By Fabian Donate

Looking at the way the health system in Nevada is structured, it is easy to identify plenty of disparities in the ways that care is accessed and delivered. For example, right now, there is a large disconnect between rural and urbanized health. In order to receive specialized care, some Nevadans in rural areas have to travel greater distances to visit a nearby metropolitan area, usually Las Vegas or Reno, to obtain further information on their diagnosis. The disparity becomes apparent when you realize that these two cities are approximately 400 miles apart from one another. 

Again and again, we’ve become accustomed to the fact that Nevada will always be ranked dead last for any particular socioeconomic study or health outcome. In regards to health care quality measures, Nevada is clustered among the ‘Bottom 10’ states for poor care services and access to clinical specialties. For mental health, Nevada is ranked last for mental illness prevalence and access to care. The list goes on and on — high rates of food insecurity, high rates of uninsured patients, one of the least educated states in the nation. Getting tired yet?

If there’s anything valuable to be learned from these past few months about Nevada’s response to the COVID-19 pandemic, it is  this: we have failed to prioritize public health. 

Pre-COVID-19 support

Up until recently, the UNR School of Medicine was the only public institution in the state facilitating the educational pipeline of physicians into Nevada’s workforce. When the UNLV School of Medicine was conceptualized in 2013, community leaders and public officials stressed the importance of this new institution as a mechanism to address the physician shortage in Southern Nevada. Essentially, the UNLV School of Medicine will help spearhead the development of the Las Vegas Medical District, provide innovative medical education to local students, and is expected to have an economic impact of $1.2 billion by 2030 — an effort that will monumentally change the way health care is delivered within Southern Nevada. 

The investment in the establishment of the UNLV School of Medicine is one prime example of how statewide collaboration can be utilized to address persistent shortcomings in the health and well-being of our communities. There is no denying the impact of what the UNLV School of Medicine will provide for local residents, both economically and in terms of accessibility to health services. However, any assumption that this new medical education institution is the end-all solution to address health disparities within Southern Nevada is detrimental and misaligned.

Nevada needs an awakening

During his 2019 State of the State address, Gov. Sisolak pledged support for mental health funding, protecting the Affordable Care Act, and addressing health policy issues. Sisolak has championed public health, especially with regards to acting swiftly to protect Nevadans amid the COVID-19 pandemic. As we’re witnessing in real-time, the wounds caused by longstanding health disparities are deep and systemic. The COVID-19 pandemic is beginning to take a heavy toll on marginalized communities, specifically amongst the Latinx and African American subpopulations. 

When Nevada casinos were given the green light to reopen in early June, casino executives made strides to develop prevention plans to mitigate the spread of the COVID-19 virus. Glass barriers were installed near gambling tables; casino floor interactions were limited; operation plans were introduced to detect high employee temperatures; and go-go dancers were equipped with face shields for prevention. Casino executives were desperate to reopen their doors, looking to restart their resorts and immediately return to profiting off of tourism — and the labor of a largely Black and Latinx workforce. With continued miscommunication and misinformation provided at the local, state, and national level, these plans were and destined to fail. The biggest oversight? Guests, by the thousands, were swarming around indoors without any face masks. 

Approximately three weeks went by before casino executives began to require all guests to follow social-distancing procedures and to utilize face masks. It got so bad, Gov. Sisolak had to step in by late-June to provide some guidance on how to address the uptick of coronavirus cases. While the COVID-19 pandemic itself may have been a difficult event to prepare for, casino executives failed to properly respond to this public health crisis during the reopening stage, and it was evident that they weren’t readily equipped with the knowledge or experience to mitigate this challenge. It jeopardized the health of their frontline employees, and now the Culinary Union is stepping in to confront this issue head-on. 

Maybe not enough public health professionals were at the decision-making table to voice their opposition, or maybe casinos were negligent in preparing for the reopening. From what we can see already, it will take a lot more than a governor’s pen to redefine Nevada’s public health system. 

The challenge and opportunity

Here’s the hardest part about this conversation – we know it’s coming and we’ve been here before during the 2008 recession – budget cuts. It’s a subject that no one ever wants to talk about, but it’s an inevitable reality for a small state that will need to make bold decisions from the economic impact caused by an international pandemic. 

Right now, Gov. Sisolak’s budget proposal is reflecting changes to agency budgets, transferring funds, and making budget adjustments to close the economic gap that was created from this public health crisis. Under the proposed plan, the Department of Health and Human Services will face a whopping $233 million in budget cuts (including devastating cuts to Medicaid reimbursement for providers and the elimination of coverage for certain procedures for Medicaid members), unless Nevada legislators can come together to find alternative solutions. Although everyone in Carson City is afraid to use the T-word, I confront this directly: some sort of new tax increase(s) will be needed now, and in the future, to invest in a public health system and in these vulnerable populations in order to mitigate a future similar crisis, should one occur. 

The challenges that Nevada will face are the same as before – finding new revenue streams, strategizing ways to diversify the economy, and spearheading innovation to solve problems (i.e. water shortages, physician ratios, solar-powered hotels, etc.). We have to accept the reality that an underfunded state cannot stand by itself anymore, and it’s well beyond time to accept the notion that more must be done to protect the health of Nevadans. Here’s my sketch for how we can get it done:

• For casino executives: Public health opportunities are endless. This pandemic must be a lesson on how we can redesign casino floors, prioritize employee wellness (beyond the standard health fair), and strategize on ways to place tourism health first. Nevada has always branded itself as the innovator of entertainment. The same spirit can be applied to redefining the guest experience and improving public health. Look at incorporating telemedicine into hotel rooms, offering more smoke-free zones, or installing quick care vendors into the casino landscape. Could you imagine feeling sick as a tourist, and knowing that your casino has the luxury of a ready-to-go practitioner at your service? That’s a sense of security that will definitely expand a casino’s position as a ‘gold standard’ hospitality provider. Casino owners must do their part to invest in the public health infrastructure of Nevada, hire more public health graduates or a chief public health officer, and find innovative solutions to deliver care to guests. They should require that management to be trained in public health, beyond the standard food handling measures that are instituted. Use this moment to position Las Vegas as the new capital of health tourism, offering the best practitioners and services anywhere in the world. 

• For statewide policy makers: Invest in public health beyond handing funds over to an institution or providing tax incentives for a large corporation. If, as an elected official, you really care about public health and the wellness of your constituents, take the time to learn about the Health in All Policies (HiAP) framework and how you can support local communities and state counties. Identify new revenue streams, with the inclusion of taxes, and find ways that you can support the infrastructure of a new Nevada. The more that we pay attention to the marginalized communities that are often left behind, the more that we can work to solve persistent health disparities. Create a policy to support translational services in health care, increase health literacy and education spending, support clinical education programs, and do your part to provide significant funding to both UNLV’s and UNR’s public health programs. Lastly, it’s time to make the move to an annual legislative session; it will allow you to cover more ground and respond in a timely manner on some of the issues that you are seeing.

• For community partners: Champion health innovation and provide leverage to local systems across the state with unmet needs. If your organization doesn’t have a strategy to incorporate public health in some way, whether it’s in the services that you deliver or the infrastructure that you support, now is the time to make that change. All types of institutions have the opportunity to support and enhance the public health infrastructure within the state. Invest in social entrepreneurs that want to solve health disparities, support public health education programs (like community farming) in K-12 schools, and do your part to start a new movement that prioritizes health as the ‘main driver’ of policy. 

• For local public servants: Make a profound change to the ways in which Nevadans live their everyday lives. Invest in mixed housing; change the blueprints that communities and transportation systems are built upon; support marginalized groups; enhance public recreational services for underserved areas; and solve the inequities created by food swamps/food deserts. Work with state officials to change Nevada’s food system, codify public health in the education curriculum, and incorporate public health as part of strategic plans in your communities. 

• For the everyday reader: Volunteer and donate to local nonprofit organizations. There are plenty of organizations that are already doing the work needed to accomplish this, like Make the Road NV, Three Square, Immunize Nevada, etc. It is also important to do your part to elect government officials who will support a ‘healthier’ economy. As Nevadans, we are the lifeline of this movement, and we need to invest our time and financial resources in people and organizations who will do this vital work. 

When I graduated from the UNLV School of Public Health, I knew that my home state was not ready to facilitate a proper conversation on the total health of its residents. Now more than ever, Nevadans are realizing that this moment has called to action the immediate need for a comprehensive reform, one that encompasses support for public health research and innovation, strengthening epidemiologic surveillance, reducing health disparities, and uplifting the health workforce in its entirety. 

Public health itself is an interdisciplinary and multi-dimensional field, meaning that it requires different sectors to collaborate with one another to develop strategies that will reduce the social determinants of poor health. If you prioritize the right strategies and adopt a commitment to public health,  the long-term return of this investment will be something worth being proud of. It’s never too late to make this change; now is the time for Nevadans to step forward. 

Fabian Donate is a native of Las Vegas, where his family still lives, and a recent alumnus of the UNLV School of Public Health. He is pursuing his Master's in Health Administration (MHA) degree at the University of Maryland. Follow him on twitter @fabiandonate or email him at [email protected]