Running the Ground Game: Local Public Health in a Time of Outbreaks and Vaccine Hesitancy 

Five years post-COVID, both our state and federal public health infrastructure have drastically shifted away from robust outbreak management and the ongoing promotion of seasonal and childhood vaccines. Although polls show that anti-vaccine sentiment is still in the minority, social media clickbait can give the impression that “everyone” is anti-vax.  And, as a measles outbreak spreads while state and federal messaging often downplays strong support for childhood immunizations, communities can be left in the dark. With funding cuts affecting local health departments (LHDs), as Health Director of the New Orleans Health Department, I can tell you that running a strong ground game is more challenging now than ever.  

Local Health Departments Operate Within Communities

Since well before the COVID pandemic, LHDs have served at the intersection of direct services and national public health policy and practice. For the most part, they worked diligently and quietly by ensuring safe water systems, promoting chronic disease prevention, providing childhood immunizations. This work, mostly notable for its consistency, is the background music of a fractured health care delivery system. When appropriately resourced and operationalized, LHDs are the best way to understand and respond to individual, neighborhood, and community-wide needs — and are uniquely able to translate scientific research and regulations into a local context. In contrast, state and federal bureaucracies are often removed from the ground game of public health, relying on information trickling up to inform policy and funding. Like it or not, LHDs are deeply immersed in community. 

Nowhere is this more apparent than with the issues of outbreaks and immunizations. During the COVID pandemic while the CDC established guidelines and states received the lion’s share of funding — it was often left to local health authorities to navigate and translate information and marshal resources based on each community’s status and needs. Without LHDs there would have been far fewer testing sites, town halls, educational campaigns, and vaccination events. However, LHDs also bore the brunt of residents’ confusion, misinformation, and anger about uncertain times and rapid shifts in messaging and policy. 

The ground game of local public health — being present in community, listening to your friends and neighbors, answering anxious questions — is critical to victory over preventable disease.  As in war or football, a strong ground game generally wins the day — but there are still threats that could derail progress. 

Managing COVID in New Orleans

Prior to COVID, our dedicated team at the New Orleans Health Department was largely from our community and deeply committed to tackling the big public health issues: violence, chronic disease, behavioral and maternal-child health, homelessness – all on the typical LHD shoestring budget. As the only LHD in the state, we worked well with our much larger and better resourced state and federal partners, particularly in previous natural disaster-sparked crises.   

Then COVID came early, and it came powerfully to New Orleans. For a period in March 2020, we led the nation in cases and deaths. Testing was scarce, the federal response lagged, and our constituents were scared and dying. We were immediately thrust into the spotlight and asked to interpret federal and state policy that was often scattered and confusing, with limited information and tools to address the crisis. The New Orleans Health Department did not have the luxury of hiding from miles away — our city was suffering, and we were expected to provide answers and solutions. 

To do this, we focused on the ground game. Understanding the unique vulnerabilities of our residents — a strong affinity for communal events; multi-generational living; high rates of chronic disease; persistent inequities in access and outcomes — we rejected the hierarchical, one-size-fits-all approach to testing being pushed initially by federal agencies and demanded resources to put sites in neighborhoods high in social vulnerability (a novel idea in March 2020). This strategy reduced spread and brought services to traditionally ignored groups and neighborhoods.   

More importantly for future efforts, this approach put New Orleans Health Department on the map for residents as a trusted governmental agency (an increasingly rare honor) and one that was responsive and present in all parts of the community.  At the grocery store, on the sidewalk, at church, in parks, there wasn’t a day when I didn’t get asked, “Are you the TV doctor?  What’s going on with the virus?”  When individuals feel comfortable enough to approach a stranger with a genuine desire to understand complex science, that’s an immediate win and one that lays the foundation for future challenges.   

Supporting Local Public Health Today

The COVID vaccination rollout proved how important — and difficult — sustaining this trust with the community can be. We adapted our successful testing campaign for vaccinations, and oversaw dozens of town halls, calls, and meetings with audiences big and small. By mid-2021, however, the initial enthusiasm for vaccines wore off, and as pandemic disruptions and frustrations grew, skeptics and those generally hesitant became more vocal. 

Around this time, while shopping, I was approached by a fellow New Orleanian who had questions about the vaccine. We spent about 20 minutes talking, and by the end, she felt was ready to get vaccinated. It hit me then: if only my team and I could do this mini townhall 400,000 more times, we’d have everyone in New Orleans vaccinated. But 400,000 one-on-one conversations is hardly realistic — and that’s the dilemma we find ourselves in today. 

What LHDs have is their persistence in being in and of the community. We should use every opportunity among our friends and neighbors to preserve our standing as trusted, honest, and compassionate public servants. We can still translate state and federal guidelines and policy (or lack thereof) and explain their implications. The recent threats to Medicaid provide fantastic opportunities for LHDs to conduct tailored messaging. Even if a resident is not a direct Medicaid recipient, their doctor and pharmacy depend on its funding to stay afloat; the nursing home where their grandmother lives or cousin works does, too.   

This can be difficult work for LHDs, particularly in states like mine where state and local public health priorities have begun to diverge. While states get the bulk of federal funding to support vaccination efforts, local public health professionals must implement and communicate efforts most directly. When states (and now, federal agencies) deemphasize immunizations or shift resources to less impactful initiatives (like researching already-debunked claims of vaccine-caused autism), LHDs can be left on their own and in the unenviable position of threading the needle between high-level guidance that conflicts with reality on the ground and science. The honesty and transparency that many LHDs earned in COVID is still a potent weapon here: Every grocery store encounter, neighborhood meeting, local radio show is an opportunity to maintain and strengthen those bonds with the community, leading to continued trust and positive outcomes.

In this uncertain time for public health, consider finding ways to support your LHDs. Elevate their messaging, particularly on social media where their communications budgets are often very limited. Find ways to partner with them. Take their messages to the streets, parks, schools, churches. Local public health departments are well suited to translate and mitigate hesitancy and confusion, and ultimately, a strong ground game wins.