Use pandemic preparedness to address public health

Creating an army of outreach workers prepared for the next pandemic would empower state and local public health departments to work on America's multiple health crises.

In the early months of the pandemic, public health officials flirted briefly with deploying contact tracing, testing and isolation to stop the spread of the COVID-19 virus. Implementation would use public health officers to descend on every confirmed case, identify infected person’s recent contacts, visit those people, test them, and, if the test was positive, ask them to remain at home until they were no longer contagious.

Widespread resistance to masking and social distancing suggested a significant fraction of the public would rebel against contact tracing’s intrusiveness. As the debate heated up, Peggy Noonan, a conservative who was cautiously supportive, warned in her Wall Street Journal column (subscription required) that contact tracing “has all the potential to be an onerous system that provokes resentment, spurs anxiety, and invites pushback.”

In any case, given the rapid rise in cases in an unprepared nation, contact tracing never got off the ground. Experts I spoke with at the time estimated it would require a small army of case officers – anywhere from 150,000 to 300,000 – deployed to nearly every corner of the country. Public health departments in the handful of states that briefly pursued the strategy had one-tenth that number, while most states and cities, which had shed 50,000 jobs in the previous decade’s cutbacks, had as little capacity to conduct contact tracing as they had appetite to pursue it.

It would have taken months to hire, train and deploy enough people to make the strategy viable. And it would have been costly, although a drop in the bucket compared to the massive economic support programs in the $1.9 trillion CARES Act, the first COVID-19 bailout bill. In any case, the Trump administration did not seek the estimated $10 billion (1/2 of 1% of the total package) it would have cost to deploy the small army of state and local public health officers needed for contact tracing.

Like this Wisconsin farmhouse, public health needs a rebuild. (Photo by Merrill Goozer)

Pandemic preparedness back on the agenda

Fast forward to the Biden administration’s commitment to pursue post-pandemic preparedness. Last July, the White House reestablished the Office of Pandemic Preparedness and Response Policy “to ensure that our country is more prepared for a pandemic than we were when (the president) took office.” Retired Major General Paul Friedrichs, who handled the Pentagon’s COVID-19 response, was recruited to coordinate the effort. If he and his team will pursue building the infrastructure for conducting contact tracing won’t be known until mid-2025, when the new office’s first biennial report to Congress is due.

Should the new office include contact tracing preparedness in its plans? As I editorialized (subscription required) in Modern Healthcare in June 2020, infusing the nation’s state and local public health departments with thousands of highly trained community outreach workers would serve a dual purpose.

They wouldn’t just be sitting around waiting for the next pandemic. Their training in outreach, testing and education would provide public health departments with the capacity to tackle the major and too often untreated epidemics that are ravaging large swaths of our population, and are the proximate causes of our declining longevity.

They could offer treatment to people most at risk of contracting heart disease and diabetes by conducting mass screening for hypertension and elevated blood sugar, which lead to those disorders and their expensive complications. They could identify and arrange treatment for people suffering from substance abuse and behavioral disorders. They could organize mass screening tests for cancers, chronic kidney disease and other maladies where early detection can reduce deaths and avoid late-stage and high-cost interventions. Reinvigorated public health departments could reach out to pregnant women to offer the pre-natal and maternal care that could reduce America’s outrageously high infant and mother mortality rates.

Pandemic screeners-in-waiting could also play a frontline role in identifying and coordinating services for people suffering from food insecurity, housing insecurity, income insecurity and chronic stress – the so-called social determinants of health. Their outreach could focus on the communities most in need of both individual and social interventions: Inner cities with large minority enclaves; deindustrialized towns and cities; areas where people are engaged predominantly in low-wage work; declining rural areas; and native American reservation communities.

It’s not just affordable, it’s cost-effective

Too costly, you say? Let’s put the front end expenditure of about $15 billion a year in perspective. It is about 20% of what we’re about to spend on military aid for Ukraine and Israel.

But unlike those expenditures, there will be a return on investment that can be measured in dollars, which is how Congress, heeding the analyses of the Congressional Budget Office chooses to evaluate new domestic programs.

Last week, I reported on a proposed program to bring hepatitis C screening and treatment to prison, Medicaid and other populations that have lacked access to the expensive drugs that can wipe out the disease. One study has already found that the proposed five-year, $5 billion program would save the federal government more than twice the money than it would cost. A CBO analysis is pending. 

Are there other conditions where investment in prevention through aggressive population health outreach would save money? The answer is “yes.” Isn’t it possible to reduce support for low-value services where the health care system wastes money and spend it instead on high-value services that reduce disease and save lives? The answer to that is also, “yes.”

In my next post, I will share a list of programs that have already been shown in clinical trials and cost-effectiveness studies to provide huge improvements in the nation’s overall health at an affordable cost. In some cases, they will even reduce spending within the CBO’s vaunted ten-year time frame.