Lawmakers often express respect for public health agencies, but the funding hasn’t matched the rhetoric.

By Rose Hoban

Local public health workers are on the front lines of North Carolina’s emerging coronavirus response.

When patients, in particular low-income patients, ask where they can get a coronavirus test, the answer is to call a local health department.

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When a person tests positive for coronavirus, the local health department in their county swings into action. Public health workers are tasked with doing “contact tracing,” that time-consuming process of calling the patient, getting them to wrack their brains for information about everywhere they went and everyone they saw, then they contact all of those people and repeat the process.

And they’re spending time in the community, educating local leaders, businesses, schools and others on what they need to do to prepare.

Local public health workers in North Carolina’s 85 local health departments (which cover all 100 counties) are busy, likely working overtime, doing all of these tasks and more.

Those same health departments have, for years, been seeing either stagnant or decreased funding and many have lost staff to those factors.

As coronavirus is growing exponentially in the state, those public health workers around North Carolina are being asked again to do more with less in a situation that is likely the most dire in a generation, if not in a century.

“An emerging infectious disease outbreak is an essential function of public health, that’s the type of work we do every day, maybe not to this intensity, but every day,” said Stacie Saunders, the health director in Alamance County.

In a presentation to the legislature in early 2018, then-director of the Pitt County Health Department John Morrow told lawmakers at the General Assembly that local public health departments responded to 320 disease outbreaks in the previous year, everything from chlamydia to pertussis to hepatitis to food poisoning.

The nurses and sanitarians who investigate these diseases have responded to more of them in recent decades, with the number of communicable disease cases and lab reports doubling in the prior decade.

But at the same time, funding to fight communicable diseases remained flat for the past decade, with federal and state dollars combined totaling between $4 million and $5 million annually, even as North Carolina’s population grew from 9.45 million in 2010 to 10.49 million 2019.

“Agencies are running very lean,” Saunders said.

Departments bleeding people, funds

“I think we have the respect and appreciation for the needs we fulfill,” said Morrow when he talked about his meetings with lawmakers, “But I think, unfortunately, our government has been in a mode of funding by crisis. Which we’re seeing now.”

Morrow said when he was leading Pitt County’s health department, several times he had to lay off workers, usually people who were funded by private or government grants that ran out. Usually, he tried to find them other work in his department or in county government so as not to lose them, and their skills, completely.

But not always.

“Public health resources have been sapped in terms of a lot of experience that has retired and left the workforce,” he said. “It’s been more of a slow bleed.”

There’s just not been the local political will in Raleigh, or Washington, D.C., to make investments.

According to reports by the Trust for America’s Health, North Carolina ranks 40th in the nation in spending on public health, even as the organization ranks the state’s health departments in the “highest tier” of preparedness. In the 2018-19 fiscal year, North Carolina appropriated a total of $157 million for public health. That’s only inched up since 2009 when North Carolina spent $147 million and ranked 42nd in the country on spending.

For a number of years in the mid-2010s, North Carolina was one of only a handful of states where public health spending actually shrank, instead of increasing. That was true again with the 2 percent decrease for the 2018-2019 fiscal year. North Carolina was one of only eight states where funding decreased, even as the state racked up a budget surplus.

Nationally, the National Association of County and City Health Officials estimates that over the past decade, public health departments have lost about a quarter of their workforce, and funding for preparedness has also decreased.

Funding for the CDC was $6.3 billion in 2010 and the agency received $6.8 billion in FY 2019-20. President Donald Trump’s 2020 budget proposal was to cut the agency by a billion dollars and by $1.3 billion in 2021. Congress did not carry out those cuts.

Morrow said the conversations with lawmakers often went like this: “‘We support you 100 percent but we don’t have any more money to give you.’”

Only after disasters

Public health funding isn’t always so lean. In the years after the 9/11 attacks and the anthrax scare in 2001 and then SARS in 2003, funding for public health preparedness and response surged.

“We built public awareness campaigns and developed a really strong preparedness and response plan, which included new emerging infectious diseases and intentionally-delivered infectious agents,” in the wake of post-9/11 funding increases, said Leah Devlin, a former state health director. “We really ramped up all of our partnerships as well. So we had built a lot of capacity to respond not just to an act of terrorism but to new emerging infectious diseases like SARS.”

At the state level, Devlin convinced the state legislature to spend more than $100 million to build a new state public health lab, for instance.

But as those incidents receded into the rear view mirror, the sense of urgency faded, something that Devlin spent years worrying about.

Money for public health preparedness has dwindled so much that often, county health directors can’t pay a person to keep their municipality ready for times such as these.

“From federal and state combined, for us at Granville Vance Public Health, serving 100,000 people with two communicable disease nurses that we’re required to have on staff, we get a total of $4,194,” said Granville Vance Public Health director Lisa Harrison.

In addition, Harrison gets a total of $39,031 in federal dollars from a public health emergency preparedness fund, a rate that’d dropped about 50 percent over her eight years as director.

“We have a … communicable disease nurse, but we also need her to work in the STD clinic, the general clinic, and the primary care clinic if we’re going to cover her salary adequately,” she said.

“The conundrum we have in public health is that we call it a ‘quiet miracle’ in that when we’re out there doing our job, so nothing bad happens,” Devlin said. “People forget we’re doing our work behind the scenes.”

And because the miracle-making is quiet, policymakers often think they don’t need to spend money to make it happen.

“It’s sort of perverse,” she said.

At least a year, if not two

“Being prepared is often the difference between harm or no harm during health emergencies and requires four things: planning, dedicated funding, interagency and jurisdictional cooperation, and a skilled public health workforce,” said John Auerbach, president and CEO of Trust for America’s Health in their most recent report on preparedness, published in February.

Being prepared means having workers who have the educational credentials, such as nursing or a public health degree, or both, and the hands-on training.

Harrison estimated that once she gets a nurse on staff, it takes a year or two to get that person up to speed on the public health side of their job. They’re markedly different skill sets.

“We have an amazingly talented, skilled and very smart and dedicated workforce,” she said. “They love the community and they love public health and we’re mission driven.”

Harrison spent several days in early March touring the offices of Congressional representatives, asking for funding for health departments’ coronavirus response. The money in the bills passed by Congress and signed into law by President Donald Trump will certainly help to pay for all the overtime and maybe to hire, but it’s hard to scale up in the middle of a crisis.

“I want them to hear that instead of having these blips of funding, preparedness is about being consistently good at being ready … whether that’s a natural disaster or communicable disease issues,” she said.

“I think people can become surprised that, all of a sudden, an emerging virus comes out, and they’re all like, ‘Well, aren’t you prepared?’”