Four_Steps_to_Building_the_Public_Health_System.16
After reading the article please answer the following: 1- Once a year nurses in the state of New York travel to the state’s capital, Albany, to lobby. Why is nurse lobby day important? 2- Based on this article, did the United States have a proactive response or a reactive response with handling the public health crisis of COVID-19? Please provide two examples with your answer. 3A- What is the role of a disease intervention specialist (DIS) in public health? 3B- To keep up with the demand for DIS, what are the 3 necessary steps to address the demand? 3C- What skills does a nurse have to fulfill the role of a DIS?
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Commentary
Four Steps to Building the Public Health System Needed
to Cope With the Next Pandemic
Brian Castrucci, DrPH, MA; Chrissie Juliano, MPP; Thomas V. Inglesby, MD
COVID-19 has revealed what many publichealth practitioners have known for sometime: our nation’s disjointed and under-
funded public health system lacks the ability to
mount a coordinated response against novel epidemic
threats. Our failure to invest in our nation’s state
and local governmental public health infrastructure,
as well as key federal programs, risks a large loss of
life from future infectious disease threats, and dur-
ing crises, jeopardizes the economy and the normal
functioning of society.
Since 2010, spending for state public health agen-
cies has dropped by 16% per capita and spending for
local health agencies has fallen by 18%.1 More than
three-fourths of Americans live in states that spend
less than $100 per person annually on public health,
compared with more than 100 times that for medical
care.1 Federal support for the Public Health Emer-
gency Preparedness Program (PHEP) and the Hospital
Preparedness Program (HPP), which are meant to
provide funding for health agencies and hospitals, re-
spectively, to prepare for a response, has declined by
30% since 2006.2 The consequences of these budget
reductions include fewer staff ready to respond at a
moment’s notice, fewer dollars available for invest-
ments in technology, and in some places, a decrease
in overall coordination between health care providers
and public health agencies.
The nation’s early response to COVID-19 showed
the country’s limited capabilities in implementing ba-
sic epidemic control steps—testing, isolating, tracing,
and quarantine. In this supplement, Hamilton and
Turner3 and Ruebush et al4 provide critical and de-
tailed reviews of the nation’s epidemiologic response
Author Affiliations: de Beaumont Foundation, Bethesda, Maryland
(Dr Castrucci); Big Cities Health Coalition/de Beaumont Foundation, Bethesda,
Maryland (Ms Juliano); and Center for Health Security, Johns Hopkins
Bloomberg School of Public Health, Baltimore, MD (Dr Inglesby).
Conflicts of Interest: None.
Correspondence: Chrissie Juliano, MPP, Big Cities Health Coalition/de
Beaumont Foundation, 7501 Wisconsin Ave, Ste 1310 East, Bethesda, MD
20814 (Juliano@bigcitieshealth.org).
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/PHH.0000000000001303
and challenges with contact tracing and disease inves-
tigation. Drawing from these 2 articles, the present
commentary identifies 4 steps to take to prepare the
public health system to respond effectively to major
future epidemic threats to the United States.
Modernize Data Systems
Thus far, the COVID-19 pandemic has been like look-
ing at a photograph where your thumb obscures half
the picture. Neglected, archaic, and siloed federal,
state, and local data systems have limited the accu-
racy and availability of public health data related to
COVID-19 in the United States. While there have been
many useful dashboards created, as Hamilton and
Turner identify, information on key variables is often
missing. While information on race and ethnicity has
been at least collected sporadically, other data critical
to shape the response and formulate appropriate pol-
icy interventions, such as income and occupation, are
unavailable. During this response where information
on the virus was changing rapidly, data reporting was
delayed by a manual-heavy process for data trans-
mission. Thus slowing our reaction time to new hot
spots and epidemiologic changes. Even where data
were available, there were often a jumble of differ-
ent collection and reporting methods, making analysis
of viral transmission difficult. If public health officials
could “see the whole picture,” they would recognize
new outbreaks more quickly, would be able to move
resources with more precision, and would be able to
communicate new information to the public about
steps they could take to reduce their risk of disease.
For example, with the current data infrastructure,
tracking vaccine distribution data will prove chal-
lenging, a problem the federal government, states,
and locals will have to fix while still in a crisis,
which should have been a strong capacity built be-
fore this pandemic. When the Health Information
Technology for Economic and Clinical Health Act
(HITECH), which was part of the American Recovery
and Reinvestment Act (ARRA) of 2009, allocated ap-
proximately $27 billion to encourage physicians and
hospitals to transition from paper medical records to
Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
S98 www.JPHMP.com January/February 2021 • Volume 27, Number 1 Supp
mailto:Juliano@bigcitieshealth.org
January/February 2021 • Volume 27, Number 1 Supp www.JPHMP.com S99
electronic medical records, there was very little fund-
ing to help public health agencies make better use of
clinical information.5 Compare this to $50 million for
public health data infrastructure included in the 2020
budget, an indicator of the huge differences in invest-
ment between clinical medicine and public health in
the United States.6
Federal investments are needed to ensure, as Hamil-
ton and Turner write, “a totally integrated, high-
speed, networked health system—from laboratories
to health care facilities to public health data.”3 The
Data is Elemental Campaign, of which Hamilton’s
organization is a founding supporter, estimates that
$1 billion over the next 10 years are needed to
fully modernize the existing public health data
infrastructure.7
Implement a New Approach to the Disease
Intervention Specialist Workforce
As Ruebush et al4 note, estimates for the number of
contact tracers, also known in public health as disease
intervention specialists (DISs), needed to effectively
respond to COVID-19 nationally range from 100 000
to 300 000, approximately 100 times more than the
existing workforce at the start of the outbreak. The
process of hiring this many people at one time into
government service, coupled with the need for train-
ing, poses a significant logistical challenge. While state
and local health agencies must ensure baseline DIS ca-
pacity, fewer DISs will be needed once the pandemic
subsides. However, this is likely not the last pandemic
that the country will face. Three steps for building
this capacity should be taken. First, the baseline num-
ber of DIS officials should be increased, so public
health agencies remain capable of broadly meeting
outbreak response needs routinely. Second, substan-
tial cross training across public health agencies should
be done so that public health officials from across
agencies could be called into action to perform DIS
work as needed in a crisis. And third, systems should
be established to hire new DIS workers rapidly in a
crisis, using best practices regarding how this has been
done during COVID-19.
Part of building the DIS workforce is to ensure
it is representative of the communities they seek to
work in and reach. Significant inequities exist in num-
bers of cases and deaths among people of color and
those who have lower income. People of color are
less likely to have paid leave and be able to do
their job responsibilities from home and are also
more likely to have the preexisting conditions that
COVID-19 has seized on—asthma, obesity, and dia-
betes, to name just a few. African American people
account for 20.7% of COVID-19 deaths and Hispanic
or Latino people account for 21.3% of deaths.8
Disease investigation efforts are likely to be more
effective if they are built on substantial local knowl-
edge of a community and acceptance by community
members. Without local trust in public health agen-
cies, outbreak investigations are likely to gather less
information and take more time, lessening the op-
portunities to identify new cases and quarantine the
exposed. Building a stronger DIS workforce that re-
flects community demographics will be critical.
Enact Policies That Support Contact Tracing
Efforts
DISs conducting contact tracing for COVID-19 have
reported a reluctance to identify contacts. Con-
cerns regarding privacy, immigration status, and the
possibilities that naming a contact could lead to
homelessness or inability to get or pay for food if
prevented from working, have combined to create
barriers to truthful reporting. A 2019 article in The
Atlantic chronicled how a city-enforced quarantine
resulting from a measles outbreak led to missed pay-
checks and subsequent eviction due to the absence of
paid sick leave.10 Policies at the state and local lev-
els that require paid sick leave, rent forgiveness or
forbearance, immigration assurances, and income re-
placement or that provide food for those named as
contacts would help facilitate reporting. With such
policies, cases would understand that their contacts
would not be harmed for being identified.
Once an outbreak reaches a certain size and pace,
contact tracing efforts are unlikely to be able to keep
up with the demand, no matter the size of the work-
force. It is critical for political leaders to understand
the role that contact tracing can play and what it
cannot do. It needs to be recognized that contact trac-
ing is not a replacement for disease control policies,
such as universal masking, physical distancing, the
avoidance of large gatherings, or widely available di-
agnostic testing. Public health officials have reported
that political leaders have, in some places, moved to
relax broader disease containment measures, with the
hope that contact tracing efforts would keep COVID-
19 in check. What is needed is a strategic combination
of both, and the ability to strengthen and loosen dis-
ease containment policies depending on the scale of
the outbreak in specific states or localities.
Increase Visibility of and Communication About
Public Health
Public health has long been struggling with an in-
visibility crisis. During the COVID-19 response, the
cost of that invisibility was concrete and clear. For
Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
S100 Castrucci, et al • 27(1 Supp), S98–S100 Commentary
some, a call from a DIS may be the first time that
they have ever been contacted by someone from a
public health department. Furthermore, the call was
all too often from a number that was “unknown” on
their caller ID—an issue that many health agencies
were able to remedy as the outbreak unfolded by en-
suring that calls were identified as the department or
a contact tracing taskforce or similar. Ruebush et al
recount strategies including “partnering with trusted
community leaders, offering incentives for participa-
tion, optimizing interviewers’ skills, and developing
communication messages.”4 However, contact tracing
and public support may be enhanced if state and local
public health agencies increase their visibility before
crisis events, such as COVID-19, occur.
Research suggests that leaders working in educa-
tion, health care, housing, and business are largely
unclear about the responsibilities and work of pub-
lic health agencies and professionals and how they
can collaborate to solve problems in other fields. In
an epidemic crisis, one consequence of that is pub-
lic health leaders may not have existing relationships
needed to effectively put in place disease control ef-
forts that depend on engagement with other parts of
a community.
A recent poll found broad national support for
public health protections such as stopping the spread
of communicable diseases, protecting environmental
quality, and supporting child and maternal health.11
It is not that people are opposed to public health
or indifferent to its outcomes. The difficulty is that
people do not know who does this work or how they
do it. Even those polled who said they support public
health could not identify the professionals respon-
sible for carrying out the work. This “disconnect”
limits understanding of what is required to do public
health work effectively, reduces support for necessary
policies, and can hinder uptake of important public
health interventions to slow the spread of COVID-
19. Through the end of this terrible pandemic and
into the future, governmental public health leaders
should be working to effectively communicate their
responsibilities and goals of their work and make the
profession more visible to their own communities.
These reflect some of the important changes needed
in public health to improve its capacity to confront
emerging infectious disease in the future. If public
health is able to take these steps forward, it will not
only increase the readiness of the country and its
communities to cope with future infectious disease
challenges, but it will also result in far more capac-
ity to help address the many public health challenges
the country faces every day.
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