Mistrust and polarization steer rural governments to reject federal public health funding

Reviewed by Emily Henderson, B.Sc.Nov 20 2022

When Elko County commissioners rejected a $500,000 grant from the Centers for Disease Control and Prevention that could have helped the county create a health department or health district, Kayla Hopkins pleaded with them to reconsider.

Hopkins, who has lived for nearly nine years in the sprawling rural county that forms the northeastern corner of Nevada, told the board how she struggled through postpartum depression and needed mental health resources.

"I was unable to get the help that I needed," Hopkins said during a public meeting in late 2021, adding that she fell into what could be considered a mental breakdown. She said she was sent by air ambulance more than 300 miles away to Carson City, where she received care in a psychiatric facility for 10 days.

"I was away from my family," Hopkins said. "I was away from my support system here, and I still struggle with mental health, and I still cannot get the help that I need because we just don't have it here."

Pleas from Hopkins and others weren't enough to sway the elected commissioners. Neither were 11 letters from local health leaders urging the board to take the infusion of public health funding. Four of the county's five commissioners, citing concerns about government overreach and their lack of trust in federal agencies, voted against pursuing the grant. Nearly a year later, as the pandemic grinds toward a third year and with the arrival of monkeypox, the county still is without a public health department to respond.

And the same mistrust of agencies administering grants for public health persists elsewhere.

Elko County, home to about 54,000 people, wasn't alone in rejecting federal aid aimed at bolstering public health in the past year. Experts say they were surprised and concerned to see the rare local or state leader, swayed by political partisanship, dismiss funding opportunities for historically limited public health systems.

As many conservative leaders and their constituents railed against measures meant to combat covid-19 — things like masking policies and promoting vaccines — the pandemic revealed long-standing fissures in the country's public health infrastructure, particularly in rural and underserved communities.

"Partisan politics has poisoned the well to a point that we're willing to sacrifice the health of our citizens," said Brian Castrucci, president and CEO of the de Beaumont Foundation, a national nonprofit that advocates for public health policy. "Is the political grandstanding worth it?"

Over the past two years, officials in Idaho, Iowa, and New Hampshire rejected covid relief money, their decisions often accompanied by political pronouncements about federal government overreach. And officials representing local governments across the country, including Cochise and Pinal counties in Arizona, echoed those moves. A survey of local governments in 15 states conducted by the National League of Cities found more than 200 small governments declined pandemic relief funds, a small percentage of the money available to small governments.

Elko commissioners turned down a workforce grant funded by the CDC, money intended to "establish, expand, and sustain a public health workforce, including school nurses." The funding would have flowed through the state to the county, allowing it to hire two employees dedicated to public health services for two years.

County workers in charge of researching the grant and pitching it to the board said the idea was to conduct a study in those two years that would help them determine how much it would cost to create a local health department or a health district, involving neighboring counties.

Elko County has not had a public health department since budget woes pushed officials to dissolve its more than 15 years ago.

Adriane Casalotti, chief of government and public affairs for the National Association of County and City Health Officials, said communities across the country have generally clamored for increased funding during the pandemic, which strained already underfunded and understaffed public health infrastructure.

"That being said," Casalotti said, "in recent months, I'd say, we've heard of a handful of health departments that either would not apply for or couldn't accept … specific grants," involving covid vaccines.

At an Elko County commission meeting in late 2021, then-transit management coordinator Abigail Wheeler pitched the grant to the board and a roomful of residents eager to air their grievances about the CDC and levy claims of federal government overreach, overspending, and corruption regarding the pandemic response.

Wheeler began by asking county commissioners to keep an open mind.

"I am very aware that this is basically the worst timing that this grant could come forward because there's a lot of distaste over public health because of what's happened with covid and our whole community, our whole country, and worldwide," she said. "We have been beat to death, the fallout of the covid pandemic."

Wheeler, now the grants and contracts manager for the county, began by reminding the commissioners that creating a local health department or district was a goal that predated the pandemic and the polarization it triggered.

A 2019 meeting with the state Department of Health and Human Services underscored the need for more local public health infrastructure.

"They're thinking about things like tuberculosis and measles and restaurant inspections," Wheeler said. "They're not thinking about covid. And they're saying to themselves, 'We can't get to you if you had a TB case. We're 370 miles away from Elko County.'"

Elko is like a landlocked island, Wheeler said during an interview with KHN. Though smaller in population compared with Clark or Washoe counties in Nevada, Elko spans more than 17,000 square miles, making it the fourth-largest county by area in the contiguous U.S. and the second-largest in Nevada.

"We have to be our own cavalry," Wheeler said.

Commissioners and community members who opposed the grant said Elko didn't need more public health resources or a health district or department. They said they were concerned about giving up local autonomy and growing bureaucracy. They also expressed mistrust of the CDC.

"You're 100% factual that the timing couldn't be worse," said Jon Karr, then the chairman of the commission, during the meeting. Although he said he did not buy into all the conspiracy theories about the CDC that others touted, he added that he did not think CDC officials should be trusted.

Commissioner Rex Steninger said he voted against the grant because he feared the commission would be "subservient" to the new entity. "Grants always have strings attached," he wrote in an emailed response to questions from KHN. "We do not want the CDC tenacles [sic] reaching in to Elko County."

Wheeler pointed to the fractured local public health system during the meeting, saying creating a health district or department could help reduce bureaucracy and give the county more control over decisions in state officials' hands. She said it's evident the county needs more resources, citing public health response duties she took on in her position as transit manager.

"We're not public health experts, we're just people who are willing to step up to the plate and take this on," Wheeler said, referring to other county employees who helped with the public health response to covid.

Wheeler was disappointed the county board turned down the grant opportunity, she told KHN in October. She said she would still like to see public health become a function of the county someday.

Since speaking at the meeting nearly a year ago, Hopkins said she found the mental health services she needed locally. But not everyone is as lucky as she is to find the help they need close to home, she said. The county's decision to reject the CDC grant makes her sad, she said, but she accepts it was the commission's decision to make.

Other local leaders saw the need for increased public health resources amid the pandemic. The Elko City Council wrote a letter of support for the CDC grant the day before the commission rejected it. "We know for sure it's not something that the city wants to tackle by ourselves," said Curtis Calder, city manager. "But if our regional partners want to do it as a partnership, we stand at the ready to assist where we can."

Other rural Nevada counties have collaborated with the University of Nevada-Reno School of Medicine to create the Central Nevada Health District, serving four counties and a small city near Reno. "If we won't step up and help ourselves and our constituents, we can't complain when the State doesn't provide what we need or expect," wrote Dr. J.J. Goicoechea, a commissioner in neighboring Eureka County and the interim state veterinarian, in an emailed response to KHN.

Casalotti said there are advantages to having local health departments staffed and run by people who live in the community as opposed to a state government hundreds of miles away.

"One of the things that we're hopeful that people can learn from the pandemic is that you don't want to have to build the plane while flying it," she said. "At some point, you need to take the leap because the next crisis is just around the corner."

But polarization remains an obstacle, Castrucci said.

"This has become a holy war, this has become a war of right and wrong," he said. "I don't know how to get through that to a place where we are prioritizing the health of our nation."