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As COVID infrastructure winds down, N.H. public health leaders worry about missed opportunity for investment

A woman in a black coat stands in front a grey shed that was offering testing.
Alli Fam
20-year old Selena Dinh was one of the last Granite Staters to get a COVID-19 test at the state's Manchester location last month, which was run in partnership with ClearChoice MD Urgent Care.

Over the past month, New Hampshire’s state-managed COVID vaccination sites, testing centers, and some mobile vaccine teams have been decommissioned. The wind down of this COVID infrastructure is part of a long-standing plan to shift the pandemic response away from state government and into the private sector healthcare system of pharmacies, community health centers and hospitals.

But public health experts say the nature of the pandemic, which comes in waves of hard to predict magnitude, makes it difficult to determine how prepared New Hampshire is for future surges, especially with legislative efforts in the State House to curtail some key public health tools.

And as public health leaders look ahead, they worry New Hampshire is missing a critical opportunity to build on the infrastructure developed over the course of the pandemic, to prepare for future public health crises.

“Our question shouldn't be: How do we get through the next three months or six months or a year?” said Anne Sosin, a policy fellow at the Nelson Rockefeller Center for Public Policy at Dartmouth College, “But rather: How do we make the investments to have a public health infrastructure for the future?"

From testing to treatment, where N.H. stands on key COVID-19 infrastructure 

Vaccination and Testing 

State managed testing and vaccination sites closed last month amidst a significant drop in demand. On average, each of the 11 state-managed vaccination sites was administering around three shots per day in March. Each of the seven testing sites averaged around 10 tests per day. Turnout was so low that staff operating some of the sites agreed it was time to close them.

For Coos County Family Health Services, which covers around 12,000 patients in the region, the closure of a nearby state-managed vaccination site in Berlin made sense. Valerie Hart, the chief operating officer and a nurse with the health center, said so far, staff have had no problem shifting their vaccination and testing services to meet swings in local demand this month. The health center has been holding more vaccine clinics, with many North Country residents newly eligible for a second booster.

But there is some concern that the pullback of state-managed COVID services could place a significant burden on some health providers, who are already short staffed, especially in the event of another large surge. That’s exactly what happened in the late fall and winter, when the state was simultaneously experiencing its worst COVID-19 surge along with high demand for boosters and the vaccine for young children.

Sosin, of Dartmouth, said basing the need for public COVID services on demand isn’t the right approach, especially as significant gaps in vaccination remain. A lull in COVID cases, such as the state is experiencing right now, she said, is the best time to focus on closing those gaps with targeted efforts.

“If we don't close the gaps in vaccination in the state, we're going to see surge after surge that impacts our rural health systems disproportionately,” Sosin said.

Sosin said rural regions have both lower rates of vaccination than the rest of the state, and also have less capacity to handle surges. New Hampshire’s winter surge, she said, was an example of the particular strain on rural hospitals, who struggled to transfer patients in need of specialized care they normally would send to larger institutions.

But New Hampshire’s public health workers, who have had to put other critical priorities on the backburner for over two years now, don’t necessarily have the bandwidth to ramp up their efforts to target the unvaccinated.

It’s a point Sosin said illustrates a larger issue: a lack of sustained funding for public health. More resources, she said, could allow for the increase of targeted vaccination outreach and support other health initiatives. While hundreds of millions of dollars in emergency federal pandemic aid have poured into the state in the past two years, it's not a long term investment.

Meanwhile, at the federal level, funding for testing, treatment and vaccines for the uninsured has run out. The bipartisan bill in Congress to provide more COVID funding does not include more money to reimburse providers who treat people without insurance.

In New Hampshire, COVID care like testing remains available for free for the uninsured, but it may be more difficult to access. The onus for a free test or treatment can fall on individuals to sign up for New Hampshire’sMedicaid COVID-19 benefit.

The benefit also covers urgent care visits and emergency room visits due to the virus, and the coverage can be applied retroactively, for 90 days before the application is submitted.

Some New Hampshire providers are not charging uninsured Granite Staters for services like testing, but others are. Chain pharmacies like CVS and Rite Aid continue to offer free tests and vaccines.

COVID-19 Treatments 

As infrastructure for vaccination and testing winds down, access to COVID-19 treatments is growing across New Hampshire. Treatments are now available at nearly 300 locations in the state, including pharmacies, health centers and hospitals.

New Hampshire continues to receive more doses of highly effective treatments, like the Paxlovid pill, which can help keep COVID positive patients out of the hospital.

But accessing the medication isn’t always simple. The antiviral is most effective early in illness, and patients need a prescription for it. New Hampshire has onlysix CVS locations with the capability to test and prescribe onsite. Some health centers that work with low income patients like Coos County Family Health also have this ability.

For patients without a primary care provider or for those who may not know about the treatment, accessing it can be difficult, said Ed Laverty, the chief medical officer at Upper Valley Connecticut Hospital in Colebrook.

Demand for the treatment at the hospital is so low right now that the hospital has widened its eligibility categories, Laverty said.

Public Support for Public Health

From masking to vaccines, public health tools are more effective the more widely they are implemented. Consequently, part of New Hampshire’s COVID-19 infrastructure is tied to Granite Staters' willingness and ability to follow public health guidance.

But New Hampshire residents have become increasingly less trusting of health agencies like the CDC as the pandemic has worn on, according to polling by the University of New Hampshire Survey Center. That can translate into local resistance to following state and federal guidelines on masking or social distancing.

Efforts at the New Hampshire State House reflect the resistance, with several bills moving forward that public health leaders worry would curtail their ability to fight future surges. One bill would weaken theeffectiveness of vaccine mandatesand another would prohibit masking requirements in schools.

Public health leaders have called these efforts an attack on their work, and worry this legislative session will have implications that last well beyond this pandemic. For example, one bill would make it harder for the state Health and Human Services Department to mandate future vaccines for school attendance. The bill requires the department to first get a supermajority vote from the Joint Legislative Oversight Committee on Health and Human Services.

The Public Health Incident remains in place, at least for now 

While there was significant uncertainty as to whether or not the state would continue its Public Health Incident declaration at the end of March, it was extended through June 30, 2022.

That means New Hampshire’s regional public health networks can continue to hold vaccine clinics and the state could have an easier time accessing some emergency funding. Emergency SNAP benefits, which are tied to the incident declaration, will also continue.

At the federal level, a public health emergency declaration also remains in place, which means New Hampshire will continue to receive federal funding for pandemic initiatives like protected Medicaid coverage.

But crisis-driven funding cycles make it difficult to build long-term public health infrastructure. So far, the pandemic hasn’t changed that in New Hampshire. 

In fact, experts say New Hampshire entered the pandemic with an already underfunded and siloed public health system.

The state has 13 regional public health networks, with limited staff. While the model can help networks develop a strong understanding of local health needs, it can also make a centralized response to a public health crisis like a pandemic difficult, said Sosin.

She compared New Hampshire's public health system to some neighboring states, like Vermont, which has district level public health offices.

Because of the pandemic, millions of dollars for vaccination, testing, and temporary staff have poured into states, including New Hampshire. But most of the funding was for specific COVID emergency response efforts, like vaccination campaigns, rather than to support long term public health infrastructure to respond to future large scale public health crises.

Scott Schuler, incident commander of the Seacoast COVID-19 complex, said they wish some of the new positions they have gotten funding for were more permanent, to allow them to build something more long term. It also also makes hiring tricky.

“How do you hire someone for six months?” Schuler said.

What Schuler wants to see is funding for a framework that will allow New Hampshire’s public health networks to “flex up and flex down,” to meet not only future surges of COVID-19 but future public health emergencies.

“It's like having your fire department: They're not busy all the time, but you can get really busy, really fast, and overwhelmed in a moment,” Schuler said.

But funding for that type of service isn't always politically palatable. Historically, the urgency to fund public health isn’t there, until the fire is already burning.

Jane Goodman, public health network strategist with the Nashua Division of Public Health and Community Services, was hopeful the pandemic could help change the boom-or-bust way public health is funded.

“We need to build our public health infrastructure because it's horrendous across the country,” said Goodman.

But the so-called Build Back Better bill, which included significant public health infrastructure investment and pandemic preparedness failed this past winter in the U.S. Senate.

Still, Goodman says the Nashua division is trying to do what it can to build longer term emergency preparedness for future outbreaks of communicable disease.

In its latest community improvement plan, which outlines five priorities for the Nashua region, the division decided to make communicable disease a top priority.

Investing in public health also means supporting staff health 

Human infrastructure is also a concern for many in New Hampshire’s public health sector, where workers have been stretched thin after two years responding to the pandemic.

Earlier this year, Ashley Desrochers left her job working in public health. Desrochers helped lead the public health response in Strafford County, including vaccination efforts across the region. Months of working 60 to 80 hour weeks responding to the crisis took a significant toll on her health. She said it felt like trying to put out a never ending fire.

“I didn't get to have the scared feelings,” she said. “I was so busy working and trying to fix it that I wasn't allowed to feel like a human. I sacrificed so much of myself to do that work.”

Towards the end of her time in the field, Desrochers took medical leave.

“My brain was dead, I couldn’t think. Noise made it hard to function. I had seizures,” Desrochers said. She’s in counseling now for PTSD.

While Desrochers said she got informal support from colleagues, she wishes there were more official support structures for both public health workers and first responders across the state.

The lack of a more robust pre-existing public health infrastructure meant many public health workers were forced to take on unmanageable workloads. The growing politicization of their work added new stress, as well.

More than half of people working in public health at the state, tribal, local and territorial levels during the pandemic reported symptoms of at least one serious mental health condition, according to a 2021 large-scale survey conducted by the CDC. The survey also found that public health workers faced higher rates of PTSD than other frontline healthcare workers.

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