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‘It never mattered more’: Missouri’s underfunded public health departments struggled to ramp up COVID response
A year of COVID-19

‘It never mattered more’: Missouri’s underfunded public health departments struggled to ramp up COVID response

From the A year of the pandemic, and its impacts on hospitals, government, nursing homes and residents, and health departments series
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ST. LOUIS — Spring Schmidt remembers back in late February 2020, just a few weeks before Missouri’s first coronavirus case was reported, when the St. Louis County Department of Public Health was among the first to get testing kits.

It had only 10, reserved for people with symptoms who had traveled from high-risk countries, said Schmidt, deputy health department director. When needed, health department staff would deliver a kit to a hospital where the tests were administered.

Back then, the Missouri Department of Health and Senior Services sent documents by fax or email about county residents who had traveled and needed to quarantine. St. Louis County’s four communicable disease nurses and a manager checked on those residents twice a day.

As the number of cases grew, contact tracing — identifying individuals an infected person may have encountered — was done with phone calls, written notes and folders.

“This was the infrastructure when we started. Everything was on paper. It was done by hand. We drove tests to different hospital systems to meet someone there,” Schmidt said.

The pandemic forced Missouri’s resource-strapped local public health departments to respond quickly and dramatically. As the most populous county in the state, St. Louis County would eventually be hit the hardest — with nearly 90,000 cases and over 2,000 deaths. At the highest point in the fall, the county would top 1,000 cases in one day.

With small staffs and dwindling funds, the 114 local public health departments across Missouri shouldered the enormous burden of the response. The little-thought-of health departments were suddenly needed by everyone in the community.

“We would set up a customer service line and break it in four hours from the number of people calling us,” Schmidt said. “Then, ‘OK, we need another customer service line and a bigger customer service line,’ and we would break that in 14 hours.”

Staff were slammed with questions that scientists were still trying to figure out. Every week, the departments were tasked with something new — finding personal protective equipment, getting more tests, organizing testing sites, expanding contact tracing, figuring out business and activity restrictions, reviewing event plans and eventually, administering vaccine.

“I had staff who I’m not sure they left the building for months,” Schmidt said. “I camped at our emergency operations center for several days.”

The county health department created a team just to work with businesses to review their safety plans, answer questions and handle complaints, she said.

“How do you take what is a good practice like you should keep 6 feet distance, and then translate that into the minutiae of how does that work in a restaurant? How does that work in a grocery store? How does that work in a business, and what if you are in queues, and what if there’s a fan blowing?” Schmidt said.

Health departments are typically tasked with important efforts, including restaurant inspections, childhood immunizations, tracking foodborne illnesses, mosquito control and preventing sexually transmitted diseases. But since 2010, spending for local health departments has fallen by 18%, according to a Kaiser Health Network and Associated Press analysis.

Missouri ranks 50th in the nation for the amount of state money dedicated to public health, with a per person rate of $7 in 2019, according to the State Health Access Data Assistance Center. The rate has changed little since 2005, when it was $8.

Federal emergency dollars help health departments during outbreaks such as H1N1, anthrax or Ebola; but then dry up when the problem goes away, said Larry Jones, director of the Missouri Center for Public Health Excellence.

“You wouldn’t think about trying to do that with your fire or police department,” Jones said. “We wouldn’t try to go out and hire firemen to put out a fire every time that a fire comes along. We want to have a fire department that’s available if our house catches on fire, and we need to be thinking about public health that same way.”

The St. Louis County health department has not seen an increase in revenue from its property tax allocation since 1984, Schmidt said. Twice it has been decreased.

For fiscal year 2021, the St. Louis County Council raised the health department’s appropriation from $60 million to $76 million.

The health department received $53 million in federal coronavirus relief funds, which was “transformational,” Schmidt said, to create computer and software systems to collect, store and share data. It added 150 to 175 positions to its 525. It paid contractors to help with technical support and data analysis.

“It gave us massive opportunities to build infrastructure rapidly,” Schmidt said. “By this fall, when we were rolling with 700, 800, 900 cases a day, we had a fully electronic system that was monitoring and reminding people and tracking case notes and pulling many of our statistics together that were automatically updating on our website. That didn’t exist five months prior.”

Threats, challenges

The Jefferson County Health Department used its $4.5 million in federal relief funds to go from 50 to 90 employees and to pay contractors for contact tracing services, said director Kelley Vollmar. She’s unsure what kind of staff she’ll be able to maintain in the future.

Departments are seeking federal assistance to help with vaccine deployment, but the money is needed now. At the end of February, the St. Louis County Health Department administered a record 9,000 doses in one week.

Vollmar said a consistent investment in public health would allow departments to maintain staff and make more upgrades such as a unified computer reporting system between state and local health departments.

“You wouldn’t have to worry about the buildup and decrease of the staff and resources, because they would be there,” she said.

On top of it all, health departments took the brunt of public anger over restrictions and prevention measures such as mask mandates. Directors and staff reported being harassed and threatened over the phone and on social media. More than a dozen directors across the state quit their jobs.

Republican-sponsored bills seeking to restrict local health officials’ ability to impose emergency health orders that curtail business operations are now making their way through the state Legislature.

Vollmar said public health officials have learned they have to walk a fine line.

“You can’t put half the effort in and expect to get the full result of what you need to keep people safe. But on the flip side, you have to be very careful, because everything that we’ve tried to do for the past year to keep people safe is coming back to potentially impact public health as we know it at the local level in terms of our authorities and our abilities,” she said. “It’s kind of a scary position to be in.”

Vollmar, who spoke publicly about the harassment she and her staff faced, said distributing vaccine has been the antidote to their frustration and stress.

“It’s almost therapy,” she said. “People are happy and are thankful. For a troupe of health care workers who have been hitting the wall for the past eight months, there is nothing sweeter to their ears than to hear, ‘thank you, thank you.’”

Schmidt acknowledges that they made mistakes moving so quickly. She wishes restrictions could have been the same across counties so residents didn’t feel unfairly treated.

“It is the most challenging possible time to be a public health official. It never mattered more,” Schmidt said. “But we are also community members who live here, who have been sick, who have had family members catch COVID. We are of our community, not some separate entity telling our community what to do, and we started from scratch and did everything we could to fulfill our mission and be there for people as much as we could.”

Saint Louis County has launched a pilot program to deliver the COVID-19 vaccine to those who are unable to leave their homes, County Executive Dr. Sam Page announced Wednesday morning. The County hopes to make this service fully available by March 18. Video courtesy St. Louis County

Photos: St. Louis County holds mass vaccination

St. Louis County held a mass vaccination clinic at the North County Recreation Center on March 6, 2021. The clinic administered the Johnson & Johnson vaccine for anyone getting their initial shot, and the Pfizer-BioNtech vaccine for those getting their second dose. "I'm just so excited to be in the same room as my family again," said Cheryl Hamm, a vaccine recipient. "It's going to be amazing." 

 

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