We can’t accept status quo in public health any longer

Town by town approach to threats is not enough

LAST WEEK, Gov. Charlie Baker signed into law the State Action for Public Health Excellence Act, which is now Chapter 72 of the Acts of 2020. The bill was signed with little fanfare and certainly no public ceremony where legislators and advocates gather for a photo-op with the governor, shake hands, and try to snag a coveted pen that the governor used to sign the bill.

As always, this bill, which deals with the organization of municipal services, flew under the radar, not rising to the level of public attention for transportation, housing, health care, and other issues that are in the daily consciousness of most residents and policymakers.  But in the middle of a global pandemic, it’s time for everyone to pay attention to this legislation and the public health system it seeks to strengthen. Our system of municipal health departments spread across Massachusetts’ 351 municipalities – east and west, rural and urban, affluent and struggling – is what stands between threats to the public’s health and our safety.

We write as leaders of the Coalition for Local Public Health, representing six statewide and regional public health organizations that in turn represent the 351 local boards of health, their members, and their staff, across the Commonwealth. Despite the typically low profile of our work, local health departments impact the health of each and every resident of the Commonwealth. Right now local boards of health continue to conduct all their usual activities to keep the residents of Massachusetts safe, while also responding to a pandemic the likes of which has not been seen in over 100 years.

Local Health During the Pandemic

In recent weeks, many have learned about contact tracing and have heard about the new Contact Tracing Collaborative launched by the Baker administration and the globally-renowned Partners in Health to assist with the need to trace contacts of positive COVID cases. But you may not know that contact tracing is in fact a core part of the local public health toolkit, used frequently by our local public health nurses and other staff in dealing with outbreaks of other infectious diseases, from chicken pox to norovirus to legionnaire’s disease.  As soon as the first cases of COVID were identified in Massachusetts, public health nurses across the Commonwealth leaned in and began case investigations, contact tracing, and quarantine and isolation monitoring.

Shortly after the state of emergency was declared, the Coalition for Local Public Health reached out to the state’s COVID-19 Command Center, asking for more support for contact tracing, among other local needs. Emergency funding was supplied by the state almost immediately and allowed local boards of health to hire additional staff and step up their contact tracing efforts to handle the unprecedented level of need during the COVID pandemic. The Contact Tracing Collaborative will provide welcome assistance for boards of health that are still overwhelmed by the number of cases in their communities, allowing the local boards of health and their public health nurses to concentrate on the most complex cases, including people living in nursing homes or shelters for the homeless. Tracking contacts for these cases requires greater knowledge of local residents, conditions, and resources – knowledge that lives with our local health departments.

Boards of health are also in overdrive in other areas – enforcing the myriad of orders being enacted at the state level around essential businesses and social distancing; providing education and information to residents; supporting people under isolation and quarantine; and collaborating with local hospitals, nursing homes, and emergency responders.

Local Public Health In “Normal” Times

While pandemic activities have taken over our work during the outbreak, they represent just a small portion of the responsibilities we have each and every day of the year. Our members inspect restaurants and public kitchens to ensure food safety and prevent outbreaks of foodborne illness; we inspect public pools and children’s camps and monitor water quality at public beaches; we respond to reports of housing code violations for residents who may be impacted by dangerous housing conditions; we enforce tobacco regulations to keep our young people safe; we ensure proper installation of septic systems to protect human and environmental health; and we work to prevent and respond to many other communicable diseases, including tuberculosis

These activities serve everyone, without exception, whether they realize it or not. We’re proud of the work we do. Our workforce is knowledgeable, passionate, committed – and usually happily “unsung.”

Despite this, our system has serious challenges that should concern everyone.

While most other states across the nation organize public health services at the county level, Massachusetts does so at the municipal level. In this decentralized system, responsibility and authority rests with each of our 351 municipalities. This means that the town of Mount Washington, population 164, has the same legal obligations to protect public health as the city of Boston, with a population over 650,000. As such, we have more local health departments than any other state in the nation. On a per capita basis, we have 17 times as many health departments as New York State and 33 times as many as California.

Furthermore, there is no direct state funding – or even recommended funding levels – for local public health, leaving decisions on funding levels exclusively to municipal leaders. The result is inconsistent and inequitable funding, leading to widely varying levels of staffing and quality of services. Hiring and retaining highly-qualified and credentialed staff is often difficult or impossible.  Small towns, in particular, often struggle. For instance, according to the Massachusetts Public Health Regionalization Project, of the 105 towns with fewer than 5,000 residents, 78 percent lack full time staff and 58 percent have no health inspector.

In an unwelcome irony, our state is a worldwide leader in health care, yet many of our cities and towns are unable to meet basic statutory requirements for public health services. More rigorous national standards are impossibly beyond the reach of all but a few communities.

A Blueprint for Change

We know there will be another outbreak, even if we don’t know when or how severe, and we need to be better prepared as a state next time around. We also must do better preventing the more ordinary health threats of the kind we address every day. In order to move toward a stronger local public health system, Massachusetts needs to make some changes.

We need clear and consistent standards which every community should be expected—and supported – to meet, no matter the size of their population or municipal budget. To meet standards, we need to be able to hire and retain highly-qualified staff. But we can’t do either of these things if we work exclusively within our individual municipalities. We’ll need to accelerate work to share services and staff across municipal boundaries so that several communities can share a public health nurse or a septic inspector they cannot afford on their own, or can hire an epidemiologist to help track and predict patterns of disease outbreak.  Sharing services is simply a more efficient way to increase capacity to deliver services and use limited public resources wisely.  Working across municipal boundaries will also allow us to more effectively assess, prevent, and respond to public health threats – like communicable diseases – that don’t respect boundaries on a map.

Last summer, the Special Commission on Local and Regional Health – established by the Legislature in 2016 to address these issues – produced a breakthrough consensus report that provides a blueprint for action going forward. The law Baker signed will begin the process of implementing these recommendations – increasing access to workforce training, providing grants to municipalities to increase shared services and adopt new workforce standards, and charting the course toward higher national standards.

But passage of the bill is not enough. Robust funding and political will from our state and local leaders will be needed to deliver significant and sustained progress.

Meet the Author

Ruth Mori

President, Massachusetts Association of Public Health Nurses
Meet the Author

Cheryl Sbarra

Senior staff attorney/Director of policy and law, Massachusetts Association of Health Boards
Meet the Author

Sigalle Reiss

President, Massachusetts Health Officers Association
Meet the Author

Laura Kittross

Executive committee representative
Meet the Author

Robin Williams

President, Massachusetts Environmental Health Association
Meet the Author

Carlene Pavlos

Executive director, Massachusetts Public Health Association
Eventually, we will emerge from the acute phase of this outbreak. We look forward to a return to restaurants, beaches, and Fenway Park at some point down the road. But we cannot accept the status quo in local public health any longer. We will not rest until every resident of every city and town has access to the same high-quality public health protections they deserve. We need our state and local leaders to join us in this effort. We have the blueprint to get there, let’s get together and make it happen.

Ruth Mori is president of the Massachusetts Association of Public Health Nurses, Cheyl Sbarra is senior staff attorney and director of policy and law at the Massachusetts Association of Health Boards, Sigalle Reiss is president of the Massachusetts Health Officers Association,  Laura Kittross is executive committee representative of the Western Public Health Association, Robin Williams is president of the Massachusetts Environmental Health Association, and Carlene Pavlos is executive director of the Massachusetts Public Health Association.