Editor’s Note: Dr. Abdul El-Sayed is a physician, epidemiologist and former health director for the city of Detroit. He is also a CNN political commentator. The views expressed here are his. Read more opinion on CNN.
America’s public health workforce is among the best in the world. But to me, reflecting on what it might be like leading a city’s response to this coronavirus outbreak, one thing is clear: Without the resources they need to do their work while operating under a culture that puts politics ahead of science, their job is much harder. And we are that much less safe for it.
As the former city health director in Detroit, I came to appreciate how much of public health is fundamentally political, a matter of the choices that elected officials make about how to keep us safe – which is the government’s primary role. At its best, that means allocating resources, believing in science and empowering trained and experienced officials. When our elected leaders fail that standard, we have a responsibility to hold them accountable.
Local health departments have been ravaged by funding cuts that took hold during the Great Recession. Thin budgets have been further stretched because of the opioid epidemic. Reaching out to former colleagues all over the country, I am hearing from them about how a lack of funding or leadership at the very top of this response to coronavirus has left them flying blind and without the resources to take preventive precautions or respond vigorously. All the while, they are waiting for what seems now to be inevitable – that coronavirus will show up in their community, too, if it hasn’t already.
Why communities are facing even bigger challenges
It didn’t have to be this way. And in the past it probably wouldn’t have been.
If you’re chasing down a potential epidemic, time is of the essence. Lest social media lead us to forget what the word “viral” actually refers to: viruses like coronavirus have the capacity to reproduce themselves exponentially so long as there are susceptible hosts – or people who are susceptible to the disease. At every stage of spread, it gets exponentially harder to stop.
That means you’ve got to take the disease on at its source. After the Ebola outbreak in 2014-2016, the Centers for Disease Control and Prevention internalized this lesson. They initiated steps to lead the fight against emerging infectious diseases abroad under a “Global Health Security Agenda,” a global partnership to “prevent, detect, and respond” to emerging pathogens all over the world. They set up localized response units in 49 countries – because you never know where the next disease will emerge.
But in 2018 and 2019, the Trump administration attempted to cut its funding by 80%, which would have forced the CDC to roll back its presence to just 10 countries. Though the cuts were averted by Congress, if public health is about planning for prevention, operating under constant fear that your program will be defunded year after year hampers your ability to plan for the long term and fulfill your mission.
When trust breaks down
Trust is everything. The best tool to stop an infectious disease for which there is no vaccine is “contact tracing.” Contact tracing involves identifying people with the disease, and then painstakingly tracing literally everyone with whom they may have come in contact – and exposed to the disease – while they were contagious, and quarantining them. It creates a quarantine “net” of sorts to catch and kill the outbreak.
But contact tracing is an exercise in trust. People need to trust the authorities in order to tell them where they’ve been and to remain in quarantine. And the health officials leading the contact tracing efforts need to trust that their leaders will deliver the resources they need to pursue this work – and that the work won’t be politicized, thereby undercutting the community’s trust in them.
A number of new cases over the weekend with no known travel history or known infected contacts raises the alarm that our contact tracing net has been porous. Part of this is attributable to the nature of the virus itself. It can spread among people who do not yet have symptoms, and symptoms can be mild in some people who may not know they have it – though they are spreading it. Furthermore, it can survive on surfaces for some time, meaning direct contact with someone who is infected is not required for spread.
But another part is that lack of trust may have hampered contact tracing efforts. The Trump administration’s well-publicized crackdown against immigrants and people of color might have kept some who might have been exposed abroad from declaring themselves to authorities for fear of reprisal from Immigrations and Customs Enforcement.
But you also need the trust of the public health professionals doing the work on the ground – doing the work I used to in Detroit. To trust the leadership, you need to know that they’ll take decisive, evidence-based actions, and provide you the resources you needed to follow them through. You need to trust that they’ll listen when you offer objective feedback.
But this administration suffers a disregard for science and a culture of authoritarianism. Remember #sharpiegate? That was just one episode in an administration arguably defined by its rejection of science and scientists.
Lack of federal leadership hobbles local health efforts
This kind of precedent has implications for how public health administrators interact with the White House. In fact, despite the CDC’s recommendations, the administration decided to fly 14 coronavirus-infected Americans back to the United States on the same airplane as those who had not contracted the virus, potentially spreading it to them. In another situation, a whistleblower reported that Health & Human Services was deployed to receive coronavirus evacuees without the necessary personal protective equipment.
Rather than the secretary of health and human services, or the director of the CDC, or the director of the National Institute for Allergy and Infectious Diseases, or the surgeon general – people with actual credibility on public health – the administration appointed the vice president to lead the administration’s coronavirus response. This was a particularly dubious choice given his history bungling an infectious disease outbreak. In 2015, while governor of Indiana, Pence delayed necessary preventive measures recommended by the CDC and his own state health department, saying that he would “go home and pray on it.” While he did eventually proceed with needle exchange, it was far later than he should have.
Pence’s lack of competent leadership, combined with the Trump administration’s cuts, leaves local health officials without the directives or resources they need as part of a coordinated response. Instead, they’re left in a precarious position, reaching out to other local leaders in the midst of their own response.
Indeed, because our public health work force is so good, they’re making do. But at best, this makes for an uncoordinated response that delays full containment. At worst, it leaves communities with weaker public health apparati in dire straits as they manage the local consequences of a global epidemic.
What to do – right now
Though the critical time and opportunity to nip this epidemic in the bud is now lost, there are a few steps the administration should take right now to limit the spread. First, it should appoint a public health official with trust, training and experience in public health to oversee the response. Second, the mere $2.5 billion the administration has requested is too little, too late – and should not come at the expense of other public health priorities.
The public health official overseeing this response should have the trust of the administration to request funding as needed to deal with the full scope of the response. Third, much of that funding should be deployed to state and local health departments, that are the front line of the response. Fourth, those local leaders need to be included in the decision-making and handling of this response, as their on-the-ground insights and feedback will be critical to salvaging this response. Fifth, American resources should support control efforts abroad as well as at home.
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The presence of coronavirus anywhere is a threat to public health everywhere in our globalized world. Sixth, investment in both vaccination and treatment research is critical right now and all effort should be made to impel action on the part of the pharmaceutical industry.