Local health departments in Missouri have scrambled to keep up with COVID-19, exposing the constraints of tight budgets for the front lines of disease prevention, which some said have been underfunded by the state for years.
Before local health departments made headlines every day with updated counts of COVID-19 cases, they did contact tracing for about 100 reportable diseases - a key function in limiting outbreaks of diseases like hepatitis, measles and tuberculosis. That work went largely unseen by the public, as long as it worked and there were no outbreaks.
Missouri is one of the states with the lowest per capita spending on public health, and that was true even before legislators started cutting state funding to local public health departments after the 2008 recession, according to data housed by the State Health Access Data Assistance Center.
State general revenue funds appropriated to fund the core functions of local health departments, including disease investigations and immunization programs, were trimmed from more than $9 million in 2009 to $7.7 million in 2012, before being slashed by 70 percent to $2.2 million. That amount stayed around $3.3 million through this year, when it budgeted $3.5 million for local health departments, the same amount currently proposed for next fiscal year's budget.
Jan Morrow, administrator for the Ripley County Public Health Center, said their budget has been whittled away. There are eight full-time employees for the center serving the county of about 13,200 people on the Arkansas border. That includes Morrow, three registered nurses, three clerks and an emergency planner.
Ripley County also has a part-time environmental specialist who handles code enforcement, inspections and complaints. That was a full-time position before budget cuts started a decade ago, and Morrow had to cut a fourth nurse position.
Morrow wants a health educator but doesn't have the budget for one. Someone who could teach about diseases in schools and the community would go a long way toward prevention in a county where the health department has seen more cases of diseases like hepatitis A and C and tick-borne diseases like Rocky Mountain spotted fever, she said.
"We need more money, of course," she said. "We've been saying that for years, and no one seems to listen."
The Legislature has bolstered the general revenue funds with federal reimbursement for services the departments have provided through the Children's Health Insurance Program - almost $10 million a year since 2017. That's kept the funding stable, but Missouri still ranks among the states with the lowest public health spending per capita.
Cole County Public Health Department Director Kristi Campbell said that's forced local health departments to be reactive to community health issues like diabetes and heart disease or a communicable disease outbreak like COVID-19.
"We kind of have to wait for a trend of something to happen - like several years ago, we were last in the nation in immunization rates, then there was a big push to get kids immunized," Campbell said. "We're constantly chasing the issue that got out of hand instead of getting ahead of it because we don't have the staff to do that prevention."
Each of the seven nurses who work in the Cole County clinic wear multiple hats under normal circumstances - balancing patient visits for immunizations, tests and treatments with public health education, disease tracking and contact tracing.
Like Morrow, Campbell wants to hire a full-time health educator but hasn't had the funds. The department has also had to go without a full-time disaster response planner, with one of the environmental specialists taking on the role - though he's spent all his time on planning during the COVID-19 outbreak, she said.
"Planning for disasters like this, or planning how we respond to tornadoes, it really is a full-time job," Campbell said.
Individual duties have been even more blurred as the 22-member staff has taken up community response to COVID-19. A nurse who usually focused on immunizations has been taking calls at the front desk, which were coming in faster than usual, with many involving medical questions a nurse needed to answer. A nurse who spent a lot of time doing worksite wellness training has been pulled in to help with contact tracing. Environmental staff were sorting through which businesses could remain open while the stay-at-home order was in effect.
In Ripley County, where administrator Morrow has worked for 54 days straight, nurses are also sharing duties, and the center has had to cut back to only essential services. Cole County has cut back clinic services, as well.
Larry Jones, executive director of the Missouri Center for Public Health Excellence, said the health departments asked for $9 million in general revenue funding in next year's budget, but a plan that passed the House this week would keep that funding at the same $3.5 million level as this year, as the Legislature cut $700 million from the budget it was considering before the COVID-19 outbreak.
That could change in the Senate, but the state also received $2 billion in federal aid, of which it will distribute $520.9 million to counties next week, including $9 million to Cole County. Jones said that aid isn't guaranteed to get to health departments, which have varying relationships with county governments across the state.
Some county health departments, including Cole County, are organized as part of the county and get significant funding from the county's budget. Most, including Ripley County, are a separate entity, with their own elected boards and property tax levies. Whether they get emergency funds through their county could depend on the county's financial needs and its relationship with the health department, he said.
The federal government usually steps in with aid when there's a disease outbreak, but the slow and uncertain nature of federal emergency aid highlights the need for consistent and adequate funding of health departments, Jones said. Public health is about prevention, and federal aid is slow. In the two months since the outbreak reached Missouri, Congress has passed billions of dollars in federal aid, but it still hasn't made an impact for local health departments.
Public health departments are the only group that collect information on how the virus is impacting communities. They're the ones who do contact tracing now and when there's an issue like a measles outbreak in a school. They're the ones who track how many people are immunized to see if there is herd immunity, Jones said.
"If you don't have the public health structures in place, it's like having a fire department to put out your fires, but you forgot to buy tires for the fire engine," he said.
Even when the money does come, it takes time to find, hire and train qualified people to do testing and contact tracing. And that doesn't do anything to make health departments more prepared for the next outbreak.
"Years from now, when we're not worried about this disease, the funding will trickle away, and those people will be laid off, and you're not ready for the next one that comes along because we think, 'Well, we've taken care of the problem, so let's take the money away,'" Jones said.
The county health department is where people look for leadership and guidance during a disease outbreak, and Morrow said it's her responsibility to be available for the people of Ripley County - a county that saw its only hospital close over a year ago.
"With the staff I have, even though we're on overload at this point, we're going to do the very best we can because we care about the folks in our county, and we want to make sure they get the best possible care they can," Morrow said.