Local public health workers were gripped with a different deadly outbreak when the coronavirus hit Washington state in January.
Hepatitis A was spreading through homeless communities and officials feared they could lose control. But with the arrival of the coronavirus, known as SARS-CoV-2, the time-consuming process of investigating each case has been placed on hold, at least in Seattle, while agencies scramble to slow the spread of COVID-19, the disease the virus causes.
It’s a familiar pattern: local health workers frantically “putting out fires,” as one state report described, unable to keep up with a mounting backlog of communicable-disease reports. For years they have been understaffed because the Legislature and Gov. Jay Inslee have declined requests by the state public health network for more funding.
The underfunding has also hit the Public Health Laboratory in Shoreline, the state’s central testing facility for coronavirus. The department can’t afford to service lab equipment or maintain the facility, according to a budget request submitted last year.
“We have gaps in several areas,” said Dennis Worsham, director of the disease-prevention division at Public Health — Seattle & King County.
The pivot to COVID-19 has hamstrung staffing for the department’s high-priority epidemiology programs, which since last year have focused on slowing the spread of spread of syphilis, gonorrhea, tuberculosis and hepatitis A. In December, a King County man died after being hospitalized with acute hepatitis A, a disease particularly prevalent among homeless people and intravenous drug users, and January saw the largest spike of cases in the previous 12 months.
The full scope of the coronavirus outbreak and its impact on the Seattle area has yet to fully unfurl, and Worsham said the system would be stressed even if it was fully funded. This week the Legislature is voting on a $100 million infusion to help the state respond.
“We aren’t fully able to address the capacity need for this outbreak without proper funding,” said Tesia Forbes, policy and finance administrator for Public Health — Seattle & King County.
Washington Department of Health Secretary John Wiesman said the lack of funding at state laboratories has not affected the agency’s response to the coronavirus, although some staffers have dropped their usual responsibilities.
“We have purchased the equipment we need to do this testing,” he said. “Some other things may take longer to get done.”
Funding woes for decades
Washington’s local public health agencies trace their shortfalls to 2000, when the Legislature repealed the motor-vehicle excise tax that funded local jurisdictions. Lawmakers found other sources for about 90% of their budgets, but that amount has not increased with population growth or inflation.
Also, much of the federal funding received by local agencies in recent years has been restricted to specific health needs — like grants to combat the spread of HIV/AIDS — and is unavailable for broader functions like epidemiology and infectious-disease investigations.
Another major financing obstacle in Olympia was the state’s McCleary education case and its contempt order with $100,000-per-day sanctions. That lifted in 2018.
“You have to realize that the funding impact of [McCleary] continues to this day,” said Sen. Randi Becker, R-Eatonville, a member of the Health & Long Term Care Committee.
Washington isn’t the only state with a strained public health system. From 2008 to 2017, local health departments across the U.S. eliminated 56,360 jobs, according to The National Association of County and City Health Officials.
“Crumbling system”
The latest public health budget drive in Olympia began in 2016, when a coalition of local public health officials and the state Department of Health rolled out a plan to boost agency budgets.
“If new funding is not provided to begin stabilizing local health jurisdictions, the erosion of critical public health services will continue to the point that the state and local communities will not be protected from disease outbreaks,” a late 2016 budget request warned.
Department of Health officials requested $30 million a year to “begin stabilizing the crumbling system.”
Inslee reduced that request to $12 million a year in his 2017 proposal to the Legislature, which ultimately appropriated $6 million per year.
Inslee spokeswoman Tara Lee said the governor must “take into consideration all the things that the state needs to fund.” She said that since 2017, Inslee has proposed adding nearly $46 million for “foundational public health services” — core priorities, including epidemiology.
He is “very committed to public health and is pushing hard for the $100 million ask to the Legislature to fight the coronavirus outbreak,” Lee said in a statement.
By 2018, the health department had clearer numbers for the amount needed at the local level. It requested an additional $150 million a year to deal with “critical gaps” in the network of 35 local agencies. It called out the state’s limited capacity to respond to major emergencies. Inslee cut that request to $11 million a year, which was approved by lawmakers.
“The public health system has been underfunded for quite some time,” said Wiesman, the health secretary. “These requests were to help the system fully investigate diseases.”
With the limited additional funding, some local agencies were able to reduce how long it takes investigators to reach patients with communicable diseases, and to begin working through a backlog of reports. The money also helps local health departments vaccinate when possible, and communicate prudent practices, such as hand-washing and self-quarantine among the sick.
“It’s really about trying to separate people who are not feeling well from people who are feeling well,” Worsham said.
The 2018 proposal would have brought Seattle and King County $60 million over two years, according to the local agency. Instead, it got $6 million.
Last year the department again requested more money, including for the Public Health Laboratory in Shoreline. The lab’s funding hasn’t changed since fiscal 2011, forcing the agency to defer “general upkeep” and causing some equipment-service contracts to lapse.
“If the lack of funding continues, the laboratories will struggle with daily operations and will have challenges in responding to emergency situations,” the report said.
Lessons learned from other outbreaks
After global outbreaks of Ebola in 2014 and Zika virus in 2016 overwhelmed Public Health — Seattle & King County, a county audit took stock of what was needed to prepare for the next one. The earlier outbreaks brought to light weaknesses in the department’s response, including a failure to plan for the hiring spurt the outbreaks commanded.
In the 3½ years since the audit, the county public health department has made many promised improvements. A followup to the audit in December 2018 showed it had enacted 11 of the 13 recommendations for improving its response to outbreaks, according to the King County Auditor’s Office.
But one of the fixes remains beyond the health department’s control: funding.
The Department of Health’s 2016 request foreshadowed today’s situation: “The unanticipated global outbreak of Zika virus infection is the most current but certainly not the last emerging infectious disease challenge to confront the U.S. public health system … Responding to these new diseases means much work is being left undone in other areas, which exposes our residents to unacceptable levels of risk.”
A previous version of this story incorrectly described the McCleary education case. The state Supreme Court issued the order and fines.