketed her home.
Republican Gov. Ron DeSantis’s administration fired Florida’s former chief coronavirus data officer Rebekah Jones in May after she said she refused to manipulate data that justified the state’s aggressive reopening plans. She has now created her own COVID-19 tracking site, and claims the state is still hiding important data.
In relaxing Georgia’s stay-at-home order, the governor ignored public health officials and even declared that local governments couldn’t impose restrictions more severe than the state’s.
Even Maryland Gov. Larry Hogan, a Republican who received high marks from public health experts for his aggressive steps to contain the virus, has recently departed from the advice of health advisers.
When Hogan last week announced a new phase in reopening, Dr. Tom Inglesby, director of the Johns Hopkins Center for Health Security and a health adviser to Hogan on the pandemic, took to Twitter to voice his objections. Allowing restaurants, gyms, malls and other indoor venues to reopen, he said, risked situations “where this virus has great capacity to spread widely.”
In response, a Hogan spokesperson insisted to the Baltimore Sun the governor had taken “a cautious, data-driven approach,” and that “key statewide health metrics continue to trend in a positive direction.”
The public outrage directed at some health officials during this pandemic may be unusually broad and intense, but controversy is often unavoidable in the profession, said Dr. Lynn Goldman, the dean of George Washington University’s Milken Institute School of Public Health.
She said public health officials also faced blowback when they sought to curtail smoking, resisted calls to quarantine those with AIDS and proposed needle exchange programs to prevent the spread of HIV. They also faced resistance when they launched lead paint abatement programs, and when they proposed, over the objections of agricultural interests, bans on pesticides harmful to humans.
But this time is different, said Jeffrey Levi, a professor of health policy and management also at George Washington University, mainly because many public officials, following the president’s lead, aren’t listening to the scientists.
“This is irresponsible at a level of magnitude that I don’t think we’ve ever seen before,” he said. “Politicians are putting public health officials in untenable positions.
“Public health officials are trained to put up with disgruntled responses to their advice, but in the past political leaders have backed them up, and that is not happening in a lot of communities.”
Out of the Loop
One example of a core public health function that has been usurped in many places by governors and other elected leaders is contact tracing. The decades-old, painstaking method of reaching out to people who test positive for an infectious disease to determine whom they’ve been in contact with and asking those people to quarantine, is often viewed with suspicion by local residents.
Many consider it an intrusion of privacy, and in some communities, where mistrust of government and the medical community run high, reaching people by phone or in person requires local knowledge and sensitivity.
That’s why David Harvey, director of the National Coalition of STD Directors, said he was dismayed when governors in some states, including California, Maryland, Massachusetts and New York, began contracting with private organizations to launch major contact tracing initiatives to prepare for reopening their economies.
“Many governors didn’t know that contact tracing and disease intervention specialists were part of the public health system and have been for decades,” he said. “It’s always been a local function that requires cultural competency.”
Instead of large-scale outsourcing, Harvey suggested, state and local governments would be better served to invest in their local health departments where the needed competency already exists. “That way the agencies would be stronger and better prepared for the next outbreak,” he said.
According to Freeman of the public health association, people have been fed a false dichotomy that communities either open and risk more sickness and death or stay in quarantine and tank the economy. Public health officials always have had to balance those two things, she said.
“We can do both. It’s not between getting your life back or having the disease. Local health officials are just as interested in getting back to normal as the rest of us,” she said. “We just want everybody to be as safe as possible, so we can get back to a new normal, wearing masks, washing hands and safely distancing.
“But we all have to follow along, because if parts of the community believe it’s a barrier to their freedom, we’re all going to suffer.”
Benjamin, of the American Public Health Association, said public health professionals should be receiving plaudits, not condemnation. “People who have been clapping every night for front-line doctors should be clapping for public health workers too,” he said. “They are saving hundreds of thousands of lives.”
Stateline, an initiative of The Pew Charitable Trusts.