Public Health Flaws

By Grace Wang @gracewang_1

Grace interviewed over 20 public health officials in both her county and other counties in Texas, and spoke with a professor and researcher in the field of health equity at the University of Pennsylvania. Here's what she learned about public health.

No one knew that a mysterious virus in Wuhan, China that was first discovered in December 2019 would eventually cause a global panic that would last over a year and cost the lives of thousands of people. Like many other countries, the US was clearly not prepared to handle the COVID-19 pandemic. A huge medical shortage at the beginning of the pandemic put the entire country behind as frontline workers scrambled to get the equipment they needed to run tests and hospitalize patients smoothly. As borders began to close around the world, America struggled to enforce the social distance and mask policies that were needed to contain the spread of the virus. While scientists raced to get the vaccine out as soon as possible to help halt the pandemic, America still faced the large issue of vaccine hesitancy and inaccessibility. There is one small thread that weaves many of these problems our country faced throughout the pandemic: public health. Public health is a field that is vastly unfamiliar to the typical person. Although people are well aware of the role that doctors and nurses have in treating patients, we often miss an important department's role in the “behind the scenes” work. Importantly, this pandemic exposed many flaws in the public health system, both at a national and state level (specifically focusing on Texas), which need to be addressed as soon as possible to ensure we are prepared for the next pandemic.

Firstly, our public health system re-enforces racial discrimination that leads people of color with worse off health and fewer opportunities to get treatment. For example, a shortage of ventilators during COVID-19 forced doctors to have to make the decision of who to give the ventilator to. In order to decide, physicians used unfair metrics that put people of color (such as African Americans) at the back of the line for a ventilator. For example, a doctor will first assess a person's baseline health to determine if they should receive a ventilator. If the assessment returns the result that shows the patient will die very soon (for example the next day), then the ventilator may go to someone who still has a longer time to live (for example 5 months) in order to not waste supplies. By taking life expectancy into account (which is one of the metrics used to assess someone's baseline health), black people will always be at a disadvantage since African Americans unfortunately have a lower life expectancy on average compared to white people (as a result of less healthcare access, higher poverty rates, and physician treatment refusal). Because African Americans often have poorer health compared to whites in large cities, every single metric used to assess a person's baseline health will put African Americans at the end of the line for a ventilator. Such health policies in America are extremely problematic and need to be fixed immediately to ensure that people who are disadvantaged are also able to access equal benefits. Either such health assessment measures mentioned above need to be removed immediately, replaced with new ones, or adjusted to account for minority populations.

Next, public health is vastly underfunded and understaffed, which is especially the case in Texas. Texas spends just $17 per resident on public health compared to $54 in Alabama, $51 in Tennessee, and $44 in Oklahoma. So why such low funds? The answer lies in national priorities. People simply don’t see public health as a department that is important. When public health is doing their job, disease outbreaks don't happen which makes governments feel like funding isn't very important since it feels like outbreaks aren't very common. Only in a national crisis like COVID do governments start to realize how important funding is. The fact that funding only starts to pour in during or after a health crisis is troubling, as it creates severe medical supply shortages and can allow a pandemic to spiral out of control. Aside from funding alone, the grant system in many states is highly restrictive in nature. In other words, only a small and restricted percentage of grant money is allowed to feed into hiring staff, and another small percentage is allowed to go into technology, etc. This is because government officials (not epidemiologists who are skilled in their fields) decide what portion of the grants can go to what sector within public health. That's why during COVID-19, epidemiologists were struggling to adapt to having so many cases to document since not only is this department historically understaffed, their software for case documenting is extremely outdated and some counties only rely on things like excel (which is not a very good database when having to share/log thousands of cases)!

The third issue with public health is a lack of coordinated communication and the absence of a shared database. This lack of communication is also reflected by the fact that in many situations, disease cases are "double logged". This means if a child isn't feeling well at school and goes to the nurse and the nurse determines that the child has COVID-19, the nurse will then inform the public health department and they will log it as one case. Then the child sees the doctor for their condition and the doctor also logs this as one case. Now there is a double log and the covid case count then becomes inaccurate which becomes troubling when the CDC uses such inaccurate data to create a national picture of COVID-19 cases.

Another flaw in the public health system that is specific to Texas and many other states is influenza reporting. In Texas, influenza is not a virus on the "notifiable conditions list", meaning people (such as school nurses, pediatricians, physicians, hospital workers, etc) are not required to report cases of influenza they see to the public health department in a county. The fact that flu reporting is voluntary is very problematic because it means flu cases end up going UNDERreported since reporting is optional, meaning national public health agencies such as the CDC will never be able to get a fully accurate picture of flu cases in regions like Texas which may be an issue because mutant flu strains that could be deadly could be missed. In addition, it is extremely difficult to amend the notifiable conditions list as the amending process is slow and laborious, de-incentivising people from adding reportable diseases.

The last hole in the public health system in the US and in Texas is there is no national or state level pandemic plan. This means that if another pandemic hits our country, we may risk repeating the same mistakes that happened during COVID which could risk thousands of lives lost. In order to move in a positive direction, we must use this pandemic as a learning experience and make sure we do not make any of these mistakes again. This means we must act quickly and enforce better policies in the health system while patching up holes that were exploited during COVID-19.