Primary care doctors need to play a major role in improving the public health system, and to do that they need better data on the community they’re serving, said Andrew Bazemore, MD, MPH, at a briefing sponsored by the Alliance for Health Policy Friday.
“I need to understand what the ‘community vital signs’ are for my team to address patients and their lives — not just folks walking through the door, but the [whole] population that I should be addressing,” said Bazemore, who is senior vice president of research and policy at the American Board of Family Medicine. However, “I don’t have the [health data] to help me do so. We need community vital signs sitting right next to our blood pressures, our respiratory rates, our temperatures, and our charts, and we need to be working as teams together with public health professionals to address these.”
More funding will also be needed, he said, citing COVID-19 vaccine distribution problems as an example. “It was obvious that cold chain was going to be a barrier to getting COVID vaccines into primary care offices early, but the real tragedy is that later in 2021, we still found our primary care teams woefully under-supplied with vaccines, when they had identified and built trust in vaccine delivery for the populations that needed them the most. It was fairly easy to get them in the suburbs, and a little harder in rural and underserved urban areas … If we can bring the primary care infrastructure and public health infrastructure together, and better fund each, we have a real chance to do better the next pandemic.”
Community health workers also need to be a bigger part of the solution, said Denise Smith, MBA, executive director of the National Association of Community Health Workers. “We’re a proven workforce with over 6 decades of documented evidence of our effectiveness in a variety [of areas including] HIV, maternal and child health, and oral health. But we remain a precarious workforce and being mostly persons of color and mostly female, we are among the lowest paid of all public health professionals.”
Although Smith said she was encouraged that the Biden administration “focused language and dollars around community-based organizations,” barriers to respect and sustainability continue to persist. Despite calls to integrate community health workers, “we are not really being evidenced and included in funding opportunities and interventions,” she said. “We saw that our community-based organizations … were not getting funding, and there were some structural problems, to the way that the funding historically flows.”
Part of the problem is that funding for public health ebbs and flows with each outbreak or pandemic, said Howard Koh, MD, MPH, professor of the practice of public health leadership at the Harvard TH Chan School of Public Health in Boston. After the terror attacks of Sept. 11, 2001 and the anthrax scares that followed, “there was much attention to public health preparedness; then, over time, it faded away,” he said.
A few years later, in 2009, Koh joined the Obama administration just as officials there were preparing for the H1N1 influenza outbreak that they were anticipating was to come in the fall. “I’ll never forget the intensity of that time, how literally everybody in government, including health officials who were well outside of [this particular] health realm, worked together to plan two simultaneous vaccination campaigns for the whole nation that fall,” Koh said. “We were very fortunate a vaccine was in the works. We were able to implement those vaccine campaigns in the fall, though it was bumpy and not easy. We would like to think, though, that we had some kind of ‘whole of government’ approach.”
Since then, however, even with several other disease outbreaks — like Ebola, MERS, and Zika — occurring in the meantime, “we have invested relative pennies in public health and we have not sustained it,” Koh said. “We have to rebuild public health from the ground up.”
Koh asked why, 2.5 years into the pandemic, health officials continue to be surprised by each COVID variant that emerges. “We’ve had very little genomic sequencing until relatively recently,” he said. “Fortunately, the CDC has been able to ramp up that capacity lately, and they have a forecasting unit. But why are we always surprised about these threats that we know are always going to be in front of us?”
This speaks to the need to build up public health’s data capacity and surveillance ability in order to do better with disease prevention, he said, adding that, “when prevention works, absolutely nothing happens except the miracle of a perfectly normal, healthy day. And we have to get that message out, so that people realize that this slow return to normalcy that we’re hopefully enjoying right now will last, and that we could have a much healthier future going forward.”
But Smith didn’t entirely agree with Koh’s assertion that things were returning to normal. “We’re not ‘out’ of anything,” she said. “We’re still in COVID. We’re waiting for flu season. We’re within monkeypox. And we have many other [problems] — HIV and a mental health crisis. We have wicked problems that are not solved in silos, and that are not short-term.”
Asked how trust in the healthcare system could be rebuilt, Koh said it starts with the local physician or local public health officials. “When you ask people, ‘Who do you trust to give you information on health?’ — particularly around vaccination — it’s always one’s own local doctor or nurse or health professional,” he said. “Have we supported the primary care professionals enough and paid them for their time, so they can dedicate their efforts to talking about this with their patients or have we just overlooked that? … They don’t particularly trust national leaders or even state leaders; it’s the local professional that they’re seeing, their doctor or their nurse, that makes the difference.”