The parking lot at the Anne Arundel County Health Department is almost empty, a row of white department sedans along one side and just two or three civilian cars on the other.
“It’s Friday,” county health officer Nilesh Kalyanaraman said by way of explanation.
OK, so most of the staff in a government office bugged out a little early on a Friday afternoon in January. It’s understandable.
For the last two years, this glass and brick building in Annapolis has been at the center of the covid pandemic in one of Maryland’s most populous counties. This is where all the testing drive-thru sites were planned, all the contract tracing plotted in the early days. This is where the idea to move school nurses into the field was born, and this is where the decision was made to extend the current emergency mask mandate through January.
Everyone who works here, including Kalyanaraman, is justified in being worn out.
“They're tired,” he said. “They're very tired.”
The pandemic arrived 22 months ago in this part of America, a stretch of Chesapeake Bay country reaching 65 miles south from Baltimore. Every time it seems like there might be an end to the days of plague, there’s a new variant or a new fight erupts over what it will take to end this.
And like public health workers everywhere, the roughly 830 employees of the county health department have been there through it all. Dressed in paper scrubs and face shields, they’ve swabbed hundreds of thousands of noses under popup tents in parking lots. They jabbed hundreds of thousands of arms in vaccination clinics set up in gymnasiums and casinos.
“They do take a tremendous amount of pride in what they do," Kalyanaraman said. “This is what we are here for … to protect people.”
Protecting people is the purpose of public health, from ancient dangers like dirty water, tainted food, and childhood diseases. It protects them from modern threats too, like lethal doses of fentanyl mixed into street drugs and rising suicides.
But nothing has challenged modern public health systems like the spread of COVID-19, with more than 900 dead in this county, 800,000 dead in this nation, and 5.6 million worldwide.
Sure, there have been deadlier plagues. Many of those occurred before the concept of public health was widely accepted as the role of government, though, or before science figured out crucial lessons on prevention and human health.
Perhaps the thing that has been most exhausting is the pushback. There have been angry protests over lockdowns and mask mandates, conspiracy theories about vaccines and microchips, and a demonization of public health figures as anti-democratic. It's been tiresome, surprising, and maybe just a little aggravating.
“You can also want folks to do their part as well. And I think that's, that can sometimes be frustrating, right?” Kalyanaraman said. “Because we're not trying to fight with folks. We want to keep them healthy.”
Tuesday, a judge will hear arguments in a lawsuit claiming that Kalyanaraman overstepped his power to protect public health when he extended an emergency mask mandate issued by County Executive Steuart Pittman in December. The County Council voted on extending it, 4 Democrats to 3 Republicans. That was one vote short of the total needed for an emergency measure.
Kalyanaraman stepped in and used a clause in state law authorizing a county health officer to take action in an emergency. On his own authority, he extended the mandate for masks in public spaces through Jan. 31. He explained it as a needed response to spiking covid cases and hospitalizations driven by the highly contagious omicron variant sweeping the world.
Both county hospitals are on an emergency footing, limiting what care they can provide as resources and staff are overwhelmed by covid cases.
Two Republican political figures, each of them a candidate to replace Pittman as county executive, organized a lawsuit to challenge the order saying, essentially, Kalyanaraman doesn't have the power to do this.
In an interview Friday, Kalyanaraman declined to talk about the lawsuit. What he would talk about, though, was this moment in public health and what happens after the pandemic ends.
First, you have to understand the difference between public health and healthcare. Healthcare is about treatment. Public health is about prevention, keeping people healthy.
Practitioners, whether at the municipal level like Kalyanaraman or at the national level like the director of the Center for Disease Control and Prevention or the surgeon general, are focused on prevention.
Some of that work is traditional, done by inspectors who make sure the water supply is safe to drink, nurses who help young mothers understand breastfeeding, or counselors working to prevent addictions.
A lot of the job is accomplished through communication, providing education on the dangers and how to avoid them. That’s always been hard to do effectively. Think about the eye-roll you probably gave to healthy living posters in high school.
But in a world where communication channels fragment more every day, it’s tougher than ever.
“People use all different ways to get their information or to entertain themselves, right? And so you've got to think about; Is this on a YouTube channel? Am I on Instagram? Is it in the newspaper? Is it on the radio?
“And so that I think part of the challenge is that there's just a wide variety of ways to communicate with people. There are modes, but then there's also who's doing the communicating.”
The effectiveness of communication is largely about trust. Do you trust the message and the messenger? That is directly related to the breakdown of traditional channels like newspapers and local TV news as the major sources of information.
Here's an example. You can tell someone that suicide is the leading cause of gun deaths and that it's older men who tend to be the ones dying most often. But the warning about the danger gets lost if it's coming from a source that's no longer trustworthy because of politics or perceptions about bias.
That’s why the county adopted a law requiring gun dealers to provide information on suicide prevention. The health department isn't arguing about whether you should or should not buy a gun. It's just saying you should understand the risk of self-harm, and it wants to enlist gun shops as allies.
Blasting it on Facebook or putting up billboards or even getting a story in the local newspaper is nice, but that may be too broad to be effective anymore – if it ever was. It gets lost in the clutter as well as the filter of political beliefs.
“It puts the best educational material in the stores where people are, who are buying a firearm or at least interested, right?” Kalyanaraman said. “And so it's getting to them in a, you know, in a location that's really relevant to the topic that we're trying to get at, right?“
The changing use of communications is a sign that public health evolves, and not just in how it works to protect. It does it through education, experience, and science but also through catastrophes and fights. What is routine now might have been revolutionary at the start. What was fine 100 years ago is rejected today because of changing standards of care, fairness, and even who gets to participate in American democracy.
Lining up in the cafeteria for immunization was a big deal for those of a certain age. Some of us have faded, round scars on our shoulders from the experience.
Today, kids get their major vaccinations at routine pediatrician visits or health department clinics for parents who can’t afford a pediatrician.
“Through those discussions and those skirmishes, we've gotten to a place where we accept that, more or less, right? So immunizations are something that the health department does. But more importantly, it's part of routine school entrance requirements, right?
“We've embedded immunizations into childhood so that we're preventing diseases. Clean water, clean food, those are all things that are a core part of the services that we offer.”
We've come to expect them, so these services are not controversial.
Over time, that frees public health to turn to other threats, like suicide and mental health, and addiction.
“We didn't talk as much about the health issues like suicide for a long time. And I remember that when I was in med school, it's like around the time where that paradigm was shifting from minimal to you can talk about it,” Kalyanaraman said.
Today, the conversation has evolved to acceptance of having those kinds of feelings and providing resources for help. It’s still a work in progress, but it's different than it was just a few years ago.
“That's an area we haven't addressed as well, from a population standpoint, right?" Kalyanaraman said. "We haven't talked to people and said, Listen, this is OK. This is OK to bring up. It’s OK … to voice your feelings on this. Get treatment for it if you need it, or just talk about it..”
Covid is no different. It is changing public health so much that most people have a pre-covid and a post-covid picture of it.
Before 2020, public health agencies worked quietly in the background. Post covid, they are the subject of angry diatribes about overzealous health officers in the local newspaper and on national news broadcasts.
Somehow the cry of “Freedom!” has gotten entangled in the debate over the proper role of public health. The fight has focused on mask mandates and vaccination requirements, but it also goes right to the heart of how much power we're willing to give agencies whose job is to keep us from getting sick.
“I think that the misconception idea is that we want to make people do things,” Kalyanaraman said. “A better way to think about it is we want to help you lead a healthier life. There's really no freedom in disease.”
Politics in public health isn’t new. How much money a society should spend on prevention, as compared to law enforcement, or schools or armies, is a legitimate political question. In a democracy, it's decided by elected officials.
“That focuses on what are the costs and benefits,” Kalyanaraman said. “Those are very much legitimate political questions, right? How much are we willing to invest to improve this? … Whatever that issue is, right?
“How much are we willing to invest in reducing gun violence, in reducing the maternal mortality and infant mortality among Black and Hispanic women? I think that's a legitimate question.”
To Kalyanaraman, that’s different than the politicization of masks and vaccines we're seeing now. He called that "reactionary."
“And it says, I don't want to hear about it, or I'm going to choose an alternative, you know, an alternative mindset that kind of ignores the realities of what's happening. And I think that's the dangerous part.”
There will have to be a political decision, decided through elections, about the role of public health. Is the anger over a mask mandate enough to give power to those who campaign on the idea that it is anti-democratic?
Right now though, Kalyanaraman sees the impact as more immediate. If a community can’t agree on what’s happening, how does it get to a decision on how to deal with it?
“I don't think it's unique to public health. But it certainly is something that we are we're concerned about,” Kalyanaraman said.
That debate has gotten ugly. In Maryland, Harford County fired its health officer without giving a reason. It followed weeks of angry protest over masks in school. The Carroll County health officer resigned after weeks of similar conflict.
Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases and the chief medical advisor to the president, gets death threats. Kalyanaraman said he’s been subject to “creepy” behavior like comments about where he lives.
“We are used to trying to get people to pay attention to us in public health, right? And so the idea that all of a sudden there would be this much attention, but also hostile attention… Disagreeing with us is not the same thing as threats and aggressive language and behavior and firing for doing your duty.”
Other county health officials have gotten more direct threats. Many of them are set to testify in Annapolis when the General Assembly takes up legislation about providing more protection.
It also affects the people working in those testing and vaccination clinics, who face harassment and long hours during the pandemic. Nationally, many in healthcare, hospitals, and nursing homes, have had enough and are leaving the field.
It hasn't been as bad in public health, but there will be an impact. As healthcare looks to fill its vacancies, some public health agencies may find it hard to compete in recruiting and retaining clinical staff.
“We're seeing some additional interest in health care professions, but I don't think we're seeing enough yet to mitigate the loss of people who are retiring or taking a break ... because they are tired,” Kalyanaraman said.
There will be other political decisions ahead, too. Increased competition for employees will mean more money for salaries. The pandemic also has exposed the need for new data systems in public health.
The demand for information on the spread of covid has been immense. Maryland put up a lot of details but not enough, according to some critics. Its covid tracking system was also shut down for weeks after a cyberattack in December, just as the omicron virus began filling hospitals.
Even the ability to use the information available is limited because most public health agencies have their data in silos.
“When you do something in this one system, you can't compare it to this other system," Kalyanaraman said. "You can’t mash that together and say, OK, I know this person got sick, or this person has whatever condition they have to be able to get vaccinated. I can't make those systems talk.”
Understanding data also directly affects decisions ahead on programming – which problems to prioritize and how to address disparities in the outcome.
“I think we've got to look at what are the priorities? What are the priorities in communities, counties, states? And then, what are the disparities? Then really commit to using that data to say we're gonna invest in improving these outcomes, whether it's maternal-infant outcomes, whether it's diabetes outcomes, whether it's opioid outcomes or gun violence, or COVID...
“It's really using that data and understanding where the gaps are.”
The biggest challenge ahead for public health may bring us back to that basic one for communication, trust.
It would have been an easy bet that the United States would be the best-prepared country in a global pandemic. We have the CDC, pandemic task forces, rich biotech companies, scientific depth in academia, and a whole factory in Baltimore under contract for emergency production of vaccines.
None of it worked out as planned. America just wasn’t ready.
“I think the part that we didn't pay as much attention to is not the science part of it, but the human part of it,” Kalyanaraman said. “How will people react, and what does it take to get consensus and shared collective action to actually take these steps?”
There’s this catchphrase in public health, “vaccines don't save lives. vaccinations do.” It doesn’t do any good to have not one but three technologically amazing vaccines if not enough people will agree to take it.
It doesn’t matter if the science says a mask will prevent the spread of the virus killing people if the message is greeted with doubt and hostility.
The question public health has to address is not only how do you communicate, but communicate convincingly. We need a greater understanding of human nature in a crisis.
"We're learning ... to focus, not just on the science piece of it, but also on the sociology on the human behavior piece of it. What is it? What does it take to communicate? What does it take to address people's issues or concerns with these interventions?”
In other words, how do you convince people to get the vaccine and wear the mask?
This essay has been updated to correct the current number of worldwide covid fatalities.
Rick Hutzell is a nationally recognized journalist. He lives in Annapolis. Contact him at meanwhileannapolis@gmail.com.
