Just before COVID-19 reached Utah, the state health department was finishing a plan for how the state should respond to an influenza pandemic. There was just one holdup.
No one could agree on who would make policy decisions during a health crisis.
“Would it be in the Legislature? Would it be in the governor’s office? Would it be in the health department?” remembers then-state epidemiologist Dr. Angela Dunn.
Those exact questions would divide state government and ensnarl Utah’s COVID-19 response in politics as hundreds, and then thousands, of Utahns fell ill while the coronavirus spread worldwide.
State and local health officials lacked the trust of — and reliable support from — many elected leaders and had to contend with a maelstrom of political forces, current and former public health officials said.
Critics contend public health officials overreacted with early stay-at-home orders, changed their recommendations too frequently or, at times, didn’t act fast enough, such as in expanding testing.
For their part, public health leaders say they felt underfunded and squeezed out of the state’s response, with little to no input as leaders signed multimillion-dollar testing and contact tracing contracts with tech companies that lacked public health experience.
Later on, they watched as the Legislature overruled their masking and social distancing orders and diluted their power to control the spread of the virus — a trend that occurred in other states nationwide.
Now, as Utah struggles with the surging delta variant, testing backlogs, a vaccination rate hovering just over 50% and continuing political divisions, current and former state officials are hoping to rebuild trust with Utahns — and pushing Gov. Spencer Cox’s administration to reinvest in public health.
“The diminished public trust in public health is a casualty of the pandemic and the politicized response,” said Carrie Butler, executive director of the Utah Public Health Association. “But public health has been underfunded for 100 years. The infrastructures that should have been in place weren’t there.”
‘Pandemic preparedness wasn’t there’
Utah’s pandemic planning fluctuated depending on who was governor, said Dr. Andrew Pavia, who has served in state pandemic planning groups and is chief of pediatric infectious diseases at University of Utah Health.
A pandemic influenza task force and other planning efforts during the administration of then-Gov. Jon Huntsman produced lengthy lists of recommendations for preparing for and responding to a health crisis. Officials called for increasing testing capacity at the Utah Public Health Laboratory, improving statewide influenza monitoring and building the capacity to deliver a new vaccine across the state’s population.
Dr. David Sundwall, who ran the Utah Department of Health from 2005 to 2011, helped create the Huntsman playbook. It was exhaustive, he said, but the state failed to follow through in ensuring it had a sufficient supply of personal protective gear, other basic equipment and testing capacity.
The health department’s reserves in early 2020 contained about 218,000 N95 masks, about 193,000 exam gloves, fewer than 10,000 face shields and a few thousand isolation gowns, according to the agency. There was no requirement to keep any specific quantity of these supplies on hand, a UDOH spokesman said.
Still, Pavia said, the state was well-prepared in some areas. Utah had hammered out a blueprint for allocating scarce health care resources in a crisis, he said, and had a robust influenza surveillance system.
And UDOH had a strong epidemiology leader in Dunn, Pavia said, with a good core of infectious disease experts.
There just weren’t enough of them at the start of the pandemic. Since then, the agency workforce has expanded nearly 30%, from 1,179 employees in September 2019 to 1,525 today.
Part of the staffing shortage stemmed from years of underfunding for public health, a concern that has emerged across the nation during the pandemic, public health advocates say.
In Utah, health department staffing levels haven’t been keeping up with the state’s explosive population growth, according to a Kaiser Health News and Associated Press report. In fact, the number of UDOH employees per resident in Utah dropped by 14% from 2010 to 2019, according to the analysis.
About 80% of the funding for the department’s infectious and chronic diseases division comes from the federal government, Dunn said. Much of that money is awarded through grants with strings attached, she said, so UDOH officials were always asking the state to contribute more.
State lawmakers provide roughly a fifth of the division’s funding, setting aside $18 million in the 2019 legislative sessions. That was cut to $16.6 million in the 2020 sessions, during the first year of the pandemic.
Former state Sen. Allen Christensen, a North Ogden Republican who spent years as head of the legislative committee that oversees health spending, acknowledges that he and his colleagues didn’t “see a pandemic coming” and talked relatively little about preparing for one.
Rep. Paul Ray, who now leads the committee, said there’s never enough money to meet all the needs, and policymakers can feel like they’re perpetually playing catch-up.
“That’s why the public health, the pandemic preparedness wasn’t there,” the Clearfield Republican said. “Because we’re trying to fund Medicaid, we’re trying to fund mental health, we’re trying to fund suicide prevention.”
‘Nobody looked at it’
Underfunding left the Utah Department of Health vulnerable when COVID-19 hit, Pavia said.
Without enough stockpiled masks, gloves or testing material, the state had to scrounge for this equipment on a global market — and, Utah auditors have noted, paid inflated prices. Utah has ordered more than $68.6 million of personal protective equipment during COVID-19, much of it outside the standard procurement processes meant to promote fairness and competition.
Auditors pointed out that the Huntsman-era pandemic plan had recommended that health officials develop a sufficient stockpile — and voiced dismay that some bureaucrats were blindsided by fragmented supply chains.
Without adequate “surge capacity,” or enough staffing for a full-blown crisis response, the agency also faced challenges in ramping up contact tracing and testing, Pavia said.
Dunn, who now directs the Salt Lake County Health Department, said people outside public health often had the misconception that the agency could simply “hire anyone off the street” to do these jobs, but it was more complicated than that.
When hiring employees to work with the public, she said, “it’s all about trust. We need the public to feel like they can trust us to give us their sensitive data. And that relationship can be ruined with just a single individual.”
Meanwhile, the state’s powerful budget manager, Kristen Cox of the Governor’s Office of Management and Budget (GOMB), wanted her office to play a leading role in Utah’s pandemic response and began second-guessing public health, according to Dr. Joseph Miner, who was UDOH executive director at the start of the pandemic.
As millions of dollars in federal coronavirus aid began pouring into the state, GOMB started to commit funding in a series of massive, no-bid contracts. To meet the demand for increased testing capacity, state officials turned to a consortium of tech companies that had offered its services, initially, at no cost. But the sole-source contracts that went to the initiative, known as TestUtah, soon ballooned and now tally in the tens of millions of dollars.
GOMB supervised the TestUtah contract with Nomi Health, a tech company that has captured nearly $34 million from the state to run a coronavirus testing initiative and later vaccination sites. Nomi Health’s CEO acknowledged his company had no prior lab testing experience, and infectious disease experts have raised concerns about the reliability of the tests initially used for the project.
“We had no input or response or were never asked about resources that we needed,” Miner, who retired late last year, said. “That was completely done separate from public health.”
Kristen Cox said the state had to be aggressive, especially when then-Gov. Gary Herbert’s office was pressing to build capacity and to act fast — to save lives and livelihoods.
One of the disagreements centered on expanding coronavirus testing to residents who did not have symptoms — something Dunn had opposed — and the ability of public health to execute on this, which was challenging at first.
“They [public health officials] may feel, ‘We should have taken the lead on it,’ but it was a collaborative effort,” Cox, who now is based at the University of Utah’s business school, said in an interview. “Everybody had a voice in this, but maybe some didn’t think they had enough. But, you know, step up and come up with a plan, bring it all together, then go for it. But despite their good intentions — and expertise — public health leaders didn’t immediately have a plan that included basic elements, like masks, asymptomatic testing and data on hospital capacity.”
Cox said she was following guidelines from the Centers for Disease Control and Prevention and a strategy described in Herbert’s Utah Leads Together plan. Public health officials, she said, hadn’t outlined any steps beyond shutting down the state. She hopes that’s a major lesson for the next crisis or pandemic.
“We have to find ways to meet the multiple needs of citizens,” she said. “Solving one problem [like slowing the spread of the pandemic] while creating others isn’t a solution.”
Still, former public health officials say that Cox’s approach — outsourcing a portion of testing — was a waste of money that could have been better spent investing in public health.
Robyn Atkinson-Dunn, who was the director of the Utah Public Health Laboratory until June 2020, said for just $2 million, capacity could have been increased in the same time it took TestUtah to be fully operational.
The state laboratory could have pooled resources with its counterparts and tapped university students in lab technician programs to help process tests; that could have had an added benefit of training the next generation of health professionals with little to no downside, Atkinson-Dunn said. The short-term investment in the state laboratory would have had long-term benefits, she added.
Turning instead to TestUtah, she said, is “a huge waste of money that goes to a company instead of building capacity for the state.”
Atkinson-Dunn later was demoted because she was unwilling to send a share of coronavirus test samples, from a temporary glut at the state health lab, to the TestUtah lab at Timpanogos Regional Hospital, after a federal inspection found it was out of compliance with federal rules. She has since left the state health department.
Miner said similar frustrations also bubbled up in his conversations with public health workers.
“They came to me and said, ‘We just can’t do our job because we’re being ordered to do this and that by Kris Cox,” he recalled, “and she won’t let us do what we’re trained to do and what we know to do.’”
Miner said a certain amount of outsourcing is to be expected during a pandemic. But, he argues, the state’s testing contracts were premature and shouldn’t have gone to companies with no public health experience.
Dunn joked that the state’s pandemic planning documents were “great for about three weeks” of COVID-19 but quickly lost relevance once elected officials took control of the response.
“It was so fascinating and frustrating when people were like, ‘Let’s document all that we’re doing in COVID so we have something we can pull off the shelf when the next pandemic happens,’” she said. “And I was like, why waste our time? We had it for flu, and nobody looked at it.”
The rise of disinformation — and frustration
As COVID-19 spread, it threw public servants in state health departments across the U.S. into the political fray, with the high-profile clashes between then-President Donald Trump and the nation’s top medical advisers replicated in smaller skirmishes across the nation.
In Utah, groups formed objecting to face covering mandates and social distancing protocols. Some defied public health orders by refusing to don masks at businesses and public meetings, and anti-mask protesters even gathered outside Dunn’s home late last year.
Miner said he’s been surprised and bitterly disappointed by the pushback to lifesaving health measures, from masks to vaccination. He’s also dismayed by how powerful such dissenters have grown.
“They are so vocal and organized that they intimidate legislators,” he said. “... Legislators don’t have the will or strength to really support the good science.”
Ray said public health officials in Utah failed to account for the political dynamics at play and should have understood that people would resist policies that they felt were forced on them.
“Science means nothing if the public doesn’t believe you,” Ray said. “And what happened was, is they would just come out and they would change their response on a daily basis sometimes. They would say one thing, and then the next day change it. And that just eroded the public trust in the system.”
The lawmaker pointed out that Dr. Anthony Fauci, the nation’s top infectious disease expert, in early 2020 advised the public against wearing masks because he wanted to preserve personal protective equipment for health care workers. Fauci and the CDC now recommend face coverings as a way to prevent disease transmission, but his early statements have become ammunition for anti-mask groups.
In years past, the state health department had a more direct line to the governor’s office, said Michael Stapley, a former acting executive director of UDOH and a retired CEO of Deseret Mutual Benefit Administrators. But that relationship had started to break down over the past decade or so, he said, and resulting tensions boiled over during the pandemic.
“The net effect of the politicization was information and disinformation leading to a confused public. And it’s only gotten worse,” he said. “It became a major factor in our ability to effectively manage the pandemic.”
Unfortunately, Miner said, the outbreak will leave public health with less power and stature than it had before COVID-19, as lawmakers have diluted the power of UDOH and local health departments.
Earlier this year, legislators prohibited school districts from imposing their own mask mandates and set up a new process for instituting any health restrictions — one that gives county commissions or councils veto power over these orders.
One of Ray’s proposals, nicknamed the “endgame bill,” rolled back nearly all of Utah’s mask mandates and other health orders in early May, as soon as the state crossed certain thresholds for vaccination and containing coronavirus spread.
Though intensive care unit numbers and coronavirus case rates have since soared well above the markers again, those public health orders remain terminated.
Dunn said she remains “so disappointed” by the Legislature’s move. ”Legislators are responsible to their constituents. Public health leaders are responsible for the health of everybody in their community, regardless of how they’re going to vote. So very different viewpoints,” she said. “I think we as a state would have been better served if both viewpoints were equally represented at the decision-making table.”
Ray argues officials are elected to make strategy decisions.
“I will never turn everything over to doctors or the health departments, to bureaucrats and say, ‘Make our decisions for us,’” he said. “That comes to why I was elected, it comes to why county commissioners were elected, why school board members were elected. Their job is to balance what they need in their area and make those calls.”
Even with the staffing UDOH has added, the agency’s workforce is exhausted after more than a year fighting a pandemic, said Nate Checketts, who became the agency’s interim executive director in June, its fourth leader during the pandemic.
“Our teams have been on this for over 18 months now,” he said. “When I came on, there was a slight lessening in the caseload, and there was hope that with the vaccinations being rolled out rapidly that we would be moving to a very different phase of the pandemic response.
“And unfortunately, with the arrival of delta ... and the caseloads increasing again, we’re back into some of the same environments we were last year.”
And, despite adding staff, the health department is still relying heavily on contractors. Several weeks ago, UDOH handed off most of its coronavirus testing sites to TestUtah so it could redeploy its teams for an anticipated surge in testing demand at schools.
Today, UDOH aims to keep at least a 90-day supply of inventory in its pandemic stockpile, which now includes 3.1 million N95 masks; 1.3 million KN95 masks; 182,000 face shields; 22.7 million isolation gowns; 82.5 million exam gloves; 601,000 swabs; and 408,000 sample collection kits.
Health officials said that should last the state at least through the winter. There’s no ongoing effort — or earmarked money — to set up a permanent stockpile in the health department, despite state auditors’ recommendation that the agency do so.
Dunn worries the state’s ongoing effort to combine the health department with the Utah Department of Human Services could undermine the goal of future pandemic planning. Without a stand-alone agency devoted to public health, she said, she’s concerned that it might get overshadowed.
Dunn said she’ll be watching these developments “with a keen eye,” and “at the same time, preparing for Salt Lake County Health Department to potentially fill any gaps that are there,” she said. “What are we going to have to do to step up if the state public health system becomes marginalized?”
Checketts said most members of the governor’s Cabinet represent several interests and noted that the merged health and human services agency will be large, compared to other state departments. That means its director will have an opportunity to speak and advocate forcefully for agency interests, he said.
And Dr. Robert Rolfs, a former state epidemiologist, said politicians and public health could sidestep some of the past pitfalls by building strong working relationships. Rolfs helped develop Utah’s pandemic response plan during the Huntsman administration and said he was keenly aware that the department could lose its authority if it was misused.
“Public health has had many of the powers it used to have curtailed,” he said. “I think ultimately that will prove to be bad. But [it’s] not totally unexpected.”
Rolfs said he understands the Legislature’s concerns about public health emergencies that stretch on for months. And Sundwall said that, in retrospect, state health officials took a sledgehammer approach to mitigating the pandemic, such as school closings in 2020, when the state could have taken a more surgical tack.
“We did a reasonably good job, but the facts belie that,” he said, pointing to how the delta variant has surged in recent months in Utah. “We’re perplexed and embarrassed — and should be.”
To win back some of the public’s trust, Sundwall said, health officials must demonstrate humility regarding past overreach. And lawmakers need to help by reinvesting in public health, he said, in what he calls “an opportunity.”
A spokeswoman for Gov. Spencer Cox suggested he has an interest in revisiting recent legislative actions to curb public health powers. In a statement, spokeswoman Jennifer Napier-Pearce said Cox believes “we should take the lessons learned from this phase of the pandemic to reevaluate laws passed last session.”
Cox also wants to “make sure we are building up public health” in the budget proposal he’s beginning to craft for next year, she said.
Senate President Stuart Adams said he anticipates some tweaks to the laws on public health powers in the coming legislative session and a continued effort to invest in UDOH.
“I have great regard for them, and I think most everyone does,” Adams, R-Layton, said of public health workers. “What’s more important than your health? It’s pretty hard to enjoy life without great public health.”
During the next session, Ray said, he’ll be advocating for more funding for local health departments and work to reserve money in case of future public health emergencies. Having $25 million or $30 million in the bank, he argues, would go a long way toward setting up an initial crisis response.
“I don’t know when it will be, but there will be another time,” he said. “It might be 20 years, it might be 100 years, but we need to make sure that we’re prepared and learn our lessons from this year.”
Editor’s note: Jon Huntsman is a brother of Paul Huntsman, the chairman of The Salt Lake Tribune’s nonprofit board of directors.