Hard lessons from a city that tried to privatize public health

If you were growing up in Detroit in the 1970s or '80s, chances are you knew the city's Herman Kiefer public health complex by both sight and reputation.

Opened at the turn of the century and later enhanced by renowned industrial architect Albert Kahn, the imposing brick complex was named after a local infectious disease doctor. As the city grew, so did the complex and the services offered within, becoming synonymous with public health in the eyes of many families and residents.

For decades, it was where you went to pick up birth records, get tested for tuberculosis, get vaccines or undergo discreet diagnosis and services for sexually transmitted diseases. It was even a place some parents told their children to go to if they needed help — the way other parents tell their kids to go to the police if they're in trouble.

That was before the lean years that led into the Great Recession of 2008. By the time the complex was abandoned more or less overnight in 2013, it had fallen into vermin-infested disrepair and held a fraction of the dedicated employees who had once walked its halls. City officials gave up on the building — and dismantled the public health department it had come to represent. Eventually, the city sold Herman Kiefer to an out-of-town developer, who has marketed it as a commercial complex.

Across the nation, public health departments have seen dramatic cuts over the past decade. It is a nationwide phenomenon, hitting communities big and small, rich and poor. When state and local government revenues falter, health departments are often the first to lose funding.

When politicians shutter a school or close a subway stop, the impacts are immediate and visible, sparking sharp public blowback. But when a health department fires its contact tracers or closes its infectious diseases lab or stops testing children for lead exposure, the impact is more subtle.

At least at first.

Detroit often experiences a magnified version of the nation's economic and health woes, and the same holds true of its experiment to streamline and privatize public health services. A health department that had 700 employees in 2008 had just five by the end of 2012. Though it has slowly been rebuilding since 2014 — it now employs approximately 270 people — damage done during the leanest years has been on stark display amid the ravages of the covid-19 pandemic.​

Vernice Davis Anthony loves thinking back on the good years. In the 1970s, she was one of dozens of public health nurses working for the Detroit Health Department. Originally from Pennsylvania, Davis Anthony moved to Detroit to attend nursing school at Wayne State University, where, as a young Black woman, she'd heard she could get a fair shot at an education and career in the majority-Black city.

She and her co-workers walked the neighborhoods building connections and trust, visited the home of every new mom, and worked in schools, tracking cases of infectious diseases and making sure kids got immunized. Wearing health department badges and uniforms, she particularly liked doing home visits in vibrant Southwest Detroit, then home to Puerto Ricans, Mexicans, Middle Easterners, Appalachian whites and Southern Blacks. The power dynamic captivated her: Unlike a hospital, where doctors and administrators ran the show, the families ultimately decided whether she could come in. "When you are in their home, the balance of power has shifted," she said.

In those days, she said, the health department had resources to back up its mission, including a world-class laboratory and a pharmacy that provided discounted medicines to residents. It ran clinics throughout the city's sprawling neighborhoods.

It also had political clout. When AIDS emerged as a devastating public health threat in the early 1980s, at the same time intravenous drug use had become rampant in some neighborhoods, the health department funded community groups to educate residents on the dangers of the human immunodeficiency virus and sharing needles.

George Gaines, then the city's deputy health director, recalled a conversation in the 1980s when he pleaded with Mayor Coleman Young to let him hand out clean needles to drug users, a controversial topic even today. "Give them the needles," he said Young told him. "Just keep your name out of the paper."

For years, Gaines dedicated resources to drug treatment programs aimed at helping poor inner-city families, even as federal funding for drug addiction was slashed.

While there's no way to prove those early efforts prevented an explosion of HIV, said Eve Mokotoff, who handled HIV data for Michigan from 1986 through 2012, that work was clearly vital in turning attention to the threat HIV posed in low-income Black communities even as much of the nation's medical community focused primarily on the threat to gay white men.

The people leading the health department at the time had "a fierce love for that city, and fierce in the most positive sense of the word," Mokotoff said. "When they saw this was going to happen, they weren't going to close their eyes to it. They weren't sitting ducks. They wanted to prevent it."

Those were the gratifying years when Detroit health officials were often called in by other cities to teach strategies for lowering rates of child lead poisoning, HIV infections and Black infant mortality.

Gaines can hardly fathom how it all fell apart so fast.

In the final decades of the 20th century, white flight to the suburbs, the struggles of the auto industry and offshoring of manufacturing all hit Detroit hard. Then came the predatory lending that helped trigger the Great Recession.

From 2008 to 2010, with the city's tax base shrinking, the health department shed more than 70% of its employees. By 2012, Mayor Dave Bing, a professional basketball player turned businessman, was preparing the city for bankruptcy. Told they had to cut costs further, leaders of the stripped-to-the-bone health department made a radical proposal: privatize and outsource services by handing nearly all their work to a nonprofit to be assembled from scratch and dubbed the Institute for Population Health.

Health departments around the country have survived perennial funding declines by turning to grants and private entities to carry out some of their work. What was unprecedented about Detroit was that it wasn't just a few programs to be outsourced; it was essentially all of the city's health services.

Those involved say it was a necessary step to save the department from the volatility of the municipal bankruptcy and the weight of union and pension obligations. In theory, it would allow the city to maintain its core health mission, even as it went through a financial overhaul.

But critics say the arrangement had nothing to do with the well-being of residents. "It was not a decision made to improve the health of people. It was purely an economic decision," said Phyllis Meadows, director of the city health department from 2004 to 2009. "This was political health; it wasn't public health."

Though a messy battle over the plan ensued — by Michigan law, the city was obligated to provide certain public health services — Bing won. By October 2012, health services were no longer housed at Herman Kiefer and nearly all the department's duties had been outsourced to the new nonprofit. The following year, the governor installed an "emergency manager" whose powers superseded those of elected officials.

Davis Anthony, who had moved on to other health agencies, initially supported the reorganization and returned to run the stripped-down, five-person city department that remained from 2012 to 2014. But her experience ultimately led her to believe public health at its very core must be a government function. The skeletal city staff was too small to provide proper oversight of public funds. "When you have public health funding that's going directly from the state to a nonprofit without any accountability, that was a problem," she said.

Community organizers and former employees say the nonprofit may have been well-meaning, but public health all but disappeared from many Detroiters' lives. Residents had no say in funding priorities. And there was no government agency with expertise and political support to serve as a backstop for the health of residents.

A local health department is charged with prevention, protection and health promotion, said Robert Pestronk, former health officer for Genesee County, Michigan, home to Flint, and former executive director of the National Association of County and City Health Officials. "It's not about conducting business. It's to make sure there's a place in our society where the roots are nourished by those concepts." Underfunding undermines that role, he said. "We live in a culture where, if you have resources, you gain some respect."

After the privatization, health officials lost the political influence needed to protect residents from basic threats, said former employees and city residents. That includes remaining largely silent as Detroit's Water and Sewerage Department, struggling with its own bankruptcy filing, began shutting off water to the homes of people late paying their bills. From 2014 to 2020, an estimated 141,000 customers lost water at some point. The shutoffs were crushing for low-income residents, many of them Black families, living in neighborhoods already buckling under the weight of the city's economic collapse.

"How are they going to use the restrooms? How are they going to cook? How are they going to prepare formula for babies?" said Dr. Kanzoni Asabigi, who held top public health positions with the city before abruptly retiring in May 2020 over disappointment at city officials' response to the pandemic. "Everybody needs water to live."

Gaines was so disgusted by the water shutoffs that at 90 years old he conducted research on the health effects in hopes elected officials would end the policy. Instead, it took a global pandemic. As officials nationwide advised Americans to wash their hands to fight the new coronavirus, Michigan Gov. Gretchen Whitmer issued a temporary moratorium on water shutoffs. In mid-December, Detroit Mayor Mike Duggan announced a plan to extend the moratorium through 2022.

It was Duggan who initiated the return of public health services to government control when he took office in 2014, less than two years after the department was all but shuttered. But rebuilding has been a painful process.

Duggan hired as executive health director Abdul El-Sayed, a native of the Detroit suburbs who was then a professor of public health at Columbia University. His first order of business was to move the department out of a conference room in the back of the city parking department. He then was tasked with revamping animal control, yet another of the department's duties, to combat negative headlines generated by the shelter's high kill rate.

From there, his job became contentious, as he got into public feuds with his boss over a range of health issues: refineries that were spewing toxic fumes in a city overburdened by asthma, sweeping neighborhood demolitions that communities believed were causing increases in child lead poisoning, and the water shutoffs to tens of thousands of Detroiters. He said he didn't play the politics well but felt compelled to weigh in.

"There's not that much money in making sure that babies have what they need to thrive. There's not that much money in making sure that restaurants are up to code," said El-Sayed. "If there was, private industry would hop to do it."

After less than two years with the department, he resigned to wage an unsuccessful run for governor.

El-Sayed was succeeded in 2017 by Dr. Joneigh Khaldun. She had joined the department as medical director the previous year, coming home to Michigan after serving as chief medical officer in the Baltimore City Health Department, which has 900 employees for a population 10% smaller than Detroit's. When Detroit was hit by an outbreak of hepatitis A in 2016 during her first week on the job, she recalled, the city had no public health lab; she didn't know where to find its contact tracers, who were state employees, and there was no protocol for a vaccination campaign.

"That infrastructure of, how do you quickly respond to an outbreak? How do you stand up clinics? How do you get the communications out so that people know where to go? That was not there," Khaldun said.

Khaldun left in 2019 to become the chief medical executive for Michigan's Department of Health and Human Services. When covid arrived in March 2020, the fledgling system she had set up with colleagues was Detroit's first line of defense. Amid the feeble response, the coronavirus cut a broad and deadly swath through the city, quickly overwhelming area hospitals and hitting hard in tightknit communities of health care workers, churchgoers and ballroom dancers.

In the year since, 1 in 10 Detroiters have been infected with covid and more than 2,400 have died — more than twice the number in Baltimore. Detroit's covid death rate is roughly double the national rate.

The pandemic has raised the department's profile, but officials are struggling to win back the community's trust. When the Centers for Disease Control and Prevention updated its mask guidance in May, saying indoor masking was no longer necessary among fully vaccinated people, just 20% of Detroit residents met that definition. Nearly three months later, just 34% of the city's residents are vaccinated, compared with 54% of Michigan residents and 50% of U.S. residents overall.

And with all hands on deck to fight covid, neglected public health issues have plunged into deeper obscurity. Programs to prevent and treat childhood lead poisoning were put on hold. The childhood vaccination rates against diseases like measles and mumps have dipped below 50%.

On nearly every health measure — HIV rates, health insurance coverage, drug-related deaths, smoking, STDs, vaccination rates, asthma and obesity — Detroiters are faring worse than Michiganders as a whole. While the average life expectancy in Michigan is 78, it is 72 in Detroit, with some neighborhoods falling as low as 62. Maternal mortality is nearly triple the state average, as is infant mortality. A 2018 health needs assessment found that 9% of children under age 6 have blood lead levels elevated above accepted thresholds, a figure that jumps to 22% in some neighborhoods.

For all the federal relief money that came pouring in for covid, the health department still lacks the resources for even the most basic services. In May, the Detroit City Council approved an $87,000 contract to outsource testing related to sexual and reproductive health. Residents who are tested at a city clinic for HIV, STDs or pregnancy-related concerns will have their labs sent to San Antonio for processing.

Today, Detroit's health department has an operating budget of $41.7 million, money that mostly comes from state and federal funds or grants.

"The pandemic really put the issue of health care disparities in everybody's face," said Davis Anthony, and that gives her hope that the city and state will continue to reinfuse the department with resources. But even if that happens, restoring its place in city life after years of absence isn't a given. "It's going to be a difficult road to travel," she said.