Before coronavirus, California let 1 in 4 of its public health labs close

Gov. Gavin Newsom has called for “targeted testing” of the new coronavirus, arguing a strategic approach will help public health officials find hot spots and determine how and where the pandemic is spreading.

But in the two decades leading up to the COVID-19 outbreak, 11 of California’s public health labs designed for the focused testing Newsom wants closed their doors.

California now relies on 29 county and city public health labs, along with the California State Laboratory in Richmond, to serve 40 million people.

It’s around “the same number we had in 1950,” said Kat DeBurgh, executive director of the Health Officers Association of California, “when the population was a little more than 10 million.”

Public health laboratories don’t have the resources to run thousands of tests a day like the privately run labs recently brought on line for coronavirus testing, but they have expertise for close surveillance and testing of potential disease outbreaks.

That kind of information could have provided the Newsom administration with a fuller picture of where coronavirus clusters would emerge, said Rick Greenwood, an epidemiology and environmental health sciences adjunct professor at UCLA.

“Doing 10,000 tests at some place with people who drive through who may not even be sick doesn’t help as much as doing 20 samples when people are out in the field looking at clusters, interviewing people,” Greenwood said. “It’s the same test, but different in the sense of where the data goes.”

Public health funding, however, has largely stalled since the Great Recession, and many local jurisdictions don’t have the dollars needed to maintain laboratory equipment and highly trained staff.

They’ve shuttered their labs, partnered with their neighboring counties and have learned, until COVID-19, to mitigate disasters through a more regional approach to testing.

Napa County first decided to close its public health lab in 1999. Berkeley followed in 2003. Mendocino, Yolo and Marin Counties all closed by 2013.

In the last five years, the city Pasadena, along with Sutter, El Dorado, Placer, Stanislaus and Santa Cruz Counties all closed their public health labs.

Funding shortfalls

Public health labs receive money from the federal and state government, and both have cut or stalled funding for local public health departments.

California allocated in its 2019-2020 budget the same amount — $3.4 billion — for public health that it had in its 2009-2010 spending plan.

President Donald Trump’s 2021 budget request, released in February, would cut the federal Department of Health and Human Services’ budget by 10 percent and shave the Centers for Disease Control and Prevention’s funding by 16 percent.

Public health departments throughout the state have had to stretch their already tightened budgets to pay for a lab and expert personnel, including qualified directors whose experience commands a competitive salary, Greenwood said.

Public health directors need a doctoral degree, experience as a supervisor and certification as a California public health microbiologist, Greenwood explained.

It’s challenging enough to build a pipeline of public health personnel, Greenwood continued, but labs have had to cut back training programs because they can’t afford to hire specialists.

“Counties need public health lab directors to run a public health lab, and there is a shortage of those,” said Jason Hoppin, spokesman for Santa Cruz County. “It took us nine years to hire our former public health lab director, who subsequently left and whose departure led to the closure.”

Pooling resources

Counties that decided to close their public health labs have instead used a regional approach for their testing needs.

Pasadena joined the Los Angeles County Health Department. Napa County now belongs to a lab that also serves Solano, Yolo and Marin Counties. Sutter and Placer Counties partner with the Sacramento Public Health Lab, Santa Cruz contracts with Santa Clara County and Stanislaus pooled its resources with San Joaquin’s county lab.

Advocates for consolidated labs say they save money and provide better services.

“Regionalization of our public health lab services has benefited Yolo County by allowing us to pool resources with these other counties to support a more robust, comprehensive, and economically efficient lab operation that is greater than any one county could support on their own,” said Yolo County spokeswoman Carolyn Jhajj.

Placer County closed after considering how its “higher ratio of staff to tests” compared to neighboring counties. The county announced in late 2017 that while its testing services averaged about $250, each only generated about $45 in revenue, a “significant financial demand on county resources.”

While combining assets is a fiscally responsible decision for some counties, the reduction has curtailed testing capacity “just when we need to increase it,” said Bruce Pomer, former executive director of the Health Officers Association of California.

The county that takes on its neighbors’ workload has to provide the resources and personnel, and make sure it’s not overburdening an already spread-thin staff and budget.

“You’ve got to look at this like police and safety, fire and roads,” Pomer said. “It’s like the military. You need to be prepared.”

The regional approach doesn’t always consider each jurisdiction’s specialized needs, Pomer continued. For example, while Kern County’s public health lab uniquely monitors Valley Fever cases, San Francisco, San Diego and Los Angeles pour energy into HIV surveillance.

When the coronavirus outbreak hit, Sacramento County, which serves Sutter and Placer Counties, could initially process only about 20 tests per day. The constraint forced the county’s public health officials to forego tracing anyone who might have been exposed to the virus for quarantine. They instead pivoted to slowing the spread through more vulnerable populations.

The county could test up to 50 people per day by last week, health director Dr. Peter Beilenson said, with help from Kaiser Permanente, Sutter Health and private companies like Labcorps and Quest Diagnostics. A drive-up testing program through Verily is now available by appointment at Sacramento’s Cal Expo.

More tests needed

California is relying heavily on private and academic labs to provide testing for the coronavirus that’s infected 4,643 residents and killed 101 as of Saturday.

California has conducted nearly 90,000 tests, according to the California Department of Public Health, administered by 22 state and county health labs, private companies and the University of California and Stanford.

But California is struggling to obtain equipment like swabs and reagents necessary to run a coronavirus test, Newsom has repeatedly said during press conferences in recent days.

The governor has instead called for strategic, “targeted testing” and “community surveillance” so the state can collect more data on who is infected with the virus and how it’s spreading.

“We want to see more tests in the state of California, smarter and more targeted testing, and more community surveillance,” Newsom said.

The coronavirus is an unprecedented pandemic, experts say, so it’s unclear how the closed labs would have affected testing capacity.

“We are getting through this,” said DeBurgh, the current Health Officers Association director. “And you can’t say for sure that 11 more public health labs would have averted disaster. But it’s pretty obvious that more labs and more trained lab personnel would be useful.”

A learning lesson?

Most experts agree that relying only on public health labs during this pandemic isn’t a viable option, but they also say this outbreak underscores California’s — and the United States’ — need to re-prioritize public health.

“Right now we’re looking through the lens of coronavirus. We do need high-volume testing,” said state Sen. Richard Pan, a Sacramento Democrat and pediatrician. “But we do need to look at lab capacity and the way we finance county health departments.”

Pan said California needs a more “strategic plan” if public health labs are to regionalize their resources. As chair of the Senate Budget Subcommittee on Health and Human Services, Pan said the state has to take another look at its funding formula so when the COVID-19 crisis dissipates, California is still financially prepared for the inevitable next outbreak.

“There’s always something coming through,” Pan said. “You have to look at this all as one system.”

President Donald Trump signed on Friday a $2.2 trillion stimulus package that provides some financial relief to American workers, small businesses and companies as the country faces recession.

In the legislation, the Centers for Disease Control and Prevention will receive $4.3 billion to help state and local public health responders, among many things, enhance surveillance, diagnostics and lab support.

Pan said the amount of money needed to support labs is a tiny fraction of what will be spent to slow the spread of coronavirus and soften the damage it’s causing to the economy.

“Just a little bit of that, a tiny fraction of that, .01 percent of that,” Pan said, “could have been really useful.”