Guest Columnist

How local health departments work, and how Iowa can make them better

Pramod Dwivedi Linn County Public Health Director. Photographed at Linn County Public Health building in northwest Cedar
Pramod Dwivedi Linn County Public Health Director. Photographed at Linn County Public Health building in northwest Cedar Rapids, Iowa, on Tuesday, July 12, 2016. (Jim Slosiarek/The Gazette)

On an unseasonably warm Iowa morning in early March, I met with my public health team to talk about the spread of a new coronavirus. I had just returned from an invited briefing in the White House for local and state health officials.

I called another meeting with the two area hospitals. The third meeting I held was with the Emergency Management Agency. And a few more followed.

A novel coronavirus, later coined as SARS-CoV-2, had just begun its relentless maraud in the United States, and it was just a matter of time before it would hit Iowa and Linn County.

We were looking at an exploding public health emergency. We needed to respond immediately.

Then my mother fell ill, half way around the world, in India. I needed to go. For the entire week, the Indian embassy did not reply to my repeated requests for a visa. And, then, India shut down its air transport. I could not go.

In late February, CDC reported a mere 14 cases of COVID-19 in six states. But by mid-March, a robust community transmission of the virus that causes COVID-19, had accelerated. On March 20, LCPH announced its first cases here in Linn County. Today we have nearly 1,900 cases. COVID-19 outbreaks in Linn County have been recorded in five long term care facilities. We have also lost 87 of our neighbors. More than 800 Iowans and 146,000 Americans have succumbed to this deadly virus. Transmission in Linn County continues.

Currently, we’re noticing cases surge. While Linn County residents are out and about, at work and social gatherings, an acceleration of infection is taking place, creating a challenge to your local health agency. A surge also means our hospitals may face capacity challenges (supplies, ICU beds and ventilators). In coming days, as we continue to reopen public activities and businesses, the number will continue to grow in Linn County and across the nation, which is certain to strain local health departments.

Any health crisis tests the capacity and limits of a local health department, which is at the front lines. Our job is to protect the health of all and prevent the spread of disease in our jurisdictions, often without adequate resources.


Public health response is a team sport. LCPH has been working with many other partners so that staff and resources are pooled together. We rely on local agencies such as emergency management, municipalities, hospitals, law enforcement and fire department to join hands.

Linn County Public Health has worked to successfully build foundational public health capacity, thanks to Board of Health and Board of Supervisors. Today, our community is reaping the benefits. We have added nearly nine staff and new infrastructural capacity of epidemiology, assessment, research, evaluation, informatics communication and policy development, along with a new, world-class building.

Your health department is also about partnership with state and federal agencies, meaning we can continuously detect cases and trace contacts. Our response also includes implementation of multiple community mitigation strategies put forth by our state and federal partners such as Iowa Department of Public Health and Centers for Disease Control and Prevention.

The local health departments perform a wide range of services without being visible. The water that we drink, the food that we eat and the air that we breathe are safer because of our work.

We assess health needs, develop health plans, immunize, educate about healthy living, and provide forum for dialogue in our communities to improve health of all, especially those who are on the margins. All of these core services must be continued while we respond to COVID-19. Plus, our staff must answer calls from frightened residents, tell people to self-quarantine, check on the infected every day, trace the contacts of those who are infected, and advise the businesses, municipalities and schools about reopening. And we combat misinformation in real time.

Still, local public health infrastructure in Iowa remains inadequate. Years of funding cuts and severe limitations on categorical grant funding have taken a toll.

A third funding source, which was established after 9/11, is Public Health Emergency Preparedness (PHEP), a federal program. But it offers scattered support to local health departments and cumbersome program rules have presented bureaucratic challenges.

Remember, when it comes to outbreak response, local health departments are at the front lines. But when it comes to funding, resources and communications, we are at the end of the line. Can we change this?


It would be prudent to develop laws for local health agencies authorizing a better response to major public health emergencies. Here are a few suggestions to develop a robust public health infrastructure.

1. Invest in public health workforce development. Often public health professionals come from an array of disciplines. They need to be trained into the core public health functions and essential services.

2. Appoint at least one trained epidemiologist in each local or district health department, who is capable of making use of data for assessing risk to enhance decision making, especially in emerging public health emergencies.

3. Establish direct two-way communication lines with federal partners such as CDC, FDA and FEMA to ensure the consistency and effectiveness of information and local decision-making.

4. Expand Iowa’s State Hygienic Laboratory’s capacity using new technologies so that timely testing and results can be obtained to assure rapid recognition and response.

5. Ensure governing boards are independent, without political agendas, to promote scientific data-driven response and policies.

6. Governing boards of health should have legislatively mandated authority to make local decisions based on local needs, such as shelter-in-place to protect public’s health.

7. Municipalities in larger counties in Iowa should consider assisting their health departments with resources.


In the meantime, your health department continues to strongly urge our residents to wear cloth face coverings, watch your distance and wash your hands to reduce/avoid the spread of COVID-19.

As far as my mother, she is resting at home, back from the hospital, still with uncertain prognosis. I haven’t seen her in nearly two years. As soon as the air transport opens, I’ll be on the first plane departing for India.

Pramod Dwivedi is health director for Linn County Public Health.

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