Time to get off the roller coaster: Public health needs adequate and stable funding
Public health emergencies require a quick, decisive, and coordinated response—but the federal funding machine is too slow and sporadic to support a permanent emergency response workforce. How can we address this challenge and prepare our workforce for the next crisis?
People in governmental public health positions have a term to describe the kind of funding they receive to respond to emergencies. The term is roller coaster. That is because core public health emergency preparedness funding has been trending downward from its peak during the post-9/11 period. Since that period, key positions have been defunded, essential planning has been curtailed, and weaknesses in the data systems have been ignored.  As a local health official after 9/11, I had enough funding to support specialized positions in hospitals and community settings and to ensure we did routine trainings and exercises to practice readiness skills. Then, less than a decade after 9/11, those funds were all cut: We lost the specialized personnel and stopped doing large-scale exercises.
Nevertheless, when the next few emergencies occurred, the federal policymakers who had cut the funds were able to identify new funding, although not always immediately. When this happened, agencies like the CDC did their best to quickly distribute the funds to state and local public health departments. But disbursement was often delayed due to the cumbersome procurement processes. Once funding reached us at the states and local levels, we scrambled to write job descriptions, advertise, interview candidates, hire the best available ones, and begin intensive training.  Often, just as these employees got up to speed and became well-trained emergency responders, they were laid off because the funding for the specific emergency ended.
That’s the roller coaster. Even when there were multiple emergencies at the same time, the funds for one couldn’t be spent on the other. In 2016, states and locals couldn’t use their still-available Ebola emergency funding when they were desperate to respond quickly to Zika; instead, they had to wait for months until Congress identified and approved Zika-specific funding. This delayed their efforts to prevent infections and led to heart-breaking outcomes.
If this sounds complicated, it doesn’t even include the other obstacles that may exist. States and locals may have personnel caps that prohibit the creation of new positions unless their elected officials decide to raise the cap. And, in some states, federal funds can’t even be accepted for use without a vote by the state elected officials, who may be in recess or disinclined to rely on federal funding. And, even if the positions are approved, health departments may not quickly find job candidates with the skills they need. Some health departments have relayed they have searched for years to fill core vacant positions, such as epidemiologists, sometimes because candidates recognize that the jobs are short-term and high stress.
Ironically the CDC and state and local agencies—who might be termed the victims in these delays—are often blamed for not spending the funding fast enough. We have seen this pattern repeated again and again from West Nile virus to the 2001 anthrax scare to Ebola to Zika and, most recently and most dramatically, with COVID-19. The New York Times highlights this pattern in an extensive article with an in-depth look at this stop-and-go federal funding phenomenon as it played out in Mississippi.
Is this any way to run an emergency response? Is there any way out of this cycle?
Well, obviously, the ideal way out would be if the CDC and the public health system writ large had sufficient, sustainable funding. This would make it more likely that they could hire an enlarged, highly skilled permanent workforce, which could effectively prevent or respond to the immediate threat of an emergency. The roller coaster effect could be curtailed and—in all likelihood—diseases, injuries, and deaths could be prevented. Members of Congress and state and local policymakers hopefully will give serious consideration to this approach.
Ongoing training and technical assistance
Training and technical assistance to help the public health workforce prepare and respond to emergencies are but two of the essential elements necessary to avoid a roller coaster approach.
It might be helpful to delve a little deeper at one often overlooked but essential part of emergency preparedness, namely, training of the workforce. We saw the urgent need for that during the multi-year COVID-19 pandemic. For example, at the CDC, there just weren’t enough full-time, well-trained emergency personnel to manage the communication, policy, programmatic, and logistical COVID-related matters. That meant the agency had to rely on others to assist, including those who were experts in tobacco, diabetes, motor vehicle safety, and infant mortality. These employees took time away from their “day jobs” to do stints in the incident command structure. Because their positions were funded by non-emergency line items, they could only stay in the response for a limited time, leading to a revolving door of leaders. In most instances, the only emergency preparedness training they had was what they got on the job.
Even if the emergency workforce were enlarged, it would be wise to train most if not all of those in the public health workforce for the likelihood they will be drawn into a future emergency response again. The CDC admirably has already indicated an interest in doing just that.
In past instances, ICF has seen the benefits of specialized workforce training particularly when new issues have arisen. For instance, the Substance Abuse and Mental Health Services Administration (SAMHSA) contracted with ICF to support the evaluation of the Garrett Lee Smith National Suicide Prevention Program—which was responding to the increasing numbers of youths aged 10 to 24 years with suicidal ideation. The grantees have provided training through in person, self-directed, online, and facilitated group events to gatekeepers across the nation to prevent youth suicide.
Closely connected to training is technical assistance or TA; that is, targeted and timely support, sometimes one-on-one from someone with expertise. This can assist the employees as they grapple with the day-to-day challenges and urgent, time-sensitive matters that arise. Technical assistance may involve having ready access to individuals who have very specialized subject matter expertise or providing well-developed resources or toolkits. An example of ICF’s development of a customized TA initiative is the Child Welfare Capacity Building Center for States, which provides hands-on guidance on such matters as reducing the length of stay of children within facilities and responding to tragic events.
And sometimes a combination of the two is required to address an urgent situation. As public health agencies increasingly grappled with the opioid crisis, some for the first time, the CDC contracted with ICF to design and implement a comprehensive training and technical assistance center (DOP TA Hub) to support state and local public health personnel. The technical assistance includes an online resource library of evidence-based practices, access to one-on-one, group, and peer-based technical assistance, as well as other support tools.
In summary, training and technical assistance to help the public health workforce prepare and respond to emergencies are but two of the essential elements necessary to avoid a roller coaster approach. Before all the COVID-19 funding runs out, it would be wise to learn the lessons from the past and ensure we are prepared for the next emergency and the one after that. Like it or not, those emergencies will occur.
