Envisioning a 21st Century Public Health Department in Pima County

Former President Donald Trump got it. His lawyer Rudy Giuliani got it. This winter, Ken Wells of Arizona got it too: an infusion of monoclonal antibodies, one of the only effective treatments available for high-risk patients with COVID-19.

Wells said that the therapy made a big difference in his recovery from the virus. “If the purpose of it is to keep people out of the hospital,” he told ABC reporters, “it’s helped me.”

The story of how Wells received a treatment that many have never even heard of connects back to the director of the Pima County Health Department: Dr. Theresa Cullen, a family physician, former assistant U.S. surgeon general, and one-time volunteer with Partners In Health in Sierra Leone.  Now, Cullen is once again collaborating with PIH, this time to alleviate COVID-19’s toll in hard-hit Pima County.

A COVID-19 Hot Spot

Cullen’s first day as health director in this southern Arizona county on the U.S.-Mexico border was May 1, 2020. “I wasn’t planning on coming into a pandemic,” she said.

But that’s exactly what she did. In less than a year Arizona would become “the hot spot of the world,” during the January surge, with the worst new infection rate of any state in the nation.

In Pima County, Cullen says, 1 in 450 residents have died of COVID-19:

“Everyone knows someone who knows someone.”

But Cullen suspected that promoting “aggressive access” to monoclonal antibody therapy as part of the county’s overall pandemic response might help curb those numbers. In national studies, these antibody treatments were shown to reduce hospitalizations and death by up to 70%. Of the many hundreds of patients who received it in Pima County, only a handful have been hospitalized, according to anecdotal reports from administrators.

Monoclonal antibodies are synthetic drugs that mimic the body’s natural antibodies, amping up the immune response to SARS-CoV-2, the virus that causes COVID-19. When VIP patients like Trump and Giuliani received the therapy last year, it wasn’t yet approved for the general public. In November, though, the FDA granted the drugs emergency use authorization for the treatment of patients with mild to moderate symptoms at high risk of being hospitalized.

Removing Barriers

But obstacles have plagued this treatment from the start.

First, the drugs must be delivered intravenously at a medical facility, with appointments taking two to three hours from start to finish. Many hospitals and health centers, already at capacity and overwhelmed by emergency cases during the winter surge, did not have the staff, space, or logistical support to establish these infusion centers. Also, to be most effective, the antibody therapy must begin within about 72 hours after the onset of symptoms (though it can be administered up to 10 days after symptoms start). 

Although the drugs are costly, the federal government sought to remove this barrier, buying one million doses this winter so that local health providers could more freely offer it to patients. Still, uptake remained sluggish.

Enter Dr. Cullen and her team. Once the drugs became available, she mobilized the health department to help coordinate the state’s supply that was being distributed to Pima County, reaching out to hospitals and care facilities.  At first, she said, there were few takers. Facilities and health care networks were overwhelmed with providing acute care. Cullen kept at it, connecting with an old friend, Dr. John Redd, the chief medical officer and assistant secretary for preparedness and response with the U.S. Department of Health and Human Services. In January, Cullen helped negotiate a pilot program, which has since been extended, at Tucson Medical Center. It was the second such program in the nation. Now, other facilities in the state and across the U.S, have extended the provision of the therapy, increasing accessibility.

Access and Accompaniment

Cullen says the key to high quality treatment and care for all patients -- and to her view of public health in general  -- is access and accompaniment. These principles, she says, came into sharp focus for her during the 2014 Ebola outbreak in West Africa, when Cullen, volunteering with PIH, helped set up a specialized unit for pregnant women exposed to Ebola so they could safely receive care and treatment.

That experience, she said, crystallized her commitment to public health at the community level. “If not for that, I wouldn’t be here today.”

To ensure that every patient in Pima County knew about the effectiveness and availability of monoclonal antibody treatment, Cullen partnered with local officials and others to amplify the message: her team organized a press conference held outside the medical center which was covered by TV, radio, and print media.

Dr. Redd, who also knew Cullen from their time in Sierra Leone, where he worked for the CDC overseeing the U.S. response during the Ebola outbreak, traveled to Arizona for the clinic’s opening event. He implored residents to use the monoclonal antibody therapeutics “avidly, quickly and as widely as possible.”  The drugs, he said, were “bought by the United States government for the people of the United States. These are meant for everyone and they are cost free. There is no ID check.”

Most critically, Cullen said, the health department decided to alert every positive case in the county to the free monoclonal antibody therapy if they qualified. That meant rewriting the scripts used by health workers handling contact tracing and case investigation. The task went to colleagues at PIH assisting with COVID-19 response in Pima County.

Cecelia Rose English, PIH’s senior project lead in Pima County, said as soon as the antibody treatment became available, her team added language to the scripts explaining the therapy and its eligibility requirements, both in English and Spanish.

That’s critical in this county, where nearly one-third of the population identifies as Latino and/or Hispanic and approximately one-fourth of residents speak Spanish at home; about 20% of the county population lives below the federal poverty line. Pima county also encompasses the Tohono O’odham Nation and the Pascua Yaqui Tribe with approximately 34,000 Native American residents; nearly one-third are unemployed, nearly 40% have less than a high school education, and 40% of Tribal members on the Nations live below the federal poverty level, according to census data.

PIH, through its U.S Public Health Accompaniment Unit (USPHAU), has been supporting the county’s overall pandemic response on several fronts -- from training contact tracers and case investigators to testing and equitable vaccine planning -- since shortly after Cullen arrived.  Launched last May, the USPHAU is currently working with cities, states, and communities throughout the country that have borne the brunt of the pandemic.

Racism as a Public Health Crisis

Beyond any particular treatment, Cullen says, COVID-19 has forced a nationwide reckoning: illness can’t be fully understood outside of its larger social and political context. The virus has exposed the deep, long standing economic and medical inequities in the U.S. fueled by this country’s history of racism. Cullen said it’s important to call this out explicitly. That’s why, in November, the health department supported the Pima Board of Supervisors in passing a resolution declaring racism a public health crisis. Joining about 70 other counties across the country, Pima administrators concluded that “racial and ethnic health disparities and income inequality in the county” has become an emergency. The resolution pledged, among other things, to expand the county health equity program and ensure a more just, fair pandemic response and future recovery.

PIH is deeply involved in these efforts and, says Cullen, critical to their success. English, the senior project lead, said her team helped forge the partnership between the health department and the Tucson Indian Center, which offers health and other essential support services to nearly 20,000 urban indigenous residents of Pima County who, because they do not live or work on one of the two Tribal Nations there, can’t access needed resources.  The USPHAU is also assisting the health department to coordinate safe back-to-school plans.  And, with USPHAU support, Pima County care resource coordinators helped more than 10,000 individuals and families connect with essential health and medical resources, from keeping the electricity on to coordinating mental health services for people suffering from anxiety and depression. 

Now, English says, while her team continues to support the emergency response, including vaccine messaging and access, they’ve also been asked to collaborate on Pima County’s ambitious new plan to “recover and rebuild” a resilient public health department of the 21st century that is stronger, more equitable and better attuned to the community’s needs.

English says what’s exciting about the Pima County engagement is the collaboration alongside a broad, diverse group of partners.

“Some days we are ‘in the weeds,’ working on a specific challenge such as scripting and data fields,” she says. “Other days we are helping the health department leadership white board a ‘Post-COVID Recovery Strategy,’ or providing policy recommendations that would impact all of the county’s 1.1 million community members. We are constantly learning and adapting our approach to ensure health equity is always front and center."

"Yes, we are working on COVID-19 response, but perhaps more importantly, we're also helping to transform the culture of the health department.”

Restoration and Resilience

To that end, Cullen recently met with Black church leaders about vaccine rollout plans. She was peppered with questions for about an hour. Why should people trust the vaccine when it hasn’t been studied long term? What about the new variants? Why is Bill Gates involved? Does it alter your DNA? (It does not.)

With each question, she responded calmly and earnestly, frankly acknowledging the health system’s profound flaws. “We know that people of color have suffered more than other people,” she said. “We just have to acknowledge that African American, American Indian, Alaskan Natives, Hispanic populations have died, and gotten the disease at a much higher rate than any other group in the county and in the country. And those groups are the same groups that have had less access to the vaccine.”

Cullen closed the discussion by noting a few “good things” about COVID-19.

“The one I’m struck by is that COVID-19 has given us this opportunity as a health department to reach out and engage with communities that we probably skittered by...but didn’t have a true collaboration with," she said. "I'm hoping that this is the beginning of that as we move forward...There is a time after COVID-19, and [with] restorative justice and resiliency, we can work together to build a healthier community.”