Pennsylvania is “health care rich and public health poor.” I found this succinct phrase in a 2008 collection of academic articles on Pennsylvania public health policy. The editor described how we are richly supplied with hospital beds and physicians, ranking in the top 10 in the United States, and spend way more than other states our size on health care.
Lancaster County certainly has excellent hospital capacity. Yet at the same time, Pennsylvania ranks at the bottom nationally in public health workers. The state’s public health system was described as woefully inadequate by experts in 2008, and has only been further hollowed out a dozen years later. These realities, combined with the COVID-19 pandemic, are finally driving a groundswell of support to start our own local public health department.
Underfunding public health is easy to do, because when it’s working — i.e., keeping bad things from happening — it’s not all that visible. When there are prevention gaps that will eventually prove expensive and damaging, like silently spreading viral hepatitis or HIV, or farm families unknowingly drinking from wells contaminated with pesticides, the costs are kicked down the road to future taxpayers.
Our public discourse over the past year has, more than ever, acknowledged the painful reality of systemic disparities: that those injured tend to be the most marginalized citizens. They are disproportionately our Black and Hispanic neighbors, our low-wage “essential” workers, or the elderly, the poor, the incarcerated, those experiencing homelessness and those with disabilities.
As a policy researcher studying the drug overdose crisis, as well as someone whose previous career in pharmaceutical sales placed me smack in its trajectory, I’m a bit shocked: Why are so few local policymakers talking about this other epidemic in terms of county public health needs? The deaths of 840,000 Americans since 1999 is a public health disaster that is getting worse. The Centers for Disease Control and Prevention reported a 22% increase in Pennsylvania deaths in the most recent 12-month provisional data. Preventable deaths. All public health policy failures.
While some of these policies must be changed on a federal level, there is plenty we can do here. A Pennsylvania judge explained presciently in 2008 why legislators must act to fix our scattered and confusing public health laws before a devastating infectious outbreak or pandemic, reviewing exactly where the statutes are outdated or conflicting. Sadly, we did not follow that advice.
Updating public health laws, in a bipartisan, carefully considered, cohesive way, will serve us better than the current rushed effort to pass a constitutional amendment focused just on disaster declarations. At least this is what we would do if the motivation for change was not simply political haymaking, but truly to improve governance.
In the 2008 journal, another article describes the last time a county public health department was studied in Lancaster County and three neighboring counties. After three years of work, faculty from Drexel’s School of Public Health concluded that starting a county public health office could be done at a reasonable cost to local taxpayers, with varying levels of staffing, based on local needs and funding decisions. Yet their reports gathered dust. Their recommendations were not implemented.
Then, as now, some naysayers believed local public health offices are duplicating public health responsibilities at the state agency level. This argument reveals a misunderstanding of best practices in public health, which require a network of both state-level and local-level offices. In fact, absent a well-coordinated local, state and federal health structure, studies show that citizens receive poor or confusing communication during outbreaks and emergencies; have more difficulty in accessing preventive health information; and pay a price for missed collection and analysis of vital surveillance data. We have experienced the truth of this ourselves in this pandemic.
Having a local public health authority would have allowed some county officials to access confidential data during the earliest COVID-19 outbreaks last spring. We could centrally collect data from numerous hospital and pharmacy vaccinators, many of whom have been failing to record vital indicators like race and ethnicity.
Don’t we often demand more local control? This is what we would gain by administering our own public health hub locally. Attempting to outsource this work to private entities does not solve the data-sharing challenges; in fact, it can make them worse.
Oddly, the feared expansion of “big government” doesn’t seem to be a problem when it comes to more visible types of public services. Our tax dollars also fund a large state police force. Yet half of the municipalities in Pennsylvania, including all of the populous ones, still fund their own law enforcement services. Why do we see the need for both local and state levels of law enforcement services, but not a similar structure for health prevention services? Is it because they aren’t duplicative, but collaborative?
And finally, why waste time and energy on another commission or task force first? Let’s start implementation now. We can advocate at the same time to strengthen state-level public health, to include funding for regional and locally administered offices, and also commit to finally updating outdated state laws and regulations.
Use our grief at the lives lost during both the COVID-19 pandemic and the drug overdose epidemic to fuel our persistence. This is the time.
Gail Groves Scott is an opioid policy researcher, public health advocate and doctoral student who holds a master’s degree in public health. She resides in Lancaster.