Public Health Infrastructure in Crisis: HHS Workforce Cuts, Reorganizations, and Funding Reductions: Impacts and Solutions

Interview with Dr. Katherine Wells

TFAH: How critical is federal funding to what your department needs to accomplish?

Dr. Wells: It’s a large percentage of our budget, about 50 percent of my department budget comes from federal pass-through dollars—25 percent from CDC to the state that then passes
through to us and another 25 percent from SAMSHA passed through to us. So, it’s the direct funding, but it’s also that these federal grants help us set direction locally. That is, the funding helps make the case for leveraging local resources either through matching dollars or inkind support like IT or facility space. By braiding federal and local funding streams, we can build more  sustainable, long-lasting public health programs that meet our community’s needs. I’ve also had to use my department’s reserve funding to respond to the measles outbreak, which left little money to deal with loss of other program funding due to the federal COVID-19 grants clawback and delays in grant funding, including for HIV prevention and emergency preparedness.

TFAH: Beyond funding, in what ways does your department rely on CDC for technical assistance and data? Are you concerned about being able to rely on that assistance going forward?

Dr. Wells: We’ve definitely felt a loss early in the measles outbreak. One thing that I think most people don’t understand is how often a local health department reaches out to CDC for help with various issues. For instance, responding to a rare event that can happen in public health, like an outbreak of a drug-resistant organism. Being able to go to CDC and talk to an expert who has dealt with that organism before is something that CDC can provide that no state can duplicate.

We also rely on the CDC for disease tracking systems that enable local health departments to detect, monitor, and respond to outbreaks in real-time. Without CDC at the helm, we will not have coordination across states and internationally.

TFAH: Our report summarizes the many funding cuts, clawbacks, and reductions-in-force made to the public health system this year. Has your department had to make cuts?

Dr. Wells: The first thing that affected us was the COVID-19 clawbacks. They required me to lay off two staffers and eliminate three unfilled positions. Beyond that, I moved people around to avoid having to layoff anyone else. What was really difficult was the quickness of all of this. If I had been given some runway to plan, if I had been told that a grant was ending in six months, I would have had time to figure out strategies to keep the work going or the opportunity to ramp down programs instead of an abrupt stop.

TFAH: Are you concerned that your department now has less capacity to do what is needed to protect public health in Lubbock?

Dr. Wells: Based on the first round of cuts, I still feel like we could respond to an emergency. I’m very concerned about any additional cuts. Any further cuts would impact the department’s ability to provide the services that the community is used to seeing. The problem is that cuts to public health take a while to show themselves—to get to a point where the community understands what’s gone. If we become a smaller department, and that happens at the state and local level too, there will be nobody to fill in. And then you’ll start seeing things that we are now able to keep under
control—like STD rates—start creeping up. I’m going to be having a very tough conversation with our Board of Health about what our public health priorities are in this new environment—what do
we keep, what do we let go? What’s more important, congenital syphilis or measles? These are tough conversations. How are we going to keep programs that I think are really benefiting the community, how are we going to keep those funded?

TFAH: Let’s talk about the measles outbreak Texas experienced earlier this year. I know your team played a key role in responding. 

Dr. Wells: We just declared last week that Lubbock is measles free–meaning the county has gone 42 days without an infection. But some counties are still seeing infections so there’s still measles circulating. We are seeing a lot less pressure on  our medical system__ERs and urgent care centers__but we need people to understand that the threat of measles is still very real. Our summer and back-to-school messaging encourages people to not let measles infection rates creep back up. We need people to understand that it’s still important to get their children vaccinated.

TFAH: The measles outbreak happened in the midst of budget cuts. How did you manage?

Dr. Wells: One thing that was really hard was that no emergency funding came in to support local health departments. Vaccines came into the community, access to testing came in, but no funding for additional resources we needed on the ground or for staff overtime. There was a lot of added stress on the department staff, but the resilience of the public health workforce is amazing; they inspire me. Many of us worked 12-hour days, seven days a week. My team was reading about cuts to CDC in the newspaper, but they keep showing up to do what’s right for their local community.

TFAH: What’s at stake? What are you worried about in terms of public health in Lubbock two, three, five years from now because of these budget cuts?

Dr. Wells: The cuts are going to impact our most vulnerable individuals, people who are helped by the health department, free clinics, and community-based organizations. That safety net isn’t very strong, grant stoppages even for a couple of weeks can destroy some of those systems. You also need an infrastructure to be able to compete for grants, to figure out what funding is available and who in your community can take on the work. If you lose that infrastructure it will take years and years for your community to be able to rebuild those systems.

TFAH: Beyond funding, what has been lost—or do you anticipate losing—in terms of federal public health expertise, experience, data, and on-the-ground help during emergencies?

Dr. Wells: The unknown is the scariest part, and it’s going to take the next emergency to figure out exactly what’s missing. It’s not just about resource losses at the health department, it’s about the impact to a bunch of entities we need to collaborate with—the emergency managers, for example. What’s the impact on hospitals, and what happens at the state level? The state provides a lot of in-kind support to us, access to the state laboratory, access to their experts. CDC has always been there when I had a question and has been able to answer my question. Until I have some need, I don’t think I’ll be able to figure out what’s missing at CDC. And then there’s impact on housing and transportation—these are public health interventions. Their going away will affect the health of the community. So, I see it as being about what happens within the walls of my department and what happens at all of those other agencies that impact the health of a community. I need a bus system to bring someone to my clinic.

TFAH: Any concluding thoughts?

Dr. Wells: I don’t want to say the public health system we have now is perfect. There are definitely places for improvement, and we should have conversations about how to make things better. But we also need to be careful about throwing the baby out with the bath water. I’d love to see a focused conversation about how we can have a better public health health system in the United States. That would be a great conversation to have, but it needs to be done strategically.