Many of Massachusetts’ 351 local public health departments — a critical component of the state’s response to the growing coronavirus outbreak — are ill-equipped and unprepared to handle major medical disasters, according to a report issued last summer by state and local public health experts.
About one in four municipal health departments in Massachusetts fell short in tests that gauged their ability to quickly respond to health alerts and advisories. Meanwhile, more than two-thirds of the agencies didn’t have plans in place for the disbursement of medication and vaccines during a public health emergency.
Overall, Massachusetts’ local public health system is more fragmented than any other in the country and has failed to keep pace with national standards, according to the report, which painted a bleak portrait of the 351 municipal agencies across the state. And that’s before the rise of the coronavirus, a growing global pandemic that is now testing the limits of this resource-strapped system.
“There’s obviously a workforce shortage and there’s a serious workforce shortage of trained personnel,” said Charlie J. Kaniecki, a member of the commission that completed the study. "This is an evolution over time of governments cutting back and cutting back to try to save money.
Kaniecki, who worked nearly two decades for the state health department as a liaison to local public health agencies, told the Globe he is concerned about how effective local departments will be in responding to this outbreak.
Governor Charlie Baker’s office did not respond to requests for comment last week.
Ann Scales, spokeswoman for the state’s public health department, said the agency regularly supports local health agencies and that the assistance is “significantly ramped up during response to a public health emergency.” The state, for example, provides a 24-hour conference line that allows local health officials to consult with state epidemiologists and clinical staff.
Local boards of public health are the front line of defense when outbreaks erupt. They investigate and report suspected cases to state officials; monitor individuals in quarantine; and communicate prevention efforts to hospitals, schools, and residents. They also help administer treatments and vaccines should they become available.
But across the country, these local agencies have faced dramatic cuts and increased challenges over the last decade. The National Association of County and City Health Officials said more than 56,000 local health department jobs — nearly one-quarter of the workforce — were lost between 2008 and 2017. Meanwhile, federal grants for emergency preparedness have dried up, according to John Auerbach, president and CEO of Trust for America’s Health, a public health policy, research, and advocacy nonprofit.
“It’s harder for local health to function when the resources available to it have been reduced,” said Auerbach, who previously led both Massachusetts’ and Boston’s public health agencies.
The Massachusetts study, released last June, found that municipal health agencies here often operate with “bare bones” budgets, leaving many understaffed and unable to comply with a “patchwork” of laws and regulations. In addition, the commission expressed concern that some health department staffers are vastly unqualified.
There are no state-level guidelines for education, training, or the credentialing needed to work for a local health department, except in the case of public health nurses. And this leads to confusion, delays, and more.
“In some cases, boards of health so poorly understand their role that they simply do not know what they need to know,” the report said.
The commission found that about 25 communities weren’t using an online state system to submit reports, investigate, and communicate about infectious disease cases and outbreaks — including the novel coronavirus. The state launched the system in 2006 and began requiring its use in 2011. “Although these numbers are small, they put all residents at risk, as infectious disease does not respect municipal boundaries,” the report said. State officials said this week that communities not using the system are submitting reports by telephone and fax.
But boundaries do matter when it comes to health services. Experts found “glaring differences” in the quality of Massachusetts’ local agencies. In general, urban municipalities fared better than rural ones, wealthy towns better than poorer ones.
But right now, even the most well-staffed local health departments are struggling with the demands of the coronavirus outbreak, said Carlene Pavlos, executive director of the Massachusetts Public Health Association.
Amid growing coronavirus concerns, state lawmakers have pitched a stop-gap solution. Lawmakers approved on Thursday $15 million for coronavirus response. Specifics on how the money will be spent haven’t been provided, but Baker indicated that some of it could flow to local health agencies.
Lawmakers last year approved $500,000 for local health agencies to collaborate and share resources, and pending legislation would seek to add more funding and adopt recommendations from the commission’s report.
The Legislature initially commissioned the study of local health departments in 2016 at the urging of advocates concerned about the agencies’ funding and structure. The 25-member commission, chaired by Department of Public Health Commissioner Dr. Monica Bharel, featured a slew of Baker-appointed health specialists, along with local officials and state lawmakers.
Their analysis took a broad view of health department functions, which include tracking infectious diseases, conducting food safety inspections at restaurants, and detecting lead during home inspections. Agencies also monitor drinking water, oversee sewage and waste disposal, plan for disasters, and more.
The commission determined that the woes of local health departments have been well known, chronicled in state reports and studies for 25 years. Despite some new initiatives, the “system has not improved," the report noted.
The study laid most of the blame on inadequate funding.
Half of Massachusetts’ local health agencies have budgets of $100,000 or less, the report noted. For nearly a third, it’s $50,000 or less.
The problems are amplified by the outdated, unorthodox set-up of the state’s public health network. The state has 351 local public health jurisdictions — one for each city and town and far more than any other state. The set-up is less efficient than county or regional systems that are more common across the country, according to the report. And unlike most other states, Massachusetts’ agencies rely almost exclusively on local property taxes and fees for funding.
Among 105 of Massachusetts’ smallest towns, about 80 percent don’t have a full-time public health staff member, according to the report. Ninety percent don’t have a public health nurse. The statistics have remained virtually the same since 2009.
“There’s not a lot of extra capacity when we have an emergency,” said Sharon Cameron, director of Peabody’s health department. “Even monitoring the [federal and state] guidance is in and of itself a full-time job because that’s constantly changing.”
Cameron’s agency, the North Shore’s second largest, has just one full-time public health nurse, a handful of other staffers, and a dozen school nurses attending to the city of 50,000-plus residents.
In recent days, she met city and school officials concerned about the coronavirus and briefed leaders of a senior center about best practices. On Thursday, it was all-hands-on-deck as her department fielded frantic calls and dealt with citizen concerns.
As the day wound down, she had to prepare for another presentation before the City Council — this one was about mental health.