Public health is becoming a team sport

By David Betts, principal, and Elizabeth Berkey Cathles, senior manager, Public Health Transformation, Deloitte Consulting LLP

Since early 2020, the public-health sector has responded to a steady flow of pathogens—from COVID-19 to monkeypox to polio, and most recently, to Ebola.¹ (Influenza and bird flu may be on the horizon.)² This persistent threat—layered with concurrent responses—reinforces the need for public health to be a team sport where different types of players work together to defeat new and formidable opponents.

Prior to COVID-19, federal, state, and local public health leaders typically developed a deep understanding of a pathogen, but also relied on the commercial market to execute widespread testing and vaccinations. But those players were unable to stay within these expected boundaries once COVID-19 became a pandemic, and the traditional public-health architecture buckled under the stress. Public health officials suddenly found themselves operating in a much more complex environment and working with a broader set of players, some for the first time. Moreover, many public health departments were ill prepared, unfunded or underfunded, inexperienced, and/or understaffed as the pandemic unfolded. Still, they stood up programs (e.g., testing, contact-tracing, mass vaccinations) on an unprecedented scale. There were successes and challenges.

Although managing multiple health emergencies simultaneously is not new for public health, the number of large outbreaks has been on the rise, and many public health agencies are taxed and stressed. If regularly emerging pathogens become the norm, public health agencies will need the infrastructure and the resources to respond swiftly and effectively. They will likely also need to work hand-in-hand with a broader ecosystem of actors, public- and private-sector alike, to build a resilient system that is more prepared for the unexpected. On October 18, the White House said it would invest in “critical multi-lateral institutions” as part of its strategy to enhance the country’s pandemic preparedness.³

The benefits of inter-agency partnerships

Public health leaders should try to become more comfortable in working with a broader set of players. They should also build patterns and systems to support interactions with those players. Many public-health departments have experienced the benefits of working with outside agencies and organizations and local jurisdictions. Most have developed inter-agency partnerships across jurisdictions that have led to greater coordination and better outcomes. Some agencies have added local universities to their advisory boards. Forging deeper and more consistent relationships with the commercial sector could help public health departments increase capacity and improve response times.

The pandemic led to a new way of thinking. The commercial market, for example, introduced new tools and technologies to detect, prevent, and treat COVID-19. Public health officials, however, have historically held tests to a high standard and had to take a leap of faith that their commercial counterparts would deliver accurate tests at scale. The public health sector now has experience in leveraging tools that had not traditionally been used so broadly. Contract-tracing apps, for example, warned the public about potential exposures. They also provided insight into how the risk was perceived by gender, generation, and race.⁴

As we emerge from the COVID-19 pandemic, public health has an opportunity to be more proactive in determining roles that can and should be played by outside organizations. For example, how much can public health departments rely on local health systems or other private-sector players to carry out important public health activities during emergencies?

Successful private-public partnerships

Early last summer, as monkeypox was emerging as a potential threat, the Department of Health and Human Services (HHS)—through the Centers for Disease Control and Prevention (CDC)—shipped virus tests to five commercial laboratories in an effort to quickly ramp up testing capacity nationwide. At the same time, the Food and Drug Administration (FDA) gave hospitals and health systems the green light to develop their own high-quality tests, which has been successful.⁵

Another example of this public-private partnership is Healthy Davis Together, a pandemic response program launched by the city of Davis, California, the University of California’s Davis campus, and local businesses. The program provided regular COVID-19 testing, promoted vaccinations, supported local businesses, and aggregated and shared data. A recent analysis concluded the program helped reduce infection rates by 60%.⁶

There are many other examples of successful private-public partnerships. However, some public health leaders might worry that such arrangements could require them to forfeit control. But working with a broad set of players can help extend resources and responsibilities and could help ensure a faster and more efficient response to public health emergencies.

Four factors that could strengthen multi-layered public health responses

Here are some of the lessons public health has learned since COVID-19 emerged…and some of the challenges it continues to grapple with:

• Infrastructure: This might be the top issue for public health. COVID-19 and monkeypox exposed some of the flaws and weaknesses of the existing system. Infrastructure determines the response to virtually every public health emergency, and is essential for being able to capture, analyze, and act on data. Infrastructure affects every piece of the puzzle. For example, if the right infrastructure is in place, replacing departing workforce (e.g., staff that performs manual administrative tasks) could be less disruptive.
  
• Funding: Many state and local public health agencies lack the staff or funding to respond to a statewide or national health emergency, especially on an extended basis. And federal dollars allocated to public health agencies tend to be prescriptive. Case in point: When monkeypox first showed up in the US, federal dollars that had been allocated for COVID-19 could not be used for the response.⁷ While the federal government later allowed these funds to support monkeypox testing and vaccinations, the delay may have caused too limited of a response at the local level. Delays in federal funding is not a new problem, but it is one that can have a significant impact on the response to a public health emergency.
  
• Preparation (and team practice!): Local health departments are critical during a public health emergency. They play a key role in coordinating responses, defining roles and responsibilities, and ensuring smooth handoffs. While training is typically required to receive Public Health Emergency Preparedness (PHEP) grants, it is sometimes inadequate. Many public health departments had spent years preparing for an influenza pandemic. But that playbook turned out to be ineffective once COVID-19 became a pandemic. Local public health officials should conduct regular table-top exercises and drills—with their counterparts across agencies and other health systems—to train staff for the unexpected and to help ensure that everyone understands their responsibilities.
  
• Response: The federal response to Hurricane Sandy in 2012 is an example of a centralized plan with a decentralized execution.⁸ A centralized plan identifies who oversees the response and who coordinates the local teams. After the hurricane hit, responders at the federal level understood their roles and were able to coordinate with state and local responders. This strategy has been effective for federal responses to natural disasters such as hurricanes and floods. In health care, the variables are almost limitless. Having a solid centralized plan usually means the responding agency has the latitude and financial resources to respond quickly and appropriately. When it comes to a public health emergency, a centralized plan with a decentralized execution could be useful because each state, county, and community could have slightly different priorities (emergency responders, testing kits, vaccines).

Conclusion

Many of our Deloitte colleagues are heading to Boston next month to participate in the American Public Health Association’s annual meeting where collaboration will be a predominant theme.

Public health officials have learned a lot since COVID-19 surfaced nearly three years ago. Collaboration has helped make the public health team bigger, stronger, and more diverse. There also appears to be less concern about who has the ball at any point in the game. As this team continues to work and practice together, it will likely only get better at the game, and more effective when it encounters new opponents.

Acknowledgements: Cecelia Gondek, Carrie Holsinger

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Endnotes:

^{1.        US to begin screening air passengers from Uganda for Ebola, New York Times, October 6, 2022
2.        Bird flu ‘prevention zone’ declared across Great Britain, October 17, 2022
3.        Fact Sheet: Biden-Harris Administration releases strategy to strengthen health security and prepare for biothreats, The White House, October 18, 2022
4.        Perception and use of COVID contact-tracing mobile applications in New York State, Association for Information Science & Technology, October 14, 2022
5.        HHS expanding monkeypox testing capacity to five commercial laboratories, HHS press release, June 22, 2022
6.        Health Davis Together: Creating a model for community control of COVID-19, American Public Health Association, July 13, 2022
7.        Monkeypox response relies on trade-offs without federal aid, Roll Call, September 28, 2022
8.        Ten years after Sandy: Barriers to resilience, New York City Comptroller, October 13, 2022}