Cracks in the System: The Effects of the Coronavirus Pandemic on Public Health Systems
| Author | Dominique Vervoort,Kate Tulenko |
| Published date | 01 August 2020 |
| Date | 01 August 2020 |
| DOI | http://doi.org/10.1177/0275074020941667 |
| Subject Matter | Institutional Responsibilities & Obligations of the Administrative State to the Citizenry IT ServesPublic Health Consequences of Deconstructing the Administrative State |
research-article2020
Public Health Consequences of Deconstructing the Administrative State
American Review of Public Administration
2020, Vol. 50(6-7) 455 –466
Cracks in the System: The Effects of the
© The Author(s) 2020
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Coronavirus Pandemic on Public Health
https://doi.org/10.1177/0275074020941667
DOI: 10.1177/0275074020941667
journals.sagepub.com/home/arp
Systems
Kate Tulenko1 and Dominique Vervoort2
Abstract
The novel coronavirus disease 2019 (COVID-19) pandemic has rapidly wrought havoc on the world, exposing the gaps in
public health systems of countries that were previously considered most prepared for infectious disease outbreaks. Notably,
despite being ranked highest on the Global Health Security Index, the United States has been severely hit with nearly
two million confirmed cases and one hundred thousand deaths by the end of May 2020. In addition to the public health
fragmentation from the federal to the state level and lagging regulations, early reports highlight substantial socioeconomic
disparities and health system barriers contributing to the spread and impact of the pandemic in the United States. In
this review, we explore the impact of COVID-19 on public health systems by assessing systems through the lens of the
Centers for Disease Control and Prevention’s Ten Essential Public Health Services. Building on prepandemic and COVID-19
observations and lessons, we propose recommendations moving forward to prepare for future waves and other disease
outbreaks.
Keywords
COVID-19, coronavirus, public health, health systems, epidemics, pandemics, global health security
Introduction
technological advancements in the U.S. health care system
were mistaken for basic and essential public health and
The novel coronavirus disease 2019 (COVID-19) and
emergency preparedness. It is clear that, although the United
SARS-CoV-2 (severe acute respiratory syndrome coronavi-
States spends nearly four trillion dollars each year on
rus 2), the virus causing COVID-19, have led to an unprec-
health—more than any country in the world—investments in
edented impact on the modern world. As of mid-May 2020,
public health have remained substantially less. Public health
nearly five million people have been confirmed with
spending in the United States is less than 3% of total health
COVID-19 worldwide, already causing tens of thousands of
spending, at only US$274 per capita per year (Christopher
deaths (Dong et al., 2020). On March 11, 2020, the World
et al., 2019; Himmelstein & Woolhandler, 2016). This is
Health Organization (WHO) officially called the SARS-
especially surprising given public health’s potentially high
CoV-2 outbreak a global pandemic, with most of the world
return on investment as high as 14-to-1 in high-income coun-
following with national lockdowns or shelter-in-place poli-
tries (Himmelstein & Woolhandler, 2016).
cies. The outbreak in the United States far exceeds the origi-
In the United States, public health is mainly a function of
nal outbreak in China and makes it—together with Western
the state and local governments, with the federal government
Europe—the new epicenter of the pandemic (Dong et al.,
playing a role through creating guidelines and regulating
2020).
interstate commerce which impacts public health goods and
Prior to the COVID-19 pandemic, the United States was
services such as testing kits and pharmaceuticals. The main
considered to have one of the most robust public health sys-
federal public health institutions include the Department of
tems in the world, especially strong in terms of emergency
preparedness. The Global Health Security Index ranked the
United States as the most prepared country in the world to
1Corvus Health, Alexandria, VA, USA
handle infectious disease outbreaks (Cameron et al., n.d.).
2Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
Ironically, the pandemic is wreaking most havoc in the pre-
Corresponding Author:
sumably most prepared country in the world. The inability of
Kate Tulenko, Corvus Health, 950 N Washington St., Alexandria, VA
the U.S. public health system to do a better in preventing and
22314, USA.
mitigating the national COVID outbreak may indicate that
Email: ktulenko@corvushealth.com
456
American Review of Public Administration 50(6-7)
Health and Human Services, the Centers for Disease Control
professionals, to more effectively and rapidly deploy
and Prevention (CDC), and the Food and Drug Administration
resources for the isolation of confirmed cases and the mitiga-
(FDA).
tion of outbreaks. (Sellers et al., 2019). Lessons from the
Here, we evaluate the impact of the COVID-19 pandemic
SARS and Ebola outbreaks, now visibly effective in keeping
on public health systems, with a particular focus on the U.S.
the spread of SARS-CoV-2 at a minimum in East Asia and
public health system, using the CDC’s Ten Essential Public
much of West and Central Africa, must be integrated into
Health Services (Table 1) (“Public Health System and the 10
conventional public health measures. This will include the
Essential Public Health Services,” 2019).
introduction of vigilant contact tracing approaches in case of
emerging or reemerging infectious diseases. It is estimated
Essential Public Health Services
that approximately 100,000 public health workers and an
investment of US$3.6 billion is necessary to establish a com-
Service 1: Monitor Health Status to Identify and
prehensive contact tracing workforce; digital contact tracing
Solve Community Health Problems
may substantially reduce costs and be equally, if not more,
effective but brings privacy concerns and perceived infringe-
Prior to COVID-19, fragmented but effective disease regis-
ment on individuals’ freedom with it. Google and Apple are
tries had been leveraged to address local health needs.
now collaborating to enable such digital contact tracing
Around the world, these have demonstrated the potential to
through Bluetooth-enabled smartphone applications, pend-
improve health care delivery adapted to local contexts and,
ing higher-level decisions (Scott, 2020).
importantly, propelled by the effective use of community
health workers surveilling households and local communi-
Service 2: Diagnose and Investigate Health
ties. Amid the pandemic, the CDC discontinued reporting
Problems and Health Hazards in the Community
new case numbers, despite it constituting one of the most
important pieces of data to assess the size of an outbreak and
Before the pandemic, the U.S. public system had a strong
the effects of mitigation measures. In this data vacuum,
public laboratory system and a strong system of screening
many different organizations and initiatives have made an
for and reporting infectious diseases, especially influenza
attempt to comprehensively map the number of confirmed
and other respiratory infections, tuberculosis, and sexually
cases, deaths, and recovered cases. The Johns Hopkins
transmitted infections, including HIV. Baseline disease sur-
University Center for Systems Science and Engineering has
veillance was conducted to identify and explore potential
established a transparent dashboard visualizing data on the
health threats in communities. For example, for the flu and
national and subregional levels on a continuous basis. The
flu-like symptoms, the United States participated in the
WHO put out global surveillance documents and situation
WHO Global Influenza Surveillance and Response System
dashboards to inform countries in terms of epidemiological,
surveilled and responded to seasonal, pandemic, and zoo-
psychosocial, and resource aspects. The Institute for Health
notic influenza, alerting the global health community in case
Metrics and Evaluation, notably responsible for tracking the
of worrisome deviations of endemic and expected epidemio-
Global Burden of Disease study, has further enabled models
logical spread (“Global Influenza Surveillance and Response
to project resource allocations and morbidity and mortality
System [GISRS],” n.d.). The United States also participates
projects for the United States and all individual states,
in other global surveillance systems such as HealthMap
depending on different public health measures taken. which serves as early warning systems curated on a real-time
Controversies occurred over states such as Virginia combin-
basis.
ing data on positive antibody tests with data on positive
During the COVID response, it is this “diagnose and
RNA tests. In addition, the states of Georgia and Florida
investigate” function that encountered the greatest chal-
received criticism for taking steps which were perceived as
lenges. Rather than using the WHO COVID-19 test which
suppressing data on positive cases.
had been developed by a prominent German lab, the United
In the post-COVID-19 rebuild, the need for more compre-
States chose to develop its own test, which it often does for
hensive regional and national disease registries, especially
new diseases. However, this “all eggs in one basket” approach
for infectious diseases, has become apparent. There is an
backfired when there was a manufacturing flaw in the CDC’s
urgency for real-time updates, similar to the CDC’s Morbidity
testing kits and weeks of potential...
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