It was personally surprising to Joneigh Khaldun to see how “surprised” America seemed to be as the COVID-19 public health emergency exploded across American cities, devastating racial and ethnic minority communities.

Khaldun, MD, MPH, the former Health Commissioner of Detroit who served as the Chief Medical Executive and Chief Deputy for Health of the Michigan Department of Health & Human Services during the first two years of the pandemic, pointed out that in 2019 America’s public health infrastructure was already a disaster waiting to get worse when COVID arrived. That, on top of the racial and ethnic disparities that already existed due to the political and discriminatory history of the country, contributed to COVID-19 disparities.

“Public health is woefully underinvested across the country,” Khaldun told the audience of the 29_^th annual Leonard Davis Institute of Health Economics’ Charles C. Leighton MD Memorial Lecture in the University of Pennsylvania’s Huntsman Hall. She said less than 5% of all the money spent on health and health care in the U.S. in 2020 was spent “on actual public health and that was actually double what it was in 2019.”

Epidemiologist Struggles

“In 2019 we were already slashing budgets. It was not uncommon for a state to not have an epidemiologist or the epidemiologist was also the director of the department trying to lead a team and look at the numbers–but not doing that very well,” said the Penn alumna who also currently practices emergency medicine at Henry Ford Hospital in Detroit.

“Communicable diseases like the flu, hepatitis A, and other often infectious diseases are reportable. You’re supposed to send that data to the local and state health department. But was that transmission of information happening? Most doctors had no idea where their health department was. Before COVID, many health departments received that information on fax machines. And don’t send something on the weekend, and you better hope your epidemiology team is not off on Monday because somebody’s got to look at the fax machine and then do the count,” said Khaldun.

“There was not–and often time still is not–a coordinated data infrastructure system where physicians at a hospital who see a patient with a certain illness like COVID can quickly and effectively report it. They perform a workup and take a history, but that does not automatically get sent to the epidemiology team at the health department,” said Khaldun.

Defined by Underinvestment

“There is a lack of connection between the government bread and butter public health system and hospitals, doctors and health care. That’s why we ended up having the pandemic disparities we see,” Khaldun continued. “We’ve got health disparities conditions like obesity and diabetes, disparities in housing and poverty. Then we have a crisis like COVID-19, where there are not enough resources in a public health system defined by its underinvestment. Why would we think that somehow, we were going to run an effective response? A system of inequity created the predictable disparities that have been a central element of the pandemic,” she said.

“The fact that the pandemic was made so political around simple things like helping each other by wearing a mask and trying not to get someone else sick–someone who, because of underlying conditions, may be more likely to get sicker and potentially lose their life from the disease. At the same time, respect for public health officials really went out the door–I don’t think anyone who went into public health realized that they would need an armed guard or have their life threatened or need security cameras on their house. Unfortunately, these things also contributed to how the pandemic unfolded.”

Implicit Bias Training

“I’m proud that in Michigan, we created a task force,” said Khaldun. “We implemented free mask policies. We increased how we collected data–public-private relationships are important and there are a lot of data scientists in the private sector. We partnered with them. We also partnered to provide testing and eventually vaccines in neighborhoods. And the state of Michigan now has a mandatory implicit bias training policy for anyone applying for a medical license. You have to take the training in order to practice.”

“It’s not just a moral imperative to address these disparities,” continued Khaldun. “More than 50% of the U.S. population will be people of color by 2050. Health disparities actually cost money. People who have diabetes, high blood pressure, and congestive heart failure are coming into the hospital and they must be admitted. That actually is costly. The U.S. health care system still doesn’t understand how prevention tends to be cheaper.”

“Similar to the general population, a large part of the health care workforce will consist of people of color, so, you’re talking about a sicker workforce if we continue the status quo when it comes to disparities,” said Khaldun. “So, addressing this issue is not just a nice thing to do. I would argue it’s an imperative for the financial success of the country as well.”

“Looking ahead,” said Khaldun, “investing in public health infrastructure, meaningfully engaging with communities to build trusted relationships before a crisis hits, having better connected systems, and intentionally collaborating with any entity that can help is really important. If we did some very intentional things like this, we likely wouldn’t have such terrible outcomes in the next national public health emergency.”

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