How inefficient is local government in Massachusetts? Every municipality in the Commonwealth, no matter how small, has its very own public health board, charged with responsibilities varying from testing well water to responding to hoarding incidents — oh, and also managing global pandemics.
COVID-19 exposed just how uneven those local authorities are. Boston and Cambridge operate whole city departments staffed with experts capable of handling a wide variety of tasks, from operating homeless shelters to responding to outbreaks of mosquito-borne diseases to organizing vaccination drives in a worldwide pandemic. But in some of the Commonwealth’s smaller or poorer municipalities . . . well, the picture looks bleaker, with short-staffed and unprepared departments that struggle to keep up with the ever-growing list of responsibilities. As the Legislature debates how to spend federal relief money, upgrading local public health boards and ensuring that all residents receive comparable services ought to be a high priority.
Most states organize public health at the county or regional level; the 351 health jurisdictions in Massachusetts are “far more than any other state,” according to a 2019 report by a state special commission. The report found that of the 105 towns in Massachusetts with populations fewer than 5,000, 78 percent of them lack even a single full-time public health staffer. Because boards are funded with local property taxes, they also reflect existing regional economic disparities, with poorer cities generally spending less on public health.
“In Massachusetts, where you live determines how safe and healthy you are likely to be,” the commission reported.
Even before the pandemic, the state was well aware of how inefficient and unfair its locally based public system had become. The long-term solution is to regionalize services, so that small towns can share personnel instead of counting on overworked staffers to be jacks-of-all-trades. (Who really has the expertise both to respond to rat infestations and inspect tattoo parlors?) The pandemic drove home the point: Local boards were overwhelmed, and many of them were unable to conduct contact tracing of people infected with the coronavirus, leading the Baker administration to spend $130 million on a statewide contact tracing collaborative instead.
Public health advocates have asked the Legislature for about $50 million a year from the relief money for training and building data collection systems. Crucially, they also want the Legislature to set credentialing standards for public health workers and provide incentives for the regionalization of services. Although the Legislature might be skeptical of using the COVID spending bill as a vehicle for policy changes, in this case the two go hand-in-hand: Passing the reforms helps ensure the money will be well spent.
A pandemic like COVID-19 might never happen again. But the cracks that the pandemic exposed in our public health infrastructure will continue to lead to unequal health outcomes unless the state addresses them. Providing public health services on a more equitable basis would mean that more residents get the kind of services that people in Boston take for granted: more lead-paint inspections, more addiction services, more education efforts about smoking and other health risks. And if there is another pandemic, some far-sighted changes now will ensure that the whole state will be better equipped to respond — and might even set an example of how the Massachusetts tradition of local control over everything from police to 911 can yield to more sensible regional solutions.
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