Sacramento County public health lab faced years of budget cuts. Then came the COVID-19 pandemic
Sacramento County’s public health program designed to ward off disease outbreaks has seen its funding dwindle for years, even as other departments saw their budgets increase and warnings of a looming pandemic intensified, a review of budget documents, meeting minutes and interviews with current and former officials found.
The Great Recession more than a decade ago led to crippling budget cuts throughout local governments. Key nursing positions and other disease detectives were downsized or eliminated outright. But even as the economy rebounded, Sacramento County failed to restore funding for its public health laboratory, which is now being overwhelmed with COVID-19 testing demands.
Cuts in 2009 were so severe, the public health lab told officials they wouldn’t be able to respond “24/7,” according to a department budget presentation. Delays in test results for diseases such as tuberculosis and rabies “could result in increased disease and deaths” and there’d be “a loss in nursing capacity to respond to an epidemic.”
Belt-tightening continued for years, including a rejection last April of just $35,000 to secure accreditation, a form of national sanctioning for well-running departments. The rejection by the county Board of Supervisors came despite nearly a decade’s worth of work by a team of health experts, community advocates and county employees to overhaul parts of the division.
Now, the long-existing fissures in local health funding are likely to widen as state and federal officials agree that counties — not the federal or state government — will lead the incremental reopening of society and the exhaustive contact tracing of those infected with the coronavirus.
The demands come as counties grapple with the reality of a new recession, budgets crumbling under the stress of far-reaching economic shutdowns.
Board of Supervisors Chair Phil Serna said the county has largely been ahead of the game when it came to preparing and taking the threat of the pandemic seriously, referring to last month’s emergency declarations and stay-at-home orders. The county now spends more than $52 million a year on public health.
“Looking back, like almost any response to any circumstance, we could probably have done some things differently,” Serna wrote in an email to a list of questions. Specifically, he said there could have been better communication between elected and public health officials about early responses.
“But that said, this is the first global public health crisis of this magnitude since the Spanish influenza outbreak 103 years ago,” he said.
Decade’s worth of work stymied
Still, the rejection of the money for accreditation was particularly disheartened to staff members in the division of public health. The request had been more than a decade in the making.
The team of health experts and community members had surveyed where gaps existed in programming and staffing. They’d readied themselves for new funding to help plan for disease outbreaks. And, with the blessing of elected officials, they would finally join the ranks of public health departments across California that had previously earned the national seal of approval called accreditation.
The final ask of $35,000 was barely a rounding error on most county budgets.
“We believe the ultimate benefits to our county’s citizens far outweigh these costs,” the advisory board chair, Dr. Steven Orkand, wrote to county officials. “Given the interest in accreditation throughout California, we also believe these efforts are necessary to document the high quality of services provided by our Division of Public Health. We hope you will support these efforts.”
After the county rejected the request, Orkand never heard an explanation why. He understood there were other county priorities and that the accreditation effort would be put on hold.
While a thumbs-up from an accreditation board isn’t necessary to smoothly run a public health agency, not having the final designation can hinder access to funding and expertise — resources experts say is in increasing demand as the novel coronavirus pandemic deepens across the country.
“Public health is about protection and prevention,” said Dr. Glennah Trochet, the county’s longtime health officer who retired in 2011. “And the trouble with prevention is you can never prove what you prevented. Usually, in times of crisis, you get funding. But when you’re trying to prevent something from happening, people just don’t pay a whole lot of attention.”
Prioritizing accreditation can be a barometer of how supported public health is, said Jacqueline Merrill, a public health expert and professor of nursing in biomedical informatics at Columbia University’s School of Nursing. Not supporting the low-dollar requests can send a “discouraging” message to departments.
“It really affects morale,” she said.
Sixteen county health departments in California are accredited, including many of those experiencing the highest number of COVID-19 cases and deaths. Sacramento County is one of only two counties without an accredited health department but with more than 1.5 million residents. The other is Alameda County.
Accredited public health departments are more streamlined and better prepared to work with community groups, especially during emergencies, experts say. The certification can help them improve and even help unlock money for responses during emergencies — something that’s going to be essential as departments rely on an army of contact tracers, testers and analysts to help reopen society.
“There’s a level of expertise that they have. And they have the knowledge and capability to lead such an effort,” Merrill said of health departments broadly. “But they do not have the resources. How could they?”
‘Those were difficult years’
While COVID-19 might be new, the pandemic threat has been warned for years.
“The probability of pandemic influenza is greater now than any time in the past 20 years,” Trochet wrote to the board in a 2006 memo requesting money to educate residents about communicable diseases and hire additional staff to study them.
For more than a decade, the county had been steadily growing its health and human services department, hiring more staffers and increasing its budget.
By 2007, the public health lab had swelled to receive $3.78 million, responsible for tamping down on communicable disease outbreaks, running tests and investigating bioterrorism threats.
Within a year, the Great Recession had started to take its toll.
Two positions were cut the following year in disease control, which county officials acknowledged in budget documents would impact the response time to disease outbreaks. In the next budget cycle, the public health division underwent “a greater than 60 percent reduction in county general funding,” according to the final budget report.
“Those were difficult years,” said county supervisor Don Nottoli.
It wouldn’t just be difficult because of budget cuts.
Two weeks after the department proposed its slashed budget, the county turned a corner on a separate public health emergency: Trochet announced the first Sacramento County death of someone infected with the H1N1 virus, better known as the swine flu.
By then, after leading the department through the post-9/11 uncertainty, it was the financial crisis that had worn her down.
Trochet said she lost roughly one-in-three public health staff members, and budget documents show the county relied on “over 500 community volunteers” to operate 35 “mass vaccination” clinics and hand out masks and medicines across Sacramento County.
The following year county officials continued gutting the public health division and rewrote the emergency preparedness program “to reflect the new reality of reduced staff and resources to address emergencies,” records show.
Trochet had had enough.
In 2011, she retired from her job as the county’s health officer. In interviews at the time, she expressed frustration that public health funding too often took a backseat to other county priorities.
“In my whole career at the county,” Trochet said, “regardless of who was on the board of supervisors, prevention just simply wasn’t a priority.”
After departure, new efforts begin
Whether at the national or the county level, elected officials routinely put public health and disaster planning at the bottom of the priority list.
Part of that is because there are limited resources available, said Njoki Mwarumba, professor of emergency management and disaster science at the University of Nebraska. But more broadly, if federal and state officials do not set a tone of public health being a priority after an emergency ends, county governments are unlikely to do so, either.
Mwarumba said most people struggle with “the realities of low probability, high impact events. And pandemics are a great example of those.”
With H1N1 and the recession fading, some in Sacramento County began looking ahead.
A group that makes public health recommendations to county supervisors in late 2010 said that it was time to focus on how to repair and refuel the division by studying how to join the ranks of other accredited public health divisions.
“For Sacramento County, the state of public health practice is in disarray, primarily a result of slashes in the budget,” a 2010 advisory report said.
The county’s efforts to receive accreditation offers a window into how the public health division was operating at the time, where its strengths and shortcomings were, how the agency measures up against national standards.
Work was taking shape by 2013, and by 2016 reviewers were coming up with improvement plans. Among the findings: the division must better communicate with the public, should bring on additional staff and increase funding for its laboratory.
“Providers operate in survival mode, making long-term strategic thinking and planning difficult,” the investigation found.
“Prevention resources have diminished,” they added. “Prevention services have beneficial long term outcomes, however, they are often cut before immediate intervention services when budgets are tight.”
In a hopeful move that year, public health received additional county funding to add staff to its communicable disease program that would respond to outbreaks such as influenza, Pertussis, E. Coli and Ebola.
Research shows that investments in county public health departments can pay dividends down the road. One UC Berkeley study in 2016 found that every $1 invested into California county public health departments resulted in $67 to $88 worth of benefits to society.
Another study found that increased spending by local health departments was associated with a statistically significant decline in statewide infectious disease morbidity.
Accredited health departments, in particular, say they respond more effectively to large-scale emergencies, said Paul Kuehnert, president and CEO of the Public Health Accreditation Board.
One department in Ohio said it had improved communicating with the public. Another in Florida said partnerships from accreditation helped officials streamline testing for the Zika virus in hard-to-reach or disadvantaged communities.
National research is underway to learn how certified departments responded to the coronavirus crisis differently from those without the national seal, Kuehnert said.
“Accreditation changes this mindset of leadership and gets people into that approach of being planful, being proactive, looking at the evidence and creating and supporting these partnerships,” Kuehnert said.
$43 million in cuts last year
Advances in public health research were stymied when the budget season arrived in 2019.
Last year, officials say the county was forced to make $43 million in cuts to finance upgrades to its jails required as part of a settlement stemming from a lawsuit alleging people in custody were subject to harsh and inhumane conditions.
That meant there was no room in the general fund for growth, according to the county’s executive team in a statement, other than to meet legal mandates.
“This has been one of the hardest budgets for us to do,” County Executive Navdeep Gill told supervisors last June after they approved the budget.”
County officials point out that the overall public health budget is 26 percent higher now than it was in 2007-08, now at about $52.5 million. And all general fund departments have felt the post-recession squeeze — total staffing levels are still 15 percent below those more than a decade ago.
But critical public health divisions responsible for managing a disease outbreak or pandemic like COVID-19, like Sacramento County’s public health lab, have never recovered from cuts incurred during the Great Recession.
The lab’s funding last year was about 73 percent of its previous high from more than a decade ago.
It’s not just the county’s general funding for public health that has lagged. State and federal funding for the county via the Public Health Emergency Preparedness program has also faltered in recent years.
In 2010, the county had received nearly $3.4 million for the program, aimed at building up the public health department’s capacity to prevent, detect and respond to crises like pandemic influenza, bioterrorist attack or large disease outbreaks.
Last year, the county received just shy of $1.95 million for the program, after years of declining funding.
“We continue to do our best with what we have,” Serna said in an email, “and what we continue to cope with is a lack of testing infrastructure which is not just frustrating, it is the single greatest obstacle to better understand the disease in our community.”
One area in the county’s public health department that has returned to pre-recession levels — funding for communicable disease control, epidemiology and immunizations. That growth has largely grown to manage rising sexually transmitted diseases rates across the county.
Public health “cannot be taken for granted,” Nottoli said. That said, he acknowledges that “maybe we got a little comfortable” that there would always be a vaccine, or that people would be immune. “Clearly that is not the case,” he said.
“In the event that it could come back a few months from now, a few years from now, what are we going to do to prepare ourselves,” Nottoli said. “That’s a question that people up and down the state and across the nation will ask themselves.”
As the county prepares its upcoming budget — which county elected officials expect to see additional reductions — Nottoli said the pandemic might lead to increased public health funding this year.
“It very well may be reflected in the June budget, if there’s a threat of this coming back in the fall,” Nottoli said.
Robert Redfield, director of the Centers for Disease Control and Prevention, has said that the key to lifting physical distancing orders and avoiding a new surge in cases will be contact tracing — the ability to investigate the spread of any flare-ups.
That vital work will not only require a “substantial expansion of public health field workers,” Redfield told NPR, but also will ultimately fall on state and county agencies to execute at the local level.
Gov. Gavin Newsom last week said California state workers could get trained for an emerging workforce of 10,000 coronavirus trackers who will be needed as the state reopens its economy and lifts the stay-at-home order.
“We believe we have the capacity to build an army of tracers, beginning with a goal of 10,000,” Newsom said on Wednesday. “That is now our stated goal: to train these tracers, building off the local infrastructure, supplementing it as we can at the state level.”
Dr. Peter Beilenson, the county’s health chief, said he did not think accreditation would have helped the county’s response to the new coronavirus pandemic. But he agreed its priority is to show “accountability and deepen credibility among stakeholders, partners and the community.”
“We were as prepared as we possibly could be in this once in a lifetime epidemic,” Beilenson said in a statement. And as for getting that national seal this budget cycle?
“Public health is close.”