COVID-19 offers lessons on how to prepare for the next public health disaster

As community transmission of COVID-19 took hold last March, state health departments launched messaging blasts that some experts say missed the mark with an overly vague suggested response, essentially giving up an opportunity to get ahead of the novel coronavirus.

Dr. Leandro Mena, a clinician-researcher and chair of the Department of Population Health Science at the University of Mississippi Medical Center, said the health departments’ instructions to the public often centered on just calling a doctor if worried or they had signs and symptoms of infection. “For me there was a little bit of a problem with the messaging and lack of awareness,” Mena said.

That early mixed messaging caused irreversible damage in some communities, including Mena’s, where uninsured rates are high, chronic diseases prevalent, and low-wage public-facing jobs dominate the employment landscape.

Those conditions formed a perfect storm for virus spread among vulnerable populations that were already harder to reach before the pandemic.

By summer, Mississippi would have the highest new case rate in the nation. “On one side the people who you saw being initially most infected by COVID … were disproportionately Black and Latino, people who are disproportionately uninsured,” Mena said. “So people who you knew probably did not have a primary-care provider, but a choice was not given to them.”

Public health leaders across the country faced similar challenges, forcing them to innovate and improvise ways to get patients the tests and treatment they needed.

Mena, with colleague Rodney Washington, an associate professor of population health, formed a task force in early September to embed in majority Black, rural Mississippi Delta counties where COVID-19 case rates were staying high, and interventions were minimal.

Moreover, the department wanted to get in front of vaccination hesitancy before distribution plans materialized from the state. Washington held community listening sessions to identify “community brokers” who could introduce COVID-19 safety and vaccination messaging directly into the community through trusted voices, such as faith leaders.

Both Washington and Mena saw views on vaccination acceptance shift in targeted Delta counties after months of bi-directional community engagement. But once it did, just in time for early Pfizer and Moderna vaccination approval, the question moved to equitable distribution. “The conversation about vaccination has gone from, ‘We don’t want it, we are afraid of it,’ to now a matter of equity,” Mena said. “It’s now, ‘Why are we not getting it?’ ”

As states scrambled to create vaccination distribution plans, only nine would formally prioritize vaccinations for communities of color in their plans. A January 2021 Kaiser Family Foundation report shows decreasing vaccination hesitancy across races, but persisting disparities in states’ patchwork efforts to reach hard-hit communities of color. By early March, 13% of whites had been vaccinated while just 7% of Blacks had been, according to Kaiser’s website.

In Utah, which kept a relatively tight lid on new cases until a late-2020 surge that rivaled most states, Mikelle Moore, senior vice president and chief community health officer at Salt Lake City-based Intermountain Healthcare, said listening to not only the community’s, but also healthcare workers’ needs drove early innovation.

Before the pandemic, Intermountain had launched a clinical intervention in behavioral health, aiming to reduce alarmingly high and growing suicide rates in the health system’s service area. When COVID-19 threw healthcare workers’ shifts and lives into chaos last year, system leaders pivoted that mental health work to their own staff. Intermountain set up a mental health hotline for staff and is transitioning it community-wide by the summer.

“We’re learning that we need those types of resources for healthcare workers to be very accessible,” Moore said. “And we, as leaders, need to be much more transparent and talking to people about how they’re really doing.” Since April 2020, the hotline has connected about 5,800 callers with mental health resources.

In Wisconsin, Marshfield Clinic Health System intensified the level of care provided in the home as a result of the pandemic. Marshfield CEO Dr. Susan Turney said that by expanding telehealth, an essential piece of the pandemic response, the health system completed about 110,000 more telehealth encounters in 2020 than 2019.

Marshfield used that surge to stand up a new convalescent program to provide hospital-level care in patients’ homes. The system’s Home Recovery Care Model reduced costs up to 30% compared with a typical hospital admission, cut readmissions by more than half, and reduced average length of stay by 38%. And patients seem to like it—satisfaction with the program stands at 98%.

To help tech-shy patients, Marshfield launched a community telehealth training program to acclimate its service area to the idea and importance of telehealth.

Physicians groups would like to do more with the vaccination effort, but feel hamstrung. Primary care has largely been an afterthought in the federal, and most state vaccination plans, said Dr. Emily Maxson, chief medical officer for Aledade, a company that helps medical groups form accountable care organizations. It works with more than 7,300 independent providers across 27 states.

While she’s encouraged that President Joe Biden added primary-care vaccine distribution to his COVID-19 response plan, she hasn’t seen any concrete efforts yet. The tools are there, it’s just a matter of utilizing them, Maxson said. She points to the Centers for Disease Control and Prevention vaccine tracking system, which was already leveraged to route and track new vaccines to pharmacies. Looping in primary care is an obvious extension, said Maxson, adding that the increasing Moderna and Johnson & Johnson supply, which can be stored more easily, are perfect opportunities to deputize the nation’s primary-care workforce.

“We’re going to be behind until we fully leverage the primary-care workforce out there,” Maxson said.

Despite delivering more than half of all U.S. vaccinations year-round, only about 15% of the 500,000 primary-care providers across the nation report having access to vaccination deliveries through states’ initial rollouts, according to American Academy of Family Physicians research.

“Primary care across the country has intrinsic value because of the trusting relationships they’re building with their patients. They’re the first line of defense in a pandemic and for any health system or healthcare issue, because they’re the ones who are going to reach that last mile in rural healthcare and make sure to serve vulnerable patients,” she said. “We can’t leave them out of the conversation again, or we risk delays and additional deaths that didn’t need to happen.”

Mary Pittman, CEO of the National Public Health Institute, based in California, said that widespread undervaluing of public health impeded the nation’s ability to get in front of the pandemic early on.

“We’re paying the price for ignoring all the research that has been out on the social determinants of health. And what we’ve also seen is that the lack of investment in our public health systems left us unprepared to be able to respond to the virus,” Pittman said.

She said ongoing vaccination disparities are a result of not only underinvestment in public health, but they’re also exacerbated by a lack of data. The National Association of County and City Health Officials, which represents the nation’s nearly 3,000 local health departments, estimates average local health department expenditures per capita decreased 30%, from $80 in 2008 to $56 in 2019.

Pittman said the industry must get back to the basics: fully funding science-driven public health departments and leveraging community-based mobile teams that can quickly adapt to local emergencies.
“I think this pandemic has shown that there are a lot of people who have not been reached by either our public health or healthcare systems.”

Erica Hensley is a freelance writer based in Jackson, Miss.