On a hot June afternoon, about 100 protesters representing local boards of health and other public health organizations stood on the steps of the Massachusetts State House to protest what they see as the privatization of public health.

"No more Band-Aids!" they yelled. It was a reference to what they said were the state's short-term fixes to some of the huge problems presented by the COVID-19 pandemic.

Whether dealing with vaccination sites, COVID testing, contact tracing, wastewater analysis, community outreach or a range of other urgent services, the Baker administration's default approach during the pandemic was to grant contracts to outside companies and organizations, rather than relying on local boards of public health to provide the services.

"And make no mistake, this has been costly," Carlene Pavlos of the Massachusetts Public Health Association told the crowd on the State House steps. "Resulting not only in time lost that could have saved lives, but in millions of dollars spent on contracts with private companies to build temporary infrastructure."

Many in Massachusetts' public health world are looking back at a state pandemic response that largely left them out in favor of large private contractors. And now they're looking to the state and federal government to ensure that local health systems get the resources they need to respond the next time the state faces a public health crisis.

Contractors and detractors

The state's reliance on outside contractors for public health tasks was extensive, but how extensive is not yet clear. And critics say that strategy hurt the state’s effectiveness in getting residents the resources and information they needed.

Seven weeks after receiving a public records request from GBH News, the state has not been able to provide a comprehensive list of emergency COVID contracts and the amounts paid to contractors. (A list of contracts related to vaccination efforts is available here.)

Among the most high-profile agreements were more than $126 million for Partners in Health to lead contact tracing efforts and huge contracts to CIC Health to run mass vaccination sites. Partners in Health’s contract, which was set to expire next month, was extended and expanded last week through the end of the year with a bigger staff of up to 430 contact tracers.

The state didn't make anyone available to comment on the strategy of relying on outside contractors.

In March, Gov. Charlie Baker defended the choice to prioritize mass vaccination sites rather than local boards of health, when grilled on the subject by members of the joint state legislative Committee on COVID-19 and Emergency Preparedness and Management. He said the decision followed guidance from federal authorities and was done in order to distribute vaccines as quickly as possible.

"As unhappy as some people may be with that decision, we are outperforming every other state in the country across most of the CDC's key performance measures," Baker said. "And I think that's an important fact with respect to whether or not the choices we made were effective or not."

Craig LeMoult / GBH News

But there have been consistent racial and ethnic disparities in the state's vaccinations, and advocacy groups say the reliance on mass vaccination sites has disadvantaged people who have less access to those sites.

“I actually didn't have a problem with a mass vaccine site concept, because I think the idea was we wanted as many people to get vaccinated as quickly as possible,” said Dianne Wilkerson of the Black Boston COVID-19 Coalition. “I think that the disconnect came in terms of how it was done.”

Wilkerson says by focusing first on vaccination sites in places like Foxborough, and by only taking registration online at first, the state left behind those in the most vulnerable communities.

“What we knew is that we were never going to reach our people if we did what the Baker administration was doing,” Wilkerson said. “So it was faulty from the beginning. It still is.”

Even now, only about half of Black and Hispanic people in the state have gotten at least one shot, compared to 65% of white people — and the disparities are even worse in some communities.

"This for-profit approach ... fails when it comes to public health and when it comes to engaging communities that have been marginalized and ignored for decades."
Dr. Julia Koehler

When the state launched an equity program in February to address the problem and encourage vaccination in those hard-to-reach communities, it again chose private companies to oversee the program.

One of those companies, a marketing firm called Archipelago Strategies Group (ASG), was hired to oversee outreach workers from local community organizations that were knocking on doors in their own neighborhoods.

In May, ASG began providing lists of addresses to outreach workers and setting quotas for how many doors they were required to knock on.

But Dr. Julia Koehler of Harvard Medical School said those quotas were unworkable.

Koehler had been accompanying outreach workers from the Chelsea-based community group La Colaborativa as they went door-to-door, encouraging residents to get vaccinated. Those conversations can take a while, Koehler said, as some people need convincing. But once the new quotas and address lists were introduced, the canvassers’ conversations had to be shorter and the way they spent their time became far less effective, she said.

"We were hiking across the whole city to complete this list. And when we finally got to where we needed to be, it was a gigantic apartment building that was all secured. Nobody was going to open the doors," Koehler said. "So basically there was a lot of wasted time. I remember we didn't sign up anybody that day."

ASG also started requiring outreach workers to verify who they'd spoken with by collecting some personal information, which several organizations objected to because of privacy concerns — especially in communities with relatively large numbers of undocumented immigrants. After the pushback, ASG backed down on both the quotas and personal information.

Koekler said the experience reinforced the hazards of relying on private contractors.

"This for-profit approach — where everything is simply measured in order to allocate money but not for the intrinsic value of care and of caring — fails when it comes to public health and when it comes to engaging communities that have been marginalized and ignored for decades," Koehler said.

In a statement to GBH News, ASG CEO Josiane Martinez defended the company’s approach.

“We know our work has helped get more people vaccinated from COVID-19 and has saved countless people from terrible illness and perhaps even death," she said. "ASG is proud of the work we have led on to help connect people in underserved communities with the information and resources necessary to make informed decisions about protecting themselves and their families from COVID-19.”

Dinanyili Paulino, Chief Operating Officer of La Colaborativa, credits ASG for adapting to feedback, but said community groups like hers should have been more involved from the beginning.

"The state has to ... work with people on the ground to fully understand what is the best model to reach the people of the community," Paulino said. "They cannot depend on coming up with guidelines and a strategy without having us at the table."

Public health protesters
Protesters at the Mass. State House on June 9, 2020
Craig LeMoult GBH News

Health boards speak out

This spring, local health departments around Massachusetts used a somewhat arcane budget process to condemn the state for marginalizing them during the pandemic.

When the state applies to the Centers for Disease Control and Prevention (CDC) for public health preparedness funds, it is required to show it has the support of local public health officials for how that money will be used. In March, at least five of the state's seven "emergency preparedness regions" objected to the state’s application to the CDC.

“This vote of non-concurrence reflects the region’s deep concern about the implementation of a COVID-19 vaccination strategy that squanders millions of federal and state dollars and resources, along with the associated capabilities that were built with those resources, town by town, region by region, throughout the Commonwealth,” wrote Timothy Muir McDonald, Needham’s Director of Health & Human Services, on behalf of Needham and 59 neighboring communities. “It also reflects our lack of confidence that our work will be used in the future, given the present underutilization and dismissal of existing State, local and regional public health preparedness resources.”

"Nobody asked us. Nobody said, 'Can you guys handle it?' And perhaps the answer would have been, 'No.' But we weren't asked."
Mike Hugo

State guidance throughout the COVID-19 pandemic often didn't align with emergency plans local boards of health had developed over the last 20 years, wrote Stacey Kokaram, director of the Boston Public Health Commission’s Office of Public Health Preparedness.

“We were not given the chance to implement any of these plans in any strategic, coordinated way during the response and now during the vaccine rollout,” Kokaram wrote. “In addition, local boards of health were left out of the statewide planning and were instead faced with reacting to guidance as it came out from the state, which often was different than the plans we have built together.”

Local health officials started developing emergency responses in the wake of the September 11 attacks and subsequent anthrax scares two decades ago, said Mike Hugo, the government affairs liaison for the Massachusetts Association of Health Boards.

"The Department of Public Health has been working hand in glove with us on this for decades now, and all of that work was ignored," Hugo said. "Nobody asked us. Nobody said, 'Can you guys handle it?' And perhaps the answer would have been, 'No.' But we weren't asked."

Hugo acknowledges that local health boards have varying levels of capability. With a different health board in each of the state's 351 cities and towns, there's a wide range in what each town can handle, based on local funding, he said. Cities like Boston and Worcester have well staffed health departments that can provide a range of essential services, he said, but “some of the health departments, you have [just] a health director, and that health director does all the restaurant inspections, contracts out the nursing and takes care of all of the environmental issues in the town, all by his or herself.”

Sigalle Reiss, president of the Massachusetts Health Officers Association and a member of Norwood's board of health, said most other states have large health departments organized at the county level.

Most Massachusetts cities and towns can meet just the basic public health requirements, she said. "And to be honest, not all municipalities have the capacity to do that."

The state DPH did hold informational calls about COVID-19 with health boards twice a week. But Reiss said it was never a dialogue.

"There was an opportunity to ask questions, but we never really had that opportunity to influence policy and be at the table to assist in some of the decision making," Reiss said.

What happens next time?

When she looks at the state's use of private contractors over public health departments, state Sen. Joanne Comerford sees both sides. And she has a particularly good view of the issue as chair of both the Joint Committee on COVID-19 and Emergency Preparedness Management and the Joint Committee on Public Health.

"It would have been very worth our while to invest, quickly, strategically, and decisively into the local public health infrastructure, which I believe then would have left us stronger coming out of COVID than when we were going into COVID," Comerford said.

But, she acknowledged, the boards of health are an "uneven foundation on which to invest."

"That's a real conundrum. And in the middle of a crisis, I can understand why the [state] command center made some of the choices it did," Comerford said. "However, if we're talking about coming out of COVID and being stronger and more equitable, let's build that foundation."

The way to support underfunded departments, a 2016 state report said, is to get cities and towns to work together to share public health resources.

And it’s starting to happen. In the pandemic, health departments teamed up to create 25 regional collaboratives that vaccinated their residents. And the 2022 budget includes $15 million to continue a competitive grant program for public health partnerships.

Carlene Pavlos of the Massachusetts Public Health Association addressed the crowd at the State House in June.
Craig LeMoult / GBH News

Public health activists like Pavlos of the Massachusetts Public Health Association say competitive grants are a good start, but they can’t solve the problem of unequal services.

“That leaves behind communities that have the most need but the least capacity to compete for those resources, because they may not have staff or a professional grant writer,” Pavlos said. Instead, her group is calling for direct funding “that will provide core resources for all municipalities so that, regardless of a municipality you live in, you have access to core public health resources.”

Advocates are also calling for a significant influx of federal money to support local boards of health.

Massachusetts is getting more than $5 billion as part of the American Rescue Plan Act (ARPA), and a partnership of advocacy groups called the Coalition for Local Public Health is calling for more than $250 million of that money to go to supporting local health boards so they can be better prepared for future public health emergencies.

Comerford has introduced a bill that would move the state’s local health boards toward a more solid baseline. It would establish minimum public health standards that each community must meet, including for training and credentialing workers and for reporting data, as well as the ability to perform other public health responsibilities. It also lays the groundwork for how state funds appropriated in the future would be spent to meet those standards.

"Now it's time to do the work, so we're prepared," Comerford said. "So we have minimum protections and standards in good times, and we have a foundation in the crises."