Each day, Charlotte Square prepares vaccine doses for dozens of kids and adults.
Square, an immunization nurse, has worked at the Wyandotte County Health Department clinic since 2012. Counting other roles, she has been with the department for nearly two decades. Lately, things have changed, she said.
“Kids don't come in like they used to before COVID,” Square said.
The waiting room at the Wyandotte County Health Department clinic used to be full of children in late July and early August, now the department mostly sees adults. Square said that goes for everything from the coronavirus vaccine to measles, mumps and rubella.
And that’s a nationwide issue. Compared to the 2020-2021 school year, vaccination rates for U.S. kindergarteners dropped nearly a full percent for all vaccines –– that’s about 38,000 less kids vaccinated. Even before the pandemic, one out of every six toddlers had not been fully vaccinated against things like MMR and chickenpox, according to one study.
In the Midwest, states are falling short of the target healthy coverage rate of 95% for MMR, polio, Varicella and other vaccines among kindergarteners. Only Nebraska hit the mark.
Square believes schools getting pushback on their vaccination requirements is contributing to fewer people coming in. Vaccine skepticism, driven by misinformation and worsened by the pandemic, is a factor as well.
“One of my goals is to work with the school nurses on bringing those students back in. The outreach is going to help a great deal,” Square said.
Public health departments’ outreach efforts to get more people to use their services is just one example of how they are picking up the pieces of the pandemic.
But in the process, these departments are struggling with sporadic and often lackluster funding, a mass exodus of staff during the pandemic and increased public scrutiny.
Adriane Casalotti, chief of government and public affairs for the National Association of County and City Health Officials, said local health departments play a critical role in making sure people are properly vaccinated.
“They all do a lot of education around the importance of vaccines,” Casalotti said. “They work to try and ensure that there's access where you might not see it. So, they help bring vaccines to people to make it easier so that you don't have to plan your day around it.”
But these health departments are fighting an uphill funding battle. They saw federal and state governments pump money during the pandemic. Most recently, the American Rescue Plan Act provided an infusion of money to tackle vaccination efforts and support other COVID-19-related expenses. Now, most of that is gone. Even the leftover funding is likely not usable for other public health efforts because it is earmarked for COVID.
It’s a repeating pattern that some public health departments have gotten used to the feast or famine reality of funding, said Kansas City Health director Marvia Jones. Public health saw funding upticks after 9/11 in response to bio-terrorism, during the 2009 H1N1 pandemic and in response to Ebola and Zika concerns.
“One of the things we realized we need to really work on is diabetes prevention and hypertension, two of the factors that made people really at higher risk for severe complications of COVID-19,” Jones said. “But we can’t divert some of these funds to other needs. That's not the way that our federal appropriations work.”
Without emergency pandemic funding, Missouri ranks lowest for state public health funding at $7 per person in 2021, according to the State Health Access Data Assistance Center. Kansas data was unavailable for 2021, but the state received $13 per person in 2019 and $15 per person in 2020.
Hunt said there needs to be a change in the tendency for large increases in funding only to deal with specific issues.
“We have to fund public health such that we have the infrastructure in place that we can be better prepared for the next pandemic or environmental disaster that occurs in our community,” she said.
A Mass Exodus
Public health is at a major crossroads, said Ray Dlugolecki, assistant director of the Jackson County Public Health.
Departments like his are constantly on alert to keep communities safe by preventing communicable diseases and providing wellness services to children and adults. These services can range from vaccinations to STI testing to mobile mammogram events.
He said, with proper investment and support, health departments can monitor and prepare for emerging health threats. But that can only happen if the public is on the same page.
“It definitely requires a larger public discourse about what we value as a society and where we're going as a society as it pertains to growth and expectations of life and ability to have a quality life,” he said.
Right now, Dlugolecki said there are signs that not everyone is on board with the idea of public health departments stepping into bigger roles.
At least 30 states including Iowa, Indiana, Missouri, Kansas and Kentucky in the Midwest have limited public health authority in some way, according to a Washington Post analysis.
In Missouri, for example, counties receiving public funds are barred from requiring proof of vaccination to use public facilities.
In Iowa, a state law enacted in 2021 expanded religious and medical exemptions to workplace vaccine mandates. Other Iowa laws prohibit any school or childcare center from requiring the COVID-19 vaccine to attend as well as prohibiting local governments and school districts from issuing mask mandates.
And in Indiana, vaccine passports are prohibited by law, although Gov. Eric Holcomb did veto a subsequent bill that would limit public health officials authority by allowing elected officials to block public health orders during emergencies.
Limited funding and restrictive laws approved by lawmakers have led many in the field to feel they can’t adequately do their job.
In a study published in the Journal of the American Medical Association, just under 32% of doctors reported feeling burned out in 2019. In 2022, that figure rose to 40%. Nurses fared similarly. Nearly 41% reported burnout in 2019 and by 2022, the number was a shade over 49%.
These compounding factors have led to a mass exodus in some states.
In Kansas, 51 local health department administrators or local health officers left their positions between March 15, 2020 and August 31, 2021. In the Kansas City metro area alone, three department directors have left their posts during the same time period.
“We're gonna be spending these next few years, trying to figure out a sustainable way to keep our staffing adequate to respond to the growing population and an increasingly diverse community in Johnson County,” he said.
Jackson County Public Health department estimates only about 20% of the county’s health care workers from before the pandemic are still with the department.
Department administrators frequently pointed to funding as a roadblock to recruitment and retention. But they also say increased public scrutiny, misinformation and restrictions passed in state legislatures wear on public health workers.
A large national survey published earlier this year found that more than one-third of U.S. adults trusted the CDC during the COVID-19 pandemic while only one-quarter trusted state and local health departments. The trust stemmed primarily from agencies’ ability to communicate clearly and follow science-based recommendations, according to the survey. Lower levels of trust, on the other hand, stemmed from the conflicting guidance and beliefs that outside forces like politics or corporations influenced health recommendations.
“Our findings suggest the need to support a robust federal, state, and local public health communications infrastructure; ensure agencies’ authority to make science-based recommendations; and develop strategies for engaging different segments of the public,” said the authors of the survey published in the journal Health Affairs.
Andrew Warland, director of Platte County Health Department, compared health care workers to firefighters after a big forest fire.
“If you spend all your time on emergency alert, just responding to that emergency day in and day out, it's actually kind of hard to go back to the regular fire station and start cleaning the fire engine and cooking and doing the things you used to do before the big forest fire,” Warland said.
Warland recognizes these patterns. He said it is not an easy readjustment with meager resources. Still, across the metro, he said they are taking steps to strengthen public trust and some departments have reported staff morale starting to trend up again.
In Clay County, the department is engaging in community conversations with the Northland Health Alliance, where they are holding events to inform the public about their work and the services they provide.
For Platte County, an important first step in that process was opening a new building at 7925 NW 110th Street, near the airport. Warland says it is centrally located and on a bus path.
The department had planned to move since 2020 but had to put plans on hold because of COVID-19.
“Those types of things, just having a well-lit structure that is professional instead of working in a building that's 63 years old that looks like scraps, it does help credibility,” Warland said.
Jackson County also opened a new building in Lee’s Summit at 3651 NE Ralph Powell Road in June. The location offers expanded waiting rooms, lactation rooms for nursing mothers and more than double the number of clinical rooms. It also brings the Jackson County Environmental Health Department and Women, Infants and Children nutrition program under the same roof for the first time.
Terrie Garrison, deputy director of the Wyandotte County Health Department, said these intra-county partnerships are one of the good things to come out of the pandemic.
“It was all hands on deck. We had to bring everybody together,” Garrison said. “We had folks in our environmental department, working our mass vaccine clinic, helping to fill out forms. We had everybody doing different jobs stepping into roles they hadn't ever stepped into before.”
Garrison says efforts to work with community partners are even more important than efforts within county offices. Garrison has found collaborating with respected institutions in the community incredibly useful to build trust during the pandemic.
She hopes to see those efforts continue across the city.
“We had many, many, many partners that came to the table, took on roles, helped with the mitigation response,” Garrison said. “Public health is not an island.”
Side Effects Public Media is a health reporting collaboration based at WFYI in Indianapolis. We partner with NPR stations across the Midwest and surrounding areas — including KBIA and KCUR in Missouri, Iowa Public Radio, Ideastream in Ohio and WFPL in Kentucky.