Coronavirus tests public health infrastructure in the heartland

Reviewed by Kate Anderton, B.Sc. (Editor)Feb 13 2020

Every weekday at noon since Jan. 27, the Missouri Department of Health and Senior Services Director Randall Williams gathers his outbreak response team for a meeting on coronavirus.

Missouri has yet to have a confirmed case of what officials are now calling COVID-19, but about 20 people statewide are being monitored for the novel viral infection originating from Wuhan, China. While 15 cases have been confirmed in the U.S. so far, tens of thousands of people have been infected worldwide and more than 1,300 have died. Global — and local — fears of the spread of the respiratory virus are fueling concerns about a lack of preparation in the U.S.

Missouri health department staff have been working overtime preparing for if, and when, the cases come by ensuring they have adequate supplies of non-expired protective gear like masks and planning how to trace the movements of those who have come in contact with potentially infected people.

They're also helping set up coronavirus testing capabilities at a regional lab based here in the state capital to evaluate potential cases from Missouri, Kansas, Nebraska and Iowa. The U.S. Centers for Disease Control and Prevention has started shipping testing kits around the country.

Coronavirus may not require a front-line battle yet in places like Missouri as it does in states with confirmed cases, such as Washington, California, Illinois and Texas. But it's still taxing public health officials in Missouri, which has one of the lowest levels in the nation for public health spending per person. And they, like health officials in other states, are stuck in the tricky position of trying not to be over- or underprepared for a potential public health crisis that may never come.

Missouri's legislature is considering an additional $300,000 in emergency funding for events like coronavirus. This money is vital for responding to outbreaks in the state, Williams said, including more common concerns like mumps and measles or ongoing fights against hepatitis A and tuberculosis.

However, according to Williams, the legislature denied such an appeal for $300,000 last year.

"We are essentially like a fire department, right? People want us to be available when there’s a fire," the director said. "But when there’s not a fire, they don’t really give a lot of thought to it."

Limited budget

As state officials gear up for possible problems from coronavirus, local health departments in Missouri are at a disadvantage because they have lost staff amid state budget cuts, according to Lindsey Baker, research director for the Missouri Budget Project, a nonprofit focused on public policy decisions.

Similar patterns hold true across the nation. Almost a quarter of local health department jobs have been lost since 2008, according to the National Association of County and City Health Officials, and a quarter of local health departments experienced budget cuts last year.

While federal funding has supplemented public health funding in Missouri, Baker said, the federal cash comes with strict rules on how it can be used.

Williams stressed that, despite Missouri's limited budget, his state ranked in the top tier for emergency preparedness by Trust for America's Health, a nonprofit advocacy group promoting public health.

Money notwithstanding, viruses like COVID-19 force the staff to work longer hours, according to state epidemiologist Dr. George Turabelidze, as the health department juggles its existing workload with pressing concerns.

"Everything else is happening — it’s not like we can switch, we have to do all this at once," Turabelidze said.

Plus, he added, since this outbreak involves world travelers arriving at all times of the day, his staff has had to work weekends to track down where travelers have come from and whether they've had contact with infected people. For now, salaried staffers — who do not receive overtime — are expected to shoulder the extra load.

Even as they work extra hours, some routine health department matters such as onsite sewage inspections "get put in the back seat," said Adam Crumbliss, chief director of Missouri's Division of Community and Public Health.

If coronavirus reaches a pandemic level — in which it spreads worldwide — Crumbliss said the National Guard could be activated.

Relying on existing relationships and stockpiles

Vital to any public health emergency response are the underlying relationships, stressed Paula Nickelson, the state's program coordinator for health care system readiness. Knowing whom to call and having an established rapport with key health care providers such as the Missouri Hospital Association is critical during a crisis.

As is experience. Nickelson said the state's response capabilities were tested and strengthened during a successful practice transport of a hypothetical Ebola patient from St. Louis to the University of Iowa in May.

Through that exercise, they learned that the material of their ISOPODs — portable, see-through isolation units that quarantine infected patients while allowing them to still see and speak to other people — was so thick it made it hard to hear those inside. Now, they are equipping them with walkie-talkies.

Another major question in recent days is a potential onslaught of shortages of protective medical equipment — everything from masks to latex gloves - often manufactured in China. Nickelson said the state has assessed what materials are on hand.

"They’re fairly small amounts," she said. "What we found over the course of a decade is that a lot of that stuff sits on the shelf, doesn’t necessarily get used, and so we’re better off to have just-in-time, vendor-managed processes in place."

Still, Nickelson noted, that could become a problem for everyone if a pandemic occurs and those vendors become swamped with orders.

"This is by no means a sprint," Crumbliss said. "This is a long wind race."