Each day, Charlotte Square goes through the process of preparing vaccines for dozens of kids and adults.
Square is an immunization nurse at the Wyandotte County Health Department clinic, where she has worked since 2012. Between that and other roles, she has been with the department for nearly two decades.
“Kids don’t come in like they used to before COVID,” Square says. “One of my goals is to work with the school nurses on bringing those students back in.”
Square believes schools getting pushback on their vaccination requirements means fewer people are coming in. Vaccine skepticism, driven by misinformation and worsened by the pandemic, is a factor as well.
Where once the waiting room would be full of children in late July and early August, now the department mostly sees adults. Square says that goes for everything from the coronavirus vaccine to measles, mumps and rubella.
In the three years since the pandemic began, a recorded 2.7 million people have come down with the virus in Kansas and Missouri, and nearly 33,000 people have died.
The average life expectancy in the United States dropped to 76.4 in 2021, the lowest since 1996.
Across the metro, departments are making similar strategic efforts to Square’s in Wyandotte County, hoping to rebuild and prepare for future health emergencies. But these departments are fighting an uphill battle against sporadic and often minimal funding, a mass exodus of staff during the pandemic and increased public scrutiny.
Ray Dlugolecki, assistant director of the Jackson County Public Health, said public health is at a major crossroads.
He says public health — with proper investment and support — 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.
Boom or Bust
Right now, Dlugolecki says there are signs that not everyone is on board with the idea of public health departments stepping into bigger roles.
During the pandemic, funding flooded into local health departments, especially from the federal government. Most recently, the American Rescue Plan Act provided an infusion of money to tackle vaccination efforts and support other COVID-19-related expenses.
But 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.
“We really need to work hard to ensure that there’s a basic level of support that ensures we meet the foundational services of public health,” Dlugolecki said. “Much in the same way we would ensure that a fire department or a police department is capable of meeting the basic services that we all expect as citizens — putting out fires, ensuring that we’re preventing or responding to crime.”
Kansas City Health director Marvia Jones said departments have gotten used to the reality of the feast or famine funding flow from the federal government. 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.
Jones also noted an issue around the rigidity of federal funding.
“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.”
Public health departments 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.
But to maintain these programs, Hunt said they need to change 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,” Hunt said.
A Mass Exodus
Hunt said Johnson County anticipates some additional federal funding will come in via state channels that should allow them to maintain staffing. That is critical in a profession that already struggled to hire and retain people for decades before the pandemic.
In the first two months of COVID-19, an estimated 1.5 million health care jobs were lost. Although staffing levels have rebounded, according to the U.S. Bureau of Labor Statistics, there are plenty of warning signs to suggest there are more hurdles to overcome.
A 2021 report by the industry market analytic firm Mercer estimated the U.S. will have a shortage of approximately 446,000 home health aides, 95,000 nursing assistants, 98,700 medical and lab technologists and technicians and more than 29,000 nurse practitioners by 2025.
In Kansas, 51 local health department administrators or local health officers left their positions due to the pandemic between March 15, 2020 and August 31, 2021. In the Kansas City metro area alone, three department directors have left their posts.
Demand will continue to grow as the U.S. population ages and areas like Johnson County see population growth, Hunt said.
“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 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.
At least 30 states, nearly all led by Republican legislatures, have passed laws since 2020 that limit public health authority, according to a Washington Post analysis.
In Missouri, a law limits local public health restrictions. Counties receiving public funds are barred from requiring proof of vaccination to use public facilities.
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%.
But across the metro, departments reported staff morale is starting to trend upward again. It isn’t an easy readjustment, though, said Andrew Warland, director of the Platte County Health Department.
Warland compared health care workers to firefighters after a big inferno.
“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.
Building Back Up
Warland says recruitment, retention and training are critical to strengthening public trust. He and department leaders across the metro say it’s essential that public health departments instill confidence in the community that they’re prepared to meet needs beyond COVID-19.
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 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.”