In Ripley County, if you want to get tested for the novel coronavirus, your options are limited.
It's been two years since the county's hospital closed its doors. An urgent care clinic that offers COVID tests has opened in its place, but it's only open weekdays. Sometimes mobile drive-through testing sites come through. However, many residents simply drive 30 miles to Poplar Bluff or across the state line to Arkansas to find one, said Jan Morrow, the director of the Ripley County Public Health Center.
An Abbott machine that would allow them to conduct rapid COVID tests was supposed to arrive at the beginning of the month. However, it's on backorder. And Morrow will probably need to hire someone to administer those tests.
Morrow has had to make decisions on what supplies are essential all while hoping purchases and time will be reimbursed through CARES Act funds. She's received more than $58,000 so far for the months of March through June, with more on the way.
Others aren't so lucky.
In Shelby County, the public health department has only been approved for $7,000 out of the $32,000 requested, said Audrey Gough, the department's administrator. And in the absence of CARES Act funding, she's had to dip into the department's savings to get by.
Local governments throughout the state were allocated roughly $520.9 million in CARES Act funding based on population, and county commissioners who are tasked with allocating those funds said they're trying to ensure all entities - from schools to nursing homes - are able to get a share.
Local public health administrators interviewed by the Missouri Independent said they believe funds should have been directly allocated to health departments from the start, just like they were for school districts. Some described the process to apply for CARES Act funds as "cumbersome," "frustrating," "a chore" and "a mess" that has left their departments behind in a public health emergency.
All the while, local health officials told the Independent that in the midst of dealing with an unprecedented public health emergency, they're experiencing an "emotional rollercoaster" as they try to curb the virus firsthand while sometimes facing backlash from their communities.
"They're our frontline soldiers," said Lynelle Phillips, the vice president of the Missouri Public Health Association. "And we're sending them into a pandemic perfect storm in a leaky little fishing boat."
Discrepancies in funding
Cities and counties with populations of more than 500,000 - which included the counties of St. Louis and Jackson in Missouri - were directly allocated a portion of the Coronavirus Relief Fund included in the CARES Act.
Under the supplemental appropriation bill Missouri lawmakers passed in April, the remaining counties received 25 percent of the state's CARES Act funds, divvied up based on population.
Public health departments have had varying degrees of success in securing CARES Act funds from their county commissioners.
According to a survey of local public health agencies by the Kansas City Star, of the 50 that responded, four health departments said they have not seen any CARES Act funds, while others have seen only a fraction of what they need.
Different counties have set their own priorities, while interpretations have differed on what counts as a reimbursable expense.
In Shelby County, Gough's biggest need is for her staff to be compensated for the long hours they're putting in. While her request for overtime was approved, using CARES Act funds to cover regular pay was not.
"I didn't plan for a pandemic, just like you wouldn't plan to have your roof blow off your house in a year's time," Gough said. "I'm sure you didn't budget for something tragic like that going on, but you still have to replace the roof on your house. That's the way COVID is."
Guidance from the U.S. Department of the Treasury notes the "full amount" of payroll and benefits may be covered through the CARES Act for employees "substantially dedicated" to responding to the pandemic, such as public health workers.
That's the way Cheryl Eversole, the administrator of the Dallas County Health Department, said she interprets it.
"But that is not how it is being interpreted in Dallas County," Eversole said.
Glenn Eagan, Shelby County's presiding commissioner and emergency management director, said while the commission understands regular hours can qualify for CARES Act funds, it ultimately decided the health department's normal budget should cover those hours.
Commissioners have had to balance the public health department's needs, along with a slew of requests from others, from their fire departments to their nursing homes.
Dick Burke, the executive director of the Missouri Association of Counties, said he thinks counties are trying to do the right thing, but it can be hard to find the right answer amid changing guidance.
"Nobody saw this coming," Burke said. "And we certainly didn't expect to see the counties get three quarters of a billion dollars sent to them in one day, essentially - that just doesn't happen. And then they all had to come up with a plan."
The issue of whether wages are an allowable expense under state guidance was "a recurring theme" that Adam Crumbliss, the director of the Department of Health and Senior Services' Division of Community and Public Health, raised in a Sept. 11 email to State Treasurer Scott Fitzpatrick; DHSS Randall Williams; Office of Administration Commissioner Sarah Steelman; Medicaid Director Todd Richardson; and Gov. Mike Parson's deputy chief of staff, Robert Knodell, among others.
In the email, obtained by the Independent through an open records request, Crumbliss wrote it appears state guidance needs to be clarified to say specifically that regular and overtime wages are allowable expenses.
"If the governing authority wants to deny them, there should at least be clarity on this matter that they can't point to the state guidance as the impediment," Crumbliss wrote. "I don't believe the governor or treasurer should bear the brunt of scapegoating for those that do not wish to honestly communicate their own disapproval."
Mary Compton, spokeswoman for Fitzpatrick, wrote in a statement Tuesday that the office's priority has been ensuring federal guidance is accessible to all counties, through multiple conference calls, answering specific questions and the office's COVID website.
"The treasurer is not concerned with who is bearing the brunt of scapegoating," Compton wrote. "He is concerned with ensuring local governments have the resources and answers they need to make necessary decisions."
Kelli Jones, the governor's spokeswoman, pointed to the General Assembly as the entity that decided counties would be the best caretakers for CARES Act funds locally, and said Parson distributed funds based on the budget they passed.
"The governor has continuously advocated, and spent many press briefings, urging counties to provide funding to their respective (local public health authority)" Jones wrote in an email Tuesday, noting Parson's work with the Treasurer's Office to streamline the process.
Williams said in a statement Monday that local public health agencies have been "true heroes," and the agency is constantly working to refine its processes.
In an Oct. 28 letter to county officials - his third urging them to use CARES Act funds to support local public health departments - Williams wrote that based on a DHSS survey, local public health departments "have indicated that they have collectively received an estimated 4 percent of the overall CARES Act funding that was distributed to county governments."
"We strongly encourage the support for your Local Public Health Agencies (LPHAs) through the use of CARES Act funding," Williams wrote. "While needs vary from county to county, what is synonymous across all counties in Missouri is that the public health systems and resources have been stretched extremely thin."
However, public health directors said the onus is on the state - which they believe should have handled the distribution of funds differently from the beginning.
In response to local public health authorities' issues, the Treasurer's Office introduced an optional "memorandum of understanding," in late August that would hold public health departments liable - rather than the counties themselves - for up to 15 percent of the county's CARES Act funding.
Distributions of CARES Act funds must be meticulously documented, and if improperly spent, may have to be returned to the state.
Lisa Cox, a spokeswoman for the state health department, wrote in an email that 16 counties signed MOU agreements with their public health departments, while 14 had declined the option, as of Oct. 26. According to a Sept. 21-24 survey of local public health agencies from DHSS, about 40 counties had not requested the option.
Randy Angst, Laclede County's presiding commissioner, said the county decided to forgo the MOU option because while it may have shielded the commission from some liability, they were concerned ultimately that the county would be held responsible as the MOU was not federal guidance directly from the U.S. Treasury.
Shelby County received $695,707 in CARES Act funds, but requests have been for nearly double that, totaling roughly $1.4 million, Eagan said. The county also decided against the memorandum option that would have allocated about $104,000 to the public health department if the full 15 percent was given.
"We just didn't feel like we could give $100,000 of the $700,000 we received to one entity when we had all these other requests," Eagan said.
The county has prioritized spending to boost its Wi-Fi and broadband capabilities to ensure students and parents working from home have the internet access they need, Eagan said.
It's been a confusing and cumbersome process for counties to navigate, too, some with small staffs who are also trying to prepare for the upcoming election.
"Every week, it seems to change. Every week, we get a little bit more clear on what we can do with the funds," said Chris May, Sullivan County's presiding commissioner, who has worked closely with the local health department to meet their needs.
An unsustainable pace
However, as cases rise across the state and take hold in more rural areas, public health departments said they need resources now - not later.
Since the beginning of October, counties with fewer than 50,000 people, with one-quarter of the state's population, have accounted for more than one-third of the new COVID-19 cases.
"It was like dangling a carrot in front of us knowing it was out there and not being able to get it," Juanita Welker, the administrator of the Bollinger County Health Center, said of CARES Act funds. Bollinger County, with 12,133 people, has the state's eighth-highest overall infection rate.
Time spent applying for funds and filling out paperwork is time that can't be spent working to respond to the pandemic at hand, administrators said. Their staff are working seven days a week, and it's a pace that's unsustainable.
"With the influx of cases on top of our normal workload, there's never enough hours in the day," said Deborah Taylor, administrator of the Sullivan County Public Health Department. Her staff of five serves a county with 6,089 people with more than 300 COVID-19 cases, the second-highest infection rate in the state and fifth-highest for October.
When public health directors have tried to take a few days off, they recounted having to come back early to deal with COVID outbreaks in their areas. And it's taken an emotional toll as they face backlash from communities some have known their entire lives.
"I'm the face of public health, so I'm the face of quarantine, I'm the face of isolation, I'm the face of we don't get to play football," Gough said.
Eversole, in Dallas County, said she avoids going to the grocery store to steer clear of confrontations and names she sometimes gets called.
In Crumbliss' September email, he recounted fielding calls from local public health staff "in crisis" and recommended expanding state guidance to make clear that mental health services for healthcare workers are allowable expenses under CARES Act funds.
"We have heard from many that have been in recovery from alcohol or abuse situations that have found themselves in relapse in recent months," Crumbliss wrote. "I am also aware that some public health staff have found themselves in moments of crisis with consideration of irreversible actions."
For local public health agencies, the entire process represents a manifestation of the disinvestment in public health that they've seen happening on the ground for years. From 2017-19, Missouri ranked last in the nation in terms of per capita state funding for public health, according to an analysis from the State Health Access Data Assistance Center located at the University of Minnesota.
Jill Holland, a physical therapist who lives in Doniphan, has seen the virus' impact firsthand after her elderly grandparents contracted COVID-19 this summer. Even before the pandemic, it had felt like Ripley County had been forgotten, Holland said.
"We need help down here," Holland said. "We need someone to act like they care."
The Missouri Independent is a nonprofit, nonpartisan news organization covering state government and its impact on Missourians.