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Expertos en salud pública temen que los fondos desaparezcan cuando termine la pandemia

En respuesta a la pandemia de covid-19, el Congreso ha invertido decenas de miles de millones de dólares en los departamentos de salud pública estatales y locales, pagando por máscaras, rastreadores de contactos y campañas educativas para persuadir a las personas de que se vacunen.

Sus funcionarios, que han manejado presupuestos famélicos durante años, están felices de tener este dinero adicional. Sin embargo, les preocupa que esta ayuda pueda desaparecer pronto, a medida que la pandemia se repliega, continuando con un ciclo de altas y bajas en la financiación, que ha plagado al sistema de salud pública de los Estados Unidos durante décadas.

Advierten que, si los presupuestos se recortan de nuevo, la nación podría volver a donde estaba antes de covid: sin preparación para enfrentar una crisis de salud.

“Necesitamos fondos con los que podamos contar año tras año”, dijo la doctora Mysheika Roberts, comisionada de salud de Columbus, Ohio.

Cuando Roberts comenzó en Columbus en 2006, una subvención de preparación para emergencias alcanzó para pagarle a más de 20 empleados. Cuando llegó la pandemia de coronavirus, alcanzó para cerca de 10. Con el dinero de ayuda que llegó el año pasado, el departamento pudo tener más equipos de respuesta a covid. Pero, aunque la financiación ha ayudado a la ciudad a hacer frente a la crisis inmediata, Roberts se pregunta si la historia se repetirá.

Una vez que termine la pandemia, los funcionarios de salud pública temen tener que volver a reunir dinero de múltiples fuentes para brindar servicios básicos a sus comunidades, como pasó después del 9/11, el SARS y el Ebola.

Cuando el virus del Zika transmitido por mosquitos atravesó Sudamérica en 2016, causando graves defectos de nacimiento en recién nacidos, los congresistas no pudieron ponerse de acuerdo sobre cómo y cuánto gastar en los Estados Unidos.

Para los esfuerzos de prevención, como la educación y la eliminación de mosquitos, los Centros para el Control y la Prevención de Enfermedades (CDC) tomaron dinero que estaba destinado al Ebola y de los fondos para los departamento de salud estatales y locales. El Congreso finalmente asignó $1.1 mil millones para el Zika. Pero, para entonces, la temporada de mosquitos ya había pasado en gran parte del país.

“Algo sucede, repartimos un montón de dinero, y luego, en uno o dos años, volvemos a nuestros presupuestos reducidos y no podemos hacer las cosas mínimas que tenemos que hacer día tras día, y mucho menos estar preparados para la próxima emergencia ”, dijo Chrissie Juliano, directora ejecutiva de Big Cities Health Coalition, que representa a líderes de más de dos docenas de departamentos de salud pública.

El financiamiento para el Public Health Emergency Preparedness, que paga por las capacidades de emergencia para los departamentos de salud estatales y locales, se redujo aproximadamente a la mitad entre los años fiscales 2003 y 2021, tomando en cuenta la inflación, según Trust for America’s Health, una organización de investigación y defensa de la salud pública.

Incluso el Fondo Federal de Prevención y Salud Pública, que se estableció con la Ley de Cuidado de Salud a Bajo Precio (ACA) para proporcionar $2 mil millones al año para la salud pública, fue allanado en busca de efectivo durante la última década. Si no se hubiera tocado ese dinero, eventualmente los departamentos habrían obtenido $12,4 mil millones adicionales.

Varios legisladores, con la senadora nacional Patty Murray (demócrata de Washington) a la cabeza, buscan poner fin a este círculo vicioso con una legislación que eventualmente proporcionaría $4,500 millones anuales en fondos básicos de salud pública. Los departamentos de salud llevan a cabo funciones gubernamentales esenciales, como administrar la seguridad del agua, emitir certificados de defunción, rastrear enfermedades de transmisión sexual, y estar listos para brotes de enfermedades infecciosas.

El gasto en estos departamentos estatales se redujo en un 16% per cápita de 2010 a 2019, y el gasto en los departamentos de salud locales bajó un 18%, reveló en julio una investigación de KHN y The Associated Press (AP).

Se perdieron al menos 38,000 empleos de salud pública a nivel estatal y local entre la recesión de 2008 y 2019. Hoy en día, se contrata a muchos trabajadores de salud pública de manera temporal o a tiempo parcial. A algunos se les paga tan mal que califican para beneficios del gobierno. Esos factores reducen la capacidad de los departamentos para retener personas con experiencia.

Para peor, la pandemia ha generado un éxodo de funcionarios de salud pública debido al acoso, la presión política y el agotamiento. Un análisis de un año realizado por AP y KHN reveló que al menos 248 líderes de departamentos de salud estatales y locales renunciaron, se retiraron o fueron despedidos entre el 1 de abril de 2020 y el 31 de marzo de 2021. Casi uno de cada 6 estadounidenses perdió a un líder de salud pública local durante la pandemia.

Expertos dicen que es el mayor éxodo de líderes de salud pública en la historia de los Estados Unidos.

Brian Castrucci, director ejecutivo de la Beaumont Foundation, que aboga por la salud pública, llama a la enorme afluencia de efectivo del Congreso en respuesta a la crisis un “vendaje temporal” porque no restaura los cimientos quebrados de la salud pública.

“Me preocupa que al final vayamos a contratar un montón de rastreadores de contactos, para despedirlos poco después”, dijo Castrucci. “Continuamos pasando de un desastre a otro sin siquiera hablar de la infraestructura real”.

Castrucci y otros dicen que necesitan dinero confiable para profesionales altamente capacitados, como epidemiólogos (detectives de enfermedades basados ​​en datos) y para actualizaciones tecnológicas que ayudarían a rastrear brotes y brindar información al público.

En Ohio, el sistema informático utilizado para informar casos al estado es anterior a la invención del iPhone. Funcionarios estatales dijeron durante años que querían mejorarlo, pero no hubo ni dinero ni voluntad política. Muchos departamentos en todo el país han tenido que confiar en las máquinas de fax para reportar casos de covid.

Durante la pandemia, el auditor del estado de Ohio descubrió que casi el 96% de los departamentos de salud locales encuestados tenían problemas con el sistema de notificación de enfermedades del estado. Roberts dijo que los trabajadores que entrevistaban a los pacientes tenían que navegar por varias páginas de preguntas, una tarea pesada cuando se manejan 500 casos al día.

El sistema estaba tan desactualizado que parte de la información solo se podía ingresar en un cuadro de comentarios que después no se podía encontrar, y los funcionarios luchaban para extraer datos del sistema para informar al público, como cuántas personas que dieron positivo en la prueba habían asistido a un marcha de Black Lives Matter, que el verano pasado fue una pregunta clave para comprender si las protestas contribuían a la propagación del virus.

Ohio está trabajando en un nuevo sistema, pero a Roberts le preocupa que, sin un presupuesto confiable, el estado tampoco pueda mantenerlo actualizado.

“Vas a necesitar actualizar eso”, dijo Roberts. “Y vas a necesitar dólares para respaldarlo”.

En Washington, Patty Hayes, la directora de salud pública de Seattle y el condado de King, dijo que todo el tiempo le preguntan por qué no hay un solo sitio centralizado para registrarse para una cita de vacunación. La respuesta se reduce al dinero: años de financiación insuficiente dejaron a los departamentos de todo el estado con sistemas informáticos anticuados que no estaban a la altura de la tarea cuando llegó covid.

Hayes recuerda un tiempo en el que su departamento realizaba simulacros de vacunación masiva, pero ese sistema se desmanteló cuando el dinero se agotó después de que se desvaneció el fantasma del 9/11.

Hace aproximadamente seis años, un análisis encontró que a su departamento le faltaban alrededor de $25 millones del dinero que necesitaba anualmente para el trabajo básico de salud pública. Hayes dijo que el año pasado demostró que esa cifra estaba subestimada. Por ejemplo, el cambio climático está generando más preocupaciones de salud pública, como el efecto en los residentes cuando el humo de los incendios forestales cubrió gran parte del noroeste del Pacífico en septiembre.

Funcionarios de salud pública en algunas áreas pueden tener dificultades para defender un financiamiento más estable porque una gran parte del público ha cuestionado, y a menudo ha sido abiertamente hostil, con los mandatos del uso de máscaras y las restricciones a los negocios impuestas a lo largo de la pandemia.

En Missouri, algunos comisionados del condado, frustrados por las restricciones de salud pública, retuvieron dinero de los departamentos.

En el condado de Knox, en Tennessee, el alcalde Glenn Jacobs narró un video publicado en el otoño que mostraba una foto de funcionarios de salud después de hacer referencia a “fuerzas siniestras”. Más tarde, alguien pintó con spray la palabra “MUERTE” en el edificio del departamento. La Junta de Salud fue despojada de sus poderes en marzo y se le otorgó una función asesora. Un vocero de la oficina del alcalde se negó a comentar sobre el video.

“Esto va a cambiar la posición de la salud pública y lo que podemos y no podemos hacer en todo el país”, dijo la doctora Martha Buchanan, jefa del Departamento de Salud. “Sé que lo va a cambiar aquí”.

Una investigación de KHN y AP en diciembre encontró que al menos 24 estados estaban elaborando una legislación que limitaría o eliminaría los poderes de salud pública.

De nuevo en Seattle, las empresas locales han aportado dinero y personal a los sitios de vacunación. Microsoft aloja a uno de estos sitios, mientras que Starbucks ofreció experiencia en servicio al cliente para ayudar a diseñarlos. Hayes está agradecida, pero se pregunta por qué una función del gobierno crítica no contó con los recursos que necesitaba durante una pandemia.

Si la salud pública hubiera recibido financiamiento confiable, su personal podría haber estado trabajando de manera más efectiva con los datos, y podría haber estado preparándose para las amenazas emergentes en el estado donde se confirmó el primer caso de covid del país.

“Mirarán hacia atrás a esta respuesta a la pandemia en este país como un gran ejemplo del fracaso de un país en priorizar la salud de sus ciudadanos, porque no hubo compromiso con la salud pública”, dijo. “Eso será parte de la historia”.

La corresponsal senior de KHN Anna Maria Barry-Jester y la corresponsal de Montana Katheryn Houghton colaboraron con este informe.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Attorney For Adam Toledo's Family: 'Adam Died Because He Complied'

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Coming up on Connections: Monday, April 19

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Public Health Experts Worry About Boom-Bust Cycle of Support

Congress has poured tens of billions of dollars into state and local public health departments in response to the covid-19 pandemic, paying for masks, contact tracers and education campaigns to persuade people to get vaccinated.

This story also ran on The Associated Press. It can be republished for free.

Public health officials who have juggled bare-bones budgets for years are happy to have the additional money. Yet they worry it will soon dry up as the pandemic recedes, continuing a boom-bust funding cycle that has plagued the U.S. public health system for decades. If budgets are slashed again, they warn, that could leave the nation where it was before covid: unprepared for a health crisis.

“We need funds that we can depend on year after year,” said Dr. Mysheika Roberts, the health commissioner of Columbus, Ohio.

When Roberts started in Columbus in 2006, an emergency preparedness grant paid for more than 20 staffers. By the time the coronavirus pandemic hit, it paid for about 10. Relief money that came through last year helped the department staff up its covid response teams. While the funding has helped the city cope with the immediate crisis, Roberts wonders if history will repeat itself.

After the pandemic is over, public health officials across the U.S. fear, they’ll be back to scraping together money from a patchwork of sources to provide basic services to their communities — much like after 9/11, SARS and Ebola.

When the mosquito-borne Zika virus tore through South America in 2016, causing serious birth defects in newborn babies, members of Congress couldn’t agree how, and how much, to spend in the U.S. for prevention efforts, such as education and mosquito abatement. The Centers for Disease Control and Prevention took money from its Ebola efforts, and from state and local health department funding, to pay for the initial Zika response. Congress eventually allocated $1.1 billion for Zika, but by then mosquito season had passed in much of the U.S.

“Something happens, we throw a ton of money at it, and then in a year or two we go back to our shrunken budgets and we can’t do the minimum things we have to do day in and day out, let alone be prepared for the next emergency,” said Chrissie Juliano, executive director of the Big Cities Health Coalition, which represents leaders of more than two dozen public health departments.

Funding for Public Health Emergency Preparedness, which pays for emergency capabilities for state and local health departments, dropped by about half between the 2003 and 2021 fiscal years, accounting for inflation, according to Trust for America’s Health, a public health research and advocacy organization.

Even the federal Prevention and Public Health Fund, established with the Affordable Care Act to provide $2 billion a year for public health, was raided for cash over the past decade. If the money hadn’t been touched, eventually local and state health departments would have gotten an additional $12.4 billion.

Several lawmakers, led by Democratic U.S. Sen. Patty Murray of Washington, are looking to end the boom-bust cycle with legislation that would eventually provide $4.5 billion annually in core public health funding. Health departments carry out essential government functions — such as managing water safety, issuing death certificates, tracking sexually transmitted diseases and preparing for infectious outbreaks.

Spending for state public health departments dropped by 16% per capita from 2010 to 2019, and spending for local health departments fell by 18%, KHN and The Associated Press found in a July investigation. At least 38,000 public health jobs were lost at the state and local level between the 2008 recession and 2019. Today, many public health workers are hired on a temporary or part-time basis. Some are paid so poorly they qualify for public aid. Those factors reduce departments’ ability to retain people with expertise.

Compounding those losses, the pandemic has prompted an exodus of public health officials because of harassment, political pressure and exhaustion. A yearlong analysis by the AP and KHN found at least 248 leaders of state and local health departments resigned, retired or were fired between April 1, 2020, and March 31, 2021. Nearly 1 in 6 Americans lost a local public health leader during the pandemic. Experts say it is the largest exodus of public health leaders in American history.

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Brian Castrucci, CEO of the de Beaumont Foundation, which advocates for public health, calls Congress’ giant influx of cash in response to the crisis “wallpaper and drapes” because it doesn’t restore public health’s crumbling foundation.

“I worry at the end of this we’re going to hire up a bunch of contact tracers — and then lay them off soon thereafter,” Castrucci said. “We are continuing to kind of go from disaster to disaster without ever talking about the actual infrastructure.”

Castrucci and others say dependable money is needed for high-skill professionals, such as epidemiologists — data-driven disease detectives — and for technology upgrades that would help track outbreaks and get information to the public.

In Ohio, the computer system used to report cases to the state predates the invention of the iPhone. State officials had said for years they wanted to upgrade it, but they lacked the money and political will. Many departments across the country have relied on fax machines to report covid cases.

During the pandemic, Ohio’s state auditor found that nearly 96% of local health departments it surveyed had problems with the state’s disease reporting system. Roberts said workers interviewing patients had to navigate several pages of questions, a major burden when handling 500 cases daily.

The system was so outdated that some information could be entered only in a non-searchable comment box, and officials struggled to pull data from the system to report to the public — such as how many people who tested positive had attended a Black Lives Matter rally, which last summer was a key question for people trying to understand whether protests contributed to the virus’s spread.

Ohio is working on a new system, but Roberts worries that, without a dependable budget, the state won’t be able to keep that one up to date either. 

“You’re going to need to upgrade that,” Roberts said. “And you're going to need dollars to support that.”

In Washington, the public health director for Seattle and King County, Patty Hayes, said she is asked all the time why there isn’t a single, central place to register for a vaccine appointment. The answer comes down to money: Years of underfunding left departments across the state with antiquated computer systems that were not up to the task when covid hit.

Hayes recalls a time when her department would conduct mass vaccination drills, but that system was dismantled when the money dried up after the specter of 9/11 faded.

Roughly six years ago, an analysis found that her department was about $25 million short of what it needed annually for core public health work. Hayes said the past year has shown that’s an underestimate. For example, climate change is prompting more public health concerns, such as the effect on residents when wildfire smoke engulfed much of the Pacific Northwest in September.

Public health officials in some areas may struggle to make the case for more stable funding because a large swath of the public has questioned — and often been openly hostile toward — the mask mandates and business restrictions that public health officials have imposed through the pandemic.

In Missouri, some county commissioners who were frustrated at public health restrictions withheld money from the departments.

In Knox County, Tennessee, Mayor Glenn Jacobs narrated a video posted in the fall that showed a photo of health officials after referencing “sinister forces.” Later, someone spray-painted “DEATH” on the department office building. The Board of Health was stripped of its powers in March and given an advisory role. A spokesperson for the mayor’s office declined to comment on the video.

“This is going to change the position of public health and what we can and cannot do across the country,” said Dr. Martha Buchanan, the head of the health department. “I know it’s going to change it here.”

A KHN and AP investigation in December found at least 24 states were crafting legislation that would limit or remove public health powers.

Back in Seattle, locally based companies have pitched in money and staff members for vaccine sites. Microsoft is hosting one location, while Starbucks offered customer service expertise to help design the sites. Hayes is grateful, but she wonders why a critical government function didn’t have the resources it needed during a pandemic.

If public health had been getting dependable funding, her staff could have been working more effectively with the data and preparing for emerging threats in the state where the first U.S. covid case was confirmed.

“They'll look back at this response to the pandemic in this country as a great example of a failure of a country to prioritize the health of its citizens, because it didn't commit to public health,” she said. “That will be part of the story.”

KHN senior correspondent Anna Maria Barry-Jester and Montana correspondent Katheryn Houghton contributed to this report.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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This story can be republished for free (details).

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Snag a Vaccine Appointment, Then Face the Next Hurdle: How to Get There?

The airport says a lot about Cortez, Colorado: The single-engine planes that fly into its one-room airport seat nine passengers at most. The city of about 9,000 is known largely as a gateway to beautiful places like Mesa Verde National Park and the Four Corners Monument. But covid vaccines have made Cortez a destination in its own right.

This story also ran on GateHouse Media. It can be republished for free.

“We had a couple fly in to get their vaccine from Denver that couldn’t get it in the Denver metro area,” said Marc Meyer, director of pharmacy services and infection control for Southwest Health System, which includes clinics and a community hospital in Cortez. Others have come from neighboring states and as far away as California, Florida and the Carolinas. “They all come back for their second dose,” he said. “Because it’s so hard to get in the cities.”

With vaccines now becoming available to the general public in much of the country, the privilege of easy access is coming into sharper focus. On the most extreme end, vaccine tourists with means can nab inoculations, as Forbes has reported, in places such as Israel, the United Arab Emirates and even Cuba, where ads offered “mojitos and vaccine.” On the flip side, some people have found it hard to get to a vaccine appointment a few miles away.

In fact, around the same time people were flying into Cortez to get their shots, Meyer said, some locals couldn’t get to vaccine locations. That was particularly true for people who are homebound or homeless.

So Meyer and his colleagues came up with a vaccine SWAT team of sorts, composed of paramedics and a handful of ambulances stocked with vaccine vials. The team visited about 40 homebound people. For 30 or so people who are homeless in the area, Meyer snagged leftover doses of the single-dose Johnson & Johnson vaccine from a nearby county.

But he said he doesn’t know if his team got to everyone who wanted vaccines. “The problem with health disparities in rural areas is there’s no data,” he said. “It would be really helpful to know how many people have transportation issues.”

A KHN analysis of Colorado health department data shows that by the end of March about 43% of Coloradans who had received their first doses, and had addresses on file, got those shots outside of their home county. At least 60,000 Coloradans — about as many people as live in Grand Junction, the biggest city in western Colorado — got their first vaccine dose 50 or more miles away, as the crow flies, from their home ZIP codes.

And the state vaccinated more than 20,000 people from out of state — tourists, traveling nurses, cross-border dwellers and others whose primary residence is elsewhere — about 1% of the total number of people who had received first doses by April 1 in Colorado.

Other states have noticed similar migrations. Missouri, for example, saw an exodus of urbanites to rural areas in search of vaccines, leading critics to say doses had been misallocated in a way that neglected cities such as St. Louis.

But traveling for a vaccine requires money, flexibility with one’s time and a vehicle. Transportation was a health issue even before the pandemic, said Lori Tremmel Freeman, CEO of the National Association of County and City Health Officials. Researchers writing in the American Journal of Public Health found that, in 2017 alone, 5.8 million people in the U.S. delayed medical care because they lacked transportation. This group was disproportionately poor and had chronic health conditions.

Access issues, Freeman said, are likely being mischaracterized as vaccine hesitancy. Even some who live in cities with robust public transportation and ride-hailing services have found themselves jumping through hoops to get to a vaccine appointment.

Bob McIntyre, 81, lives in Denver in an apartment close enough to a major highway that the traffic “sounds like ocean waves in the distance.” But he doesn’t have a car. “It’s just too expensive,” he said. Before the pandemic hit, McIntyre could walk or take public transit. With the coronavirus circulating, though, he’d rather not be closed in a box with a bunch of strangers. “So, I’ve been hermitized.”

Ride-hailing companies Uber and Lyft have offered free rides to vaccine appointments, but McIntyre doesn’t feel safe using those services. He eventually learned of A Little Help, a nonprofit that offers everything from free yardwork to rides for covid vaccine appointments. Volunteer drivers took him to both of his vaccine slots, which were about 15 minutes from his home but otherwise would have remained out of reach.

Maggie Lea, director of programs at Mile High Connects, worries others may not be as lucky. Her organization believes more affordable and accessible transportation is key to achieving a racially and economically equitable Denver — especially right now.

“There are people who may or may not be motivated already to get the vaccine,” she said. “If they don’t have access to transport, or it’s particularly expensive for them to get over there, or burdensome for them to get to a vaccine site, we’re noticing that they just won’t go.”

Transit systems can use federal covid relief funding to help people get their vaccines, said Amy Conrick, director of the National Center for Mobility Management.

In West Texas, the SPARTAN public transit agency offers free rides to covid vaccine appointments, including many at its headquarters.

In Oxford, Ohio, older adults can get vaccinated by nurses aboard buses that accommodate oxygen tanks and wheelchairs. The city set up a hotline for residents to schedule their vaccine and transportation in one call.

“We live in a rural community where some people just don’t have internet,” said Assistant City Manager Jessica Greene.

Transit systems need to talk to public health officials, Conrick said. “Now is the time,” she said. “Well, actually, yesterday was the time.”

But many places lack decent public transit. For them, Freeman of NACCHO imagines covid shots waiting anywhere people congregate, even at NASCAR races, once the supply increases. “You should be able to just turn in any direction and be able to get a vaccine,” she said.

For now, demand is so high that vaccines go into arms as soon as they are available, Freeman said, but soon public health officials will have plenty of vaccine but a shrinking group of people who want to bother getting it. “We will hit a hard stop where we’re looking full face onto the universe of people that do not want to get the vaccine.”

Then, she said, it will be even more important for vaccination to not only be possible, but for it to be easy.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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