Abstract
Background
The COVID-19
Unfortunately, the pandemic also accentuated the underlying issues that prevent us from responding even more effectively in the future. It is likely that these issues contributed to higher levels of morbidity and mortality due to COVID-19 as compared with other nations. The US public health system is largely decentralized, with several federal agencies responsible for public health, 55 state or territorial health agencies, and over 3,000 local health departments (LHDs). 4 The COVID-19 pandemic exacerbated gaps between these agencies and the multitude of other sectors that participated in the response to the pandemic.
Although LHDs have long responded to disease outbreaks and health impacts of emergencies, before September 11, 2001, few local health departments had formal public health emergency preparedness programs. In 2002, the US Centers for Disease Control and Prevention (CDC) Office of Public Health Emergency Preparedness 5 was established to coordinate activities related to preparing for acts of bioterrorism and other public health threats. In December 2006, in the wake of Hurricane Katrina, the Pandemic and All-Hazards Preparedness Act 6 was passed to strengthen the nation's capacity to prepare for and respond to emergencies. This act expanded grant programs for STLT preparedness activities and created new standards to measure the success of these efforts. The original law was reauthorized first in 2013 and again in 2019, 7 continuing the essential programs established under the act. Public health preparedness at the STLT levels is primarily funded through 2 federal cooperative agreements: the Hospital Preparedness Program (HPP) 8 and the Public Health Emergency Preparedness (PHEP) program. 5
Through these funding and policy initiatives, the public health sector established and expanded all-hazards emergency preparedness and response programs. Over the past 20 years, these programs equipped 9 LHDs to effectively address the range of disasters their communities encountered, from hurricanes, floods, tornadoes, and wildfires to emerging diseases like H1N1, Ebola, and Zika, and reemerging diseases such as measles, hepatitis A, and polio. Public health emergency preparedness funding, in particular, increased the number of public health preparedness professionals available to health departments.
Efforts to standardize the capabilities of local public health agencies through the Public Health Emergency Preparedness and Response Capabilities: National Standards for State, Local, Tribal, and Territorial Public Health 10 ensure a baseline level of preparedness and continue to lead to substantial improvement in the health security of communities. LHDs have built plans and protocols to more effectively marshal resources and respond to future health threats. Public health agencies routinely conduct exercises and drills for continuous improvement and incorporate lessons learned into each emergency response.
Purpose of This Retrospective
This commentary provides some initial insights gleaned from diverse LHD experts who serve on the National Association of County and City Health Officials (NACCHO) Preparedness Policy Advisory Group (PPAG). PPAG recruits members from each of the 50 states and has representation across the country. PPAG members have extensive public health emergency response experience and serve in leadership positions within their organizations; they work collaboratively to understand and convey the experiences of all LHDs in their states. Over the course of the COVID-19 response, PPAG members shared lessons learned, identified solutions to critical issues, and worked to ensure that the perspectives of LHDs informed national decisionmaking about response efforts. Although drawn from diverse jurisdictions, the findings were remarkably similar, and some of the most salient findings are presented in this commentary. The issues identified here are not intended to be all-encompassing of the pandemic response.
The takeaways presented in this retrospective encourage a different kind of investment that will address foundational needs to advance public health emergency preparedness and response. This commentary is intended to reflect discussions of the PPAG and to highlight initial reflections that should inform national discussions about improvements necessary to ensure we are better prepared for the next pandemic.
Initial Reflections and Priorities
Based on discussions with PPAG members throughout the COVID-19 response, 3 areas were consistently identified as being among the highest priority to address: (1) partnerships, (2) data modernization, and (3) incident management. While these issues do not represent the totality of critical areas for improvement, they represent areas where focused investment of human and financial resources is necessary to improve the public health system's collective ability to respond to future public health emergencies.
Partnerships
One of the major strengths of the PHEP program over the last 20 years has been the development and maintenance of relationships that support the whole community. The public health system is broader than LHDs, and only a portion of the response was dependent on the direct actions of local public health departments. Internal partnerships are also important, including divisions of public health outside of emergency preparedness.
PHEP coordinators often collaborate heavily with traditional emergency response partners such as emergency management, healthcare, emergency medical services, fire, and law enforcement.11,12 As with any emergency, these traditional partnerships were important during the COVID-19 response.
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Nontraditional response partnerships also had major impacts on the COVID-19 response and will be critical to responding to future incidents. Some of these nontraditional partners were community and nonprofit organizations, such as organizations that support people experiencing homelessness, disability organizations, organizations that support marginalized communities, and senior centers. These nontraditional partners enabled LHDs to:
Connect response efforts directly to individuals in the community who may have been reluctant to engage with public health services due to fear or mistrust. Increase equitable access to vaccination through community-based vaccination clinics. Disseminate messaging to high-risk and marginalized communities and serve as trusted messengers.
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Ensure community concerns and needs were being represented to governmental public decisionmakers about vaccine prioritization, access to limited vaccine supplies and testing, accessibility of services, and other issues.
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Work across city and county governments to engage personnel for response roles and the deployment of local, state, and federal resources.
As noted in the Public Health Emergency Preparedness and Response Capabilities: National Standards for State, Local, Tribal, and Territorial Public Health, 10 LHDs are expected to take the lead during disease outbreaks, but they must also coordinate with a variety of partners to refine public health lead and support roles and responsibilities. The following COVID-19 partnership examples from LHDs are varied and demonstrate how engagement and coordination promoted awareness and access to public health resources and services:
In Las Vegas, Nevada, an existing barbershop program within the LHD's Office of Chronic Disease Prevention and Health Promotion that provides heart health education and blood pressure screening in African American communities was leveraged to counteract misinformation and disinformation in the community and to encourage community members to get vaccinated. 16 Vaccines were offered onsite in local barbershops to people in communities with higher risk for complications from COVID-19 and high case rates, who would not have received a vaccination otherwise.
The Ottawa County Human Services response team, comprising more than 40 partners, advised Ottawa County and discussed barriers and problems weekly with potential improvements for implementation. 17 The team was led by the director of Community SPOKE and the Lakeshore Nonprofit Alliance and consisted of trusted community members, faith-based organizations, and established nonprofit organizations, including the Community Foundation of the Holland/Zeeland Area and Community Action House. Ottawa County implemented improvements to ensure health equity in the community, such as providing additional translation services for Spanish-speaking individuals after learning that messaging was unclear and more in-person translators were needed onsite. Working with the Ottawa County Medical Reserve Corps and county staff, the number of Spanish-speaking individuals at each site increased to create a sense of safety and trust for Spanish-speaking individuals.
King County, Washington, formed the Pandemic and Racism Community Advisory Group, Community Navigators, Priority Population Workgroups, and the Equity Response Team in order to center community members and intentionally cocreate response strategies with them. The implementation of these partnerships and strategies led to some of the highest vaccination rates in the United States, including a minimum of 70% of all eligible adults across all racial and ethnic groups and regions of the county. 18
These partnerships, developed before and during the COVID-19 pandemic, were essential to ensuring the successful delivery of public health interventions. 19 It is important to highlight successful collaborations, learn how to do better by community partners, and identify mechanisms, including funding, to sustain the partnerships. Partnerships require continuous sustenance and support. Substantial time and resources were invested over the course of the pandemic, and these partnerships can support not only the next public health emergency but also routine public health activities. It should also be noted that partners have increased expectations for ongoing engagement with LHDs, regardless of the boom-and-bust cycles of funding, and those expectations should be considered as LHDs design preparedness and outreach programs going forward. 20
Data Modernization
The COVID-19 response exacerbated longstanding gaps in the public health data infrastructure. LHDs scrambled to organize and rapidly scale case and contact investigations, track the distribution and administration of medical countermeasures and vaccines, and provide near real-time updates about the status of the pandemic in their communities.
While substantial investments have been made in electronic medical record systems to expand their use and interoperability for coordinating care and supporting analytical review in healthcare settings, relatively little investment has been made to enhance the integration of these systems with the public health sector. In addition, little has been done to update the systems that LHDs rely on day-to-day for communicable disease reporting, vaccine registries, and more. 21 This underinvestment results in health departments continuing to use systems that have limited ability to support disaggregation of demographic data, connect to a geographic information system, or enable real-time analytics that inform decisionmaking. An especially relevant example is that LHDs frequently faced challenges in collecting, analyzing, and reporting data about the recipients and locations of COVID-19 vaccines and therapeutics administered within their communities, which is crucial for making informed decisions about strategies to address gaps in equitable distribution.
As the COVID-19 pandemic emerged, health departments rushed to scale systems that barely met routine requirements into systems able to handle substantial increases in volume and frequency of data inputs and reporting. The availability of COVID-19 response funding, including the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) 22 and the American Rescue Plan Act, 23 enabled many LHDs to implement new systems. However, it is not ideal timing to scope, implement, and support systems in the midst of a national public health emergency. This rapid scaling and infusion of 1-time funding has resulted in the implementation of systems that are not fully interoperable with similar products and electronic health records, implementation of software as a service system that cannot be sustained once funding for the COVID-19 response is reallocated or no longer available to health departments, and implementation of 1-time use systems that were developed quickly but may not be applicable to future use cases.
Opportunities for improving data management begin with modernizing the public health infrastructure. Strategic, sustained investments are needed to update and integrate data systems that the public health sector relies upon to effectively respond to public health emergencies. COVID-19 highlighted the critical need for decisionmakers to have access to up-to-date and complete information about the status of the outbreak, health system infrastructure, and resources available to enable an effective response. This requires building data systems that can be effectively integrated across all levels of the government and include data from all related industries and fields. Many public health agencies have already made substantial investments to update and connect electronic medical record systems, vaccine registries, case investigation and contact-tracing systems, inventory management, and others. These investments enabled improved management of the response and evaluation of response strategies, but they are not sufficient on their own. Future investments must be made to accomplish the following:
Standardize data collection to ensure complete datasets (eg, demographics, diagnosis, vaccine administration, treatment).
Equip systems to smoothly handle substantial surges in data that are anticipated during public health emergencies.
Ensure public health agencies that support data integration have staff who are adequately trained and available to support the collection, analysis, and reporting of data in real time.
Embed customizable analytics and dashboards that make data more accessible to all communities.
Support the ongoing use of these systems during nonemergency response efforts.
The CDC's Data Modernization Initiative holds promise to support the modernization of core data and surveillance infrastructure across the federal and state public health landscape. 24 Funding over the next 5 years from CDC's Public Health Workforce and Infrastructure grants to state, local, and territorial jurisdictions is intended to help support enhancements to foundational elements of the public health data systems. Instead of past practices that provided funding only during emergencies, ongoing, sustained investments in these efforts will enable substantial improvements and strengthen the public health sector's ability to protect the health of the United States.
Incident Management
The Incident Command System (ICS) has both mechanistic and organic aspects. 25 These aspects of management structures were first described by Burns and Stalker in 1961. 26 They defined a mechanistic system as one that uses rules and hierarchy to manage workers and an organic system as one that relies on communication and cooperation to manage interactions between individuals. Industries like manufacturing or a restaurant's kitchen operations often take a mechanistic approach to ensure consistency and uniformity in their work product. By contrast, organic systems excel at managing complex situations, in which the anticipated actions must adapt to a changing landscape marked by unexpected events. Political campaigns, for example, operate in such rapidly changing environments and would be best suited for management through organic systems.
The Federal Emergency Management Agency (FEMA) describes ICS in the following way:
ICS is a standardized approach to the command, control, and coordination of on-scene incident management that provides a common hierarchy within which personnel from multiple organizations can be effective. ICS specifies an organizational structure for incident management that integrates and coordinates a combination of procedures, personnel, equipment, facilities, and communications.
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It is intended for use in incidents of any size or complexity, though its success has been inconsistent across incidents and industries. 25
During the public health response to COVID-19, experiences with using ICS varied across LHDs. While most LHDs reported “going into ICS” for at least a period of the response, many indicated that its implementation did not provide the operational benefit that they anticipated. Potential reasons for this include the following:
The complexity and unprecedented nature 28 of the COVID-19 response lent itself to management through an organic-oriented response system, which was incompatible with the mechanistic-oriented components of ICS. 25
Even if ICS were operated to be sufficiently organic, the complexity of the incident required an extensive organizational structure to scale with the scope of the response, 27 exceeding the capacity of LHDs to staff all necessary positions. Without sufficient access to incident management teams or extensive support from other agencies, the response organization was unable to fill all essential roles.
The COVID-19 response relied heavily on volunteer and nongovernmental organizations, and researchers have noted the weakness of ICS in effectively integrating these entities. 25
Unlike law enforcement agencies and fire departments, which are fully staffed with response personnel, the majority of staff at LHDs have responsibilities beyond response that cannot be suspended without resulting in other impacts on public health. This prevented the exclusive assignment of public health personnel to incident management, limiting their ability to manage the incident through ICS.
Most LHD staff are not response personnel, resulting in 2 other challenges: (1) most staff lack sufficient training and have limited experience working within ICS, and (2) the differences in culture between public health and traditional response disciplines are associated with an unwillingness among staff to operate within ICS. Researchers Neal and Webb noted that when this occurs, organizations “[rely] upon their own system of doing business” rather than ICS.25,29 This was observed among LHDs in their response to the COVID-19 pandemic.
Finally, many of the core functions of LHDs could not be delegated to other entities because they required the execution of public health authorities that were vested in the organizations themselves. Thus, LHDs were predisposed to rely on day-to-day procedures to ensure their essential response duties could be implemented, rather than converting to an ICS approach to manage the pandemic.
Although ICS has demonstrated its effectiveness in supporting incident management in various scenarios, the challenges encountered during the pandemic posed significant barriers to its full use within the public health sector. These challenges may also create complications for its future use in handling public health incidents.
Recommendations for Advancing Public Health Preparedness and Response
Partnerships
Ensure cross-sector collaboration at all levels of the government, which is crucial for the future of public health. The public health sector cannot do its work alone, especially during an emergency response. Through cross-sector collaborations, the public health sector can address social determinants of health and build a stronger base of support for response activities, guidance, and policy recommendations.
Local public health departments should collaborate with community partners and trusted leaders to combat misinformation and disinformation. Community organizations are well-positioned to provide accurate and timely information to individuals in ways that they are more likely to accept.
Local public health departments should collaborate with community partners to create response strategies that allocate resources where communities believe they would be most beneficial.
Incorporate trusted leaders and community organizations into local health department response structures. Communities have solutions and experiences that enrich our ability to respond to public health incidents and emergencies.
Formalize relationships developed during the COVID-19 pandemic and develop mechanisms, such as memoranda of understanding, training, and exercises, to ensure that partnerships are maintained and strengthened at all levels of the government.
Conduct administrative preparedness planning to support developing and sustaining partnerships within LHDs such as finance, human resources, and other divisions not traditionally involved in emergency response.
Develop the partnerships from an all-hazards approach at the federal, state, and local levels. For example, the environmental impacts of climate change will necessitate diversity in partnerships and creative strategies.
Data Modernization
Expand the use of near real-time data dashboards and other public-facing reporting tools across all levels of the government that promote transparency, information sharing, and coordination.
Ensure that federal-level data systems used to track medical countermeasure distribution, vaccine registries, and case reporting support integration through nationally accepted health information technology standards.
Develop, maintain, and continuously improve federal-level data systems for day-to-day use (eg, immunization registries, hospital bed reporting, medical countermeasure distribution) to ensure ongoing functionality and the ability to adapt to future public health emergencies.
Prioritize and fund federal-level investments in core public data systems as has been done for electronic medical record implementation and expansion.
Federal and state partners need to engage LHDs in developing requirements and collaborating as critical stakeholders when new data systems, data workflows, and data exchange methods are implemented before, during, and after emergency response.
Support and fund efforts to increase the number of health informatics and other data professionals working in federal and STLT public health agencies.
Expand training programs and provide federal funding for health data/informatics professionals to work in local, state, and federal public health agencies.
The federal level should support regional or national centers of excellence to provide training and technical assistance for local, state, and federal health data modernization efforts.
Incident Management
All levels of the government need to continue to engage with public and private sector partners to plan for, respond to, and recover from public health emergencies.
Locally expand and enhance partnerships and formal coalitions with public and private sectors that sustain situational awareness, support mutual aid resources, and coordinate prevention, response, and recovery within communities.
The federal government must develop standard incident response structures that better meet cultural and organizational needs within the public health sector, while conforming to National Incident Management System principles, 30 and allow for necessary customization by STLT agencies.
Establish multiagency coordination groups at the local level with sufficient staffing support to ensure the capability exists to maintain extended operations that typify public health emergencies.
Expand joint training and exercises across all levels of the government that use public health emergencies as the primary incident in order to increase familiarity and acceptance of ICS within the public health sector.
Identify and expand staffing resources across all levels of the government—both within and beyond the public health sector—to fill all positions that would be required to effectively manage a complex public health incident.
Academia should partner with local and state public health agencies to conduct additional research on the implementation of the National Incident Management System and ICS to identify changes that would support their broader use beyond traditional response disciplines.
Conclusion
Critical investments made in LHDs over the past 20 years have led to substantial improvements in the nation's health security. LHDs hired and trained staff, developed and tested plans, responded to public health emergencies, and coordinated extensively with partners throughout their communities. As the frequency and types of threats to our nation's health continue to evolve, it is essential to continue investing in public health preparedness and response efforts.
LHDs have an essential role in protecting the health of communities across the country, especially during emergencies like the COVID-19 pandemic, for which the public health sector is best equipped to lead and coordinate response efforts. The COVID-19 response highlighted the tremendous gains made by the public health sector in coordinating with multisector stakeholders to manage a complex response, rapidly scale and sustain biosurveillance efforts, distribute and administer hundreds of millions of medical countermeasures, and surge healthcare resources, among other actions to protect individuals in communities across the country. The response strained every sector and revealed critical gaps in the nation's ability to respond to a complex public health emergency.
It is crucial to acknowledge and apply the lessons learned from the COVID-19 pandemic in order to progress and sustain our efforts. Consistent and targeted funding is essential to support this work and implement innovations to advance the public health sector. Our nation's health depends on a robust, integrated public health preparedness and response system. Public health agencies are poised to provide critical leadership before and during the next health crisis. By making strategic investments now, we can ensure that such leadership is possible.
Footnotes
Acknowledgments
The authors would like to thank the following people for their contributions to this commentary: Dee Ann Bagwell, MPH, MA, Los Angeles County Department of Public Health; Beth Hess, National Association of County and City Health Officials; Jerry Joseph, MPH, National Association of County and City Health Officials; and Rachel Santamaria-Schwartz, Esq, MPH, NYC Department of Health and Mental Hygiene.