INTRO COMMENTS: Hello and welcome to Modern Healthcare’s Next Up, the podcast for emerging healthcare leaders. My name is Kadesha Smith. I'm your host and I am also the CEO of CareContent, a digital strategy agency for healthcare organizations.
This topic is a tough one. It is very difficult to hear that public health officials in local and state health department officials are being threatened, and fired, and forced to resign in the middle of a pandemic.
On Next Up, we have talked about how this pandemic is affecting specific groups. Dr. Rosemary Morgan of Johns Hopkins University shared her research into how it affects women healthcare workers.
We have talked with Dr. Carladenise Edwards of Henry Ford Health about how this pandemic is only exacerbating existing health disparities among African Americans in the nation as we wrestle with a history of systemic racism.
Today, we are highlighting a different group that I feel is often forgotten, but so important to making sure that our communities are safely navigating the COVID-19 pandemic.
We are talking with Emily Brown, former director of the Rio Grande County Public Health Department in rural Colorado. She was fired in May 2020, after more than 6 years of service. Her experience and abrupt departure are a snapshot of the battle many local and state public health officials have found themselves in as we deal with this pandemic.
SPONSOR MESSAGE: Before we hear from Emily Brown, I’d like to acknowledge Masimo, the sponsor for this episode.
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MODERN HEALTHCARE: Now, let’s dive into our conversation with Emily Brown.
Hello, Emily Brown, how are you doing?
EMILY BROWN: I'm good, thank you for having me on.
MODERN HEALTHCARE: Thank you for making the time. Before we dive into our discussion, I just want to share a couple of highlights of some data that we know about the situation with public health departments.
We know that on a call with state and local health directors across Colorado, about 80% of directors participating in that call said they received some type of threat to themselves or their property. This also includes national figures, like Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, and then also small community leaders. Does that surprise you at all?
EMILY BROWN: I wish it did, but it doesn’t. We are definitely seeing that trend, and it’s scary for the current response, as well as for what that means for the future.
MODERN HEALTHCARE: Yes. We also know that since April, 49 state and local public health leaders across 23 states have resigned, retired, or been fired. And according to a Modern Healthcare article published on August 10, the firings and resignations are because of several factors, like burnout, conflicts over shutdowns, social distancing rules, and mask orders. And some come from state officials who didn’t provide resources, such as working technology, but then blamed the problems on the public health officials.
And then lastly, we also know that state public health departments were already suffering before COVID-19. State spending on public health departments have dropped 16% per capita since 2010, and the amount devoted to local health departments has dropped 18%. Since the 2008 recession, more than 38,000 state and local health jobs have disappeared. According to a Modern Health article in May, experts say that we may need another 300,000 public health workers in the US to suppress another outbreak. Does any of that surprise you as well?
EMILY BROWN: I think that’s one of the key reasons that we’re seeing some of these situations occurring across the nation. We have hollowed out our public health system at the state and local level, and when we need to be the leads to respond to this unprecedented pandemic, we just haven’t had the resources to do it as fully as needed.
MODERN HEALTHCARE: So, my first question for you is, public health officials have been on the frontlines of this pandemic, making sure that hospitals and communities are aware of the efforts to contain the virus. But state and local public health departments — how does their role in this pandemic cross over with hospitals? And what would you say their most critical roles are?
EMILY BROWN: So, I think probably the most critical role is one that’s been a traditional role of public health for quite a while. And that’s simply communicable disease control. So, this is something that public health agencies have done for many, many years — working on controlling spread of tuberculosis or measles. And this is a really critical relationship with hospitals. Public health agencies are the ones that are on that behind-the-scenes line, where you’re contacting individuals and doing case investigation, and recommending immunizations.
But the hospitals are really the ones that are identifying the disease upfront, working with an individual for that initial treatment, and providing some of that basic information. So, this is something that — we’ve had this relationship as public health to hospitals, but it’s just expanded with the scope of the pandemic. And because the COVID-19 virus is so novel, and the information we have about it has changed so rapidly, this is just a process that’s extremely sped up. And having those relationships between public health and hospitals is really key to figuring out next steps we take.
I think another piece of this is just that general situational awareness and communication. Most hospitals across the country should have an opportunity to connect with a regional healthcare coalition. And these healthcare coalitions are an opportunity for collaboration that’s set up though a national structure, where public health and health response partners — such as hospitals, public health, EMS, emergency transport, emergency managers, long-term care facilities — meet regularly to know who partners are in their region and what resources are available. So, when a health emergency happens, you can respond more efficiently and more quickly. And healthcare coalitions continue to play a really important role in this pandemic response because partners have to work together so closely to figure out how to share limited resources.
MODERN HEALTHCARE: Mmhmm, wow. You were the director of the Rio Grande County Public Health Department in Colorado. Can you paint us a picture of a day in your life during this pandemic when you were in that role?
EMILY BROWN: Sure. So, I think a big part of it was meetings. But it was really important for that, partially because I and all of my staff were working remotely, and so we were all at home or limited time in the office, and so we weren’t able to have our regular communication where we sit in a room and hash out issues all together. So, we needed to have a lot of opportunities to talk to each other.
But then also there was also just so much information and so much data that changed rapidly, that it was just a constant process of trying to figure out how to condense that all and get it back out to the public and to partners. A normal day for me would be a 7:30 or 8:30 meeting with regional partners — so five other health departments that work really closely with each other in the region, as well as regional staff, public health, and outside of public health that were helping to support our regional incident command structure. And we would really hash over on a daily basis what major issues we saw coming up, questions that we had, trying to get support for how to handle issues we were having, as well as trying to put together what public communication we were going to be issuing daily on the public health front.
Then, we would have a local meeting — so our local emergency operation center, our county level operation center. I’d be updating staff and other county partners on information that had just come up or would be coming out, and then assigning out work for the day for follow-ups that we needed to be having. We’d have different meetings that would either be with our healthcare coalition partners or with state epidemiologists, or with our other community partners in the towns, or with the schools.
And then another large part of the day would really be following up with different individuals that had questions, so staff would be able to do that contact investigation piece. I have had two nurses at my office that were really the ones that were doing that intensive behind-the-scenes work of identifying contacts of positive cases, and helping to make sure that disease wasn’t spreading. And then I would handle a lot of the questions that would be individual interpretation of how does an agency decide to open up their building again, or a new state guidance came out and how do we interpret that at the local level? So, a lot of that communication with the public and trying to interpret information, get it out to the public.
MODERN HEALTHCARE: And that messaging was often like a moving target, right? Like it would change by the minute, by the hour, by the day. So, what time would you say your day would wrap?
EMILY BROWN: It really depended. Another unique piece of this pandemic is I also had young kids that were at home with me, and so it was trying to find that balance of how to split up time of when meetings were and when you got a big chunk of work done. Be able to spend some time with them and help them with the home schooling. And then, continue after bed into the evening, trying to get out daily updates or that final closing out. So, my day could end — at a normal day around 4, might end at noon or 2, and then start back up again at 8 for a few hours, in the evening.
MODERN HEALTHCARE: Well, if you figure out that balance, let us all know. I mentioned that the conflicts over regulation is a big reason why public health officials are leaving, right? What regulations are the real hot-button issues that are causing these conflicts?
EMILY BROWN: I want to start off with — before getting into the regulations — talking a little bit about some of the public health roles. And one of those things is that public health at the state and local level does have the authority to issue orders to control the spread of disease.
And I think that this is a point worth mentioning, because this isn’t a power that public health has to put in place very often. There’s a lot of other ways, like education or setting up policy — so things like school-required immunizations are a public health strategy that’s become implemented in policy and helps to control disease.
But we do have the power to issue orders that limit movement or close events if it is pertinent in order to control a disease. And so, we’ve seen this during the pandemic, that there are public health orders, or different regulations that are put in place, on a very wide-scale level. And this is something that is not practiced or not easily understood in a lot of communities, but it’s also something that … it is very, very stressful at the public health level and at the community level to have these restrictions in place. And so, this causes a lot of fear and frustration, as well as, just — a lot of education is needed about what these kinds of regulations mean.
A couple things that have definitely caused a lot of conflicts are things like how to open up businesses or different events once things have been closed down. So, a lot of states or communities had put in place really strict stay-at-home orders or may still have some of those in place. If you have a variance process for opening things back up, or trying to make decisions for who gets to go out more or have more movement, that can be a very contentious issue.
Right now, we’re really seeing masking as a contentious regulation. Some states or localities are recommending this, some have mandated it. And this is a very hard issue to implement and discuss on a case-by-case basis, because it’s a best practice right now but ...
MODERN HEALTHCARE: It’s not popular, that’s for sure.
EMILY BROWN: Yeah, exactly. And I think then that another one is just around the communication piece. It’s not as much regulation, but it’s some of that role of public health, and how you balance that and how you educate the community on that. So, things like how you share and what information you share about cases. Are you sharing this information just for staff? With your governing body? With the public? And how much of that is — how much is protected so you don’t share the identity of positive cases, and how much is helpful to make sure that the community knows enough information to prevent spread of disease?
Also, things like talking about how to share that information with different entities, who needs to know, who gets to be part of the planning process. So it’s not as much a regulation piece, but it’s — there’s a lot of people that need this information and a lot of agencies, so how do you make sure that you’re working with all the right partners and then also getting it out swiftly?
MODERN HEALTHCARE: And I can see where that would cause contention. Because you have all of these different organizations looking to their state or local health department for guidance. The hospitals are looking for guidance, the businesses are looking for guidance, the schools — and sometimes they don’t like what you say.
EMILY BROWN: Yeah, exactly. And I think that a big place where we’ve seen that balance across the nation is trying to figure out if you prioritize health or if you prioritize economy? And those shouldn’t be on opposite sides. If your economy is failing, if people don’t have jobs, if families can’t afford healthcare — this is going to affect your health, and this is not something that public health entities want to be happening.
But there has to be that balance between how broadly to make this happen and which regulations maybe are more important to the time. So, that’s a really hard place for public health to be in discussions, because there are times when health concerns need to be prioritized over what’s best for the economy.
MID-INTERVIEW SPONSOR MESSAGE: Before we continue with our discussion with Emily Brown, let’s say a thank you again to our sponsor, Masimo. At Masimo, they are revolutionizing the care experience in the hospital and beyond. Hospital automation powered by Masimo encompasses vendor-agnostic device connectivity, patient surveillance, alarm management, and EMR integration to help streamline workflows and prioritize your patients’ safety every step of the way. Visit Masimo.com to learn more.
MODERN HEALTHCARE: Now, back to our final thoughts from Emily Brown. So, when people don’t like that you prioritize health over the economy, or they don’t like the regulation you come back with, a lot of public health officials have said they have experienced threats. Like personal threats of violence — on social media, through other means. Let’s talk about that for a second. Tell me about the personal threat that you received, and were you shocked by this at all?
EMILY BROWN: I was shocked. This field of public health is — while it’s not without contention, there’s plenty of places where protecting the health of the general population can come into conflict with individual freedoms. But a lot of the times, we’re behind the scenes or we’re working at that broader collaboration level, or we’re trying to do things that are more happy and positive because we’re trying to improve health. Especially for me and for the small agency and the small community that I lived and worked in, you don’t see that level of personal threats regularly. I had never seen something like this.
MODERN HEALTHCARE: Right.
EMILY BROWN: We were starting to hear this, like you mentioned, at the statewide level from other health departments about having their car broken into, or having social media sites set up calling for their resignation. This is just so disheartening when you’re in the middle of such an unprecedented response, that you’re putting all your energy toward supporting the community and trying to figure out how to best protect health. Efforts don’t have to be agreed with in all regards, but when it starts to get into personal attacks or threats, this is really disheartening and makes it hard to continue the work you’re doing.
MODERN HEALTHCARE: Absolutely.
EMILY BROWN: And so, when we had had — social media posted about the health directors in our region, basically calling out that because of how we looked and the fact that we were women, the advice that we were offering shouldn’t be trusted. And then moving into threats related to firearms and stringing us up that we’re just uncalled for and very, very, very disheartening.
MODERN HEALTHCARE: I like to play armchair psychologist sometimes — but what do you think is the mentality behind that? What drives somebody to actually threaten the life of somebody who is doing their job and ultimately trying to help the larger cause in the larger community?
EMILY BROWN: I’m not going to say that threats like this are ever validated, or should be validated, but I can understand that there is a lot of fear and a lot of frustration around a loss of control over your life. And whether it’s loss of control because of the regulations that are being put in place at a county or state level. And not feeling like these apply to where you live — maybe because in our area, we’re a very rural area — and feeling maybe like some of these are regulations that only apply for much more highly populated urban areas. Or, purely just the fact that this pandemic and what it means for our country and the world is unknown. How you react to that could at some times really be from a place of anger.
MODERN HEALTHCARE: Yeah, definitely. Well, I’m really sorry that you had to go through that, and I’m really sorry for all the public health workers who have to go through this. It’s not like the pandemic is affecting you differently — you too have to limit your movement, you too have to be at home with these kids trying to also do work — like everybody is kind of being affected. But I’m sorry that even though you’re doing your job to protect your community, you are also a target.
What role should clinicians and hospital administrators play in, number one, collaborating with public health officials, and also mitigating the effects of public health officials resigning and being fired?
EMILY BROWN: I think that clinicians and hospitals are so key in how this response plays out. In one way, they are just such trusted partners in our community. The role of a doctor to a patient has been long established as a very trusted role. And I think, you know, coming from a rural community, you especially see this in areas where the hospital is maybe one of the major employers, or one of those key high-level professionals in the community. And they’re really an entity that others in the community look to for advice, especially trusted advice in a situation like a pandemic.
So, I think one of the ways that there can be support is reaching out to your local public health agency and figuring out how you can connect in with, kind of, connecting in to communications. So, this might be participating in local emergency operations meetings. It might be inviting your public health official to your own incident command structure. It might be participating in other community meetings that are being held. But make sure that you are — know who your local public health official is, but that you also have a way to have a united front in the community.
And then, along with that, trying to figure out how you have the same messaging as your public health agency. Maybe it’s something around testing and making sure that whatever you’re saying about how the community should get tested is also what your public health agency is saying. And then having a way behind the scenes to work through the details of how that’s not working. So there continues, and there’s going to continue to be issues around much of this response.
And if you can work through that and figure out how to use the two different systems — hospital has a whole bunch of a great partners, public health has a whole bunch of great partners — so how do we really make sure that those are aligned and that we are knowing what resources each other has and can bring to the table — we're going to succeed a lot better. And I think that there’s also some opportunities to be publicly vocal about supporting public health.
One of the things that was frustrating to me and that I’ve been so happy to see since the time that I was fired, is that we get to hear a lot about frontline workers. We are so supportive of those nurses and doctors that are having to wear PPE for hours and hours on end to take care of these critical patients. But we don’t get to hear as much about those public health workers that are behind the scenes.
MODERN HEALTHCARE: Yup.
EMILY BROWN: And I think it’s also so easy to see that vitriol of people who are angry using social media and other platforms to protest public health. And if key industries like hospitals can be more vocal about even just, simply saying, “We support our public health officials. Thank you for this work.” I think that will go a long way into building up the ability of public health to continue their behind the scenes slog for this pandemic. Because it’s not going to be fast. We’re not anywhere near through this yet.
MODERN HEALTHCARE: You’re absolutely right. That public show of endorsement for your state or local public health agency can go a long way in helping people listen to what those agencies have to say. Again, I’m so sorry for what you’ve been through, but you still have such a great commitment to public health and to helping communities sort of navigate this pandemic.
EMILY BROWN: Thank you so much. I really appreciate the time, and I know we have a lot of professionals — both in hospitals and healthcare as well as in public health — that are continuing to give everything they’ve got to try to figure out this pandemic. So, thank you to all of them.
OUTRO COMMENTS: Thank you so much, Emily Brown, for shedding light on the particular struggles of public health department leaders during this pandemic.
Again, I’m your host, Kadesha Smith, CEO of CareContent. Our agency helps health systems reach their growth goals through digital strategy and content.
We’d also like to thank Masimo, the sponsor of this episode.
I invite you to go to modernhealthcare.com to read more on how the COVID-19 pandemic continues to affect different areas of the healthcare sector.
And look for more episodes of Next Up at modernhealthcare.com/podcasts, or subscribe at Apple podcasts, Google podcasts or your preferred podcatcher. Thank you again for listening.