Five years ago, West Virginia lawmakers cut state funding to local health departments by 25%.
The move — equivalent to an annual loss of $4 million — was a hit to the infrastructure that supports the well-being of our communities: the local workers who protect West Virginians against the spread of communicable disease, inspecting restaurants, responding to environmental hazards and providing basic health care services to residents in need.
Although lawmakers restored about half of that funding in 2019, local health officials say they’ve felt the impact.
“Public health has always been underfunded, and back when those cuts were made, a lot of departments lost staff and programming,” said Lloyd White, administrator of the Marion County Health Department.
Fast forward to 2021. For more than a year, local health officials have been working overtime, guiding West Virginia through the pandemic by testing, contact-tracing, vaccinating and fielding phone call upon phone call from West Virginians seeking help and information about COVID-19.
“Now it’s health departments that are being asked to do the impossible,” White said.
And they’re doing it with smaller budgets, stressed-out staffs and — soon — less autonomy than they used to have, due to legislation that puts some health decisions in the hands of politicians.
White and other local health officials said they’ve been working seven days a week for the last year, and staff have accumulated hundreds of hours of unpaid overtime, sacrificing time to serve West Virginians.
Given the work being done, they would have liked to see West Virginia lawmakers take action to provide more financial support and resources to public health departments this year. But that didn’t happen.
“We don’t feel appreciated by the Legislature. We don’t feel like what we do really matters to them,” White said. “It would have been a great time to show the local health departments taking care of the citizens of our state that they appreciate what we’re doing. But they didn’t do that. This session was largely seen as an attack on public health.”
Overworked and unresourced
Dr. Michael Kilkenny, physician director of the Cabell-Huntington Health Department, said health departments small and large had already eliminated staff pre-pandemic due to budget cuts.
But recently, they’ve lost more people: In Cabell County, 10 employees, a third of the total staff, have left due to burnout.
“A lot of people have retired or resigned over the stresses and the workload and just the feeling that they weren’t able to accomplish anything in public health,” Kilkenny said.
He said the department has worked to refill these staff positions, but the hiring process takes time and resources, and is dependent on the right people applying for the job. It’s a challenge in itself.
The losses in Cabell are mirrored in departments across the state — and the country.
“We’re seeing a lot of people just quit,” said Tom Susman, a lobbyist for the state’s local health departments. “It’s a human resources problem. You’re asking people to do unbelievable things for long hours without a whole lot of support.”
At the state level, around 24% of public health positions are vacant according to a budget presentation given in February by the West Virginia Department of Health and Human Resources. DHHR has permanently eliminated more than 200 positions in the Bureau for Public Health since 2007. And at least five of the state’s 49 health departments — in Raleigh, Mercer, Morgan, Wyoming and Clay counties — have had the head of their health department resign or retire since the pandemic began.
Across the country, local health departments have experienced more permanent downsizing to staff, too.
From 2008 to 2019, local health departments in the U.S. lost 20% of their workforce, according to Adriane Casalotti, chief of government and public affairs for the National Association of County and City Health Officials.
She said alongside the loss of state funds, health departments have lost federal dollars as well.
It takes a pandemic to thrust public health into the spotlight, and then, according to Cassalotti, the public sees the gaps, and the challenges that these departments have been facing for years.
“We look to [health departments] to say, ‘help us, save us’,” Casalotti said. “And there’s not as many people to pick up the phone on the other end.”
The size of health departments across West Virginia varies. But more than half have fewer than five full-time employees, according to a report by the West Virginia Center on Budget and Policy. Some of the smallest health departments, like the one in McDowell County, operate with just one full-time and one part-time worker.
“We’re a skeleton crew,” said Bonnie Woodrum, an infectious disease specialist for the Randolph-Elkins Health Department, which has a staff of 13. “The state expects us to keep on keeping on when they take away our resources. We’re doing our best. We’re doing a great job. But we could be doing more if we had more help.”
Band-Aids for bullet holes
Rather than offering greater support to the workers on the ground, included in the health-related measures that made it through this year’s legislative session are two provisions that actually take authority away from health officials, placing it instead in the hands of local politicians.
Senate Bill 12, signed by Gov. Jim Justice in March, requires the county commission and city council approve any new public health rules set by local boards of health before they go into effect.
Notably, public health officials opposed the bill; they included former state health officer Dr. Cathy Slemp, who wrote that public health decisions should be left to public health officials and remain absent from the influence of politics. The County Commissioners Association of West Virginia also opposed the bill.
Senate Bill 334, which places restrictions on harm reduction programs across West Virginia, would also require health departments to obtain permission from local governing bodies before operating a syringe access program in the state.
“It makes absolutely no sense to me,” said Dr. Lee Smith, the head of the Monongalia County Health Department. “At the health department we take an oath to protect people. Politicians don’t take that oath.”
For a brief moment this legislative session, local health departments had hope that lawmakers might restore funding.
During debate of the state budget in early April, Delegate Barbara Fleischauer, D-Monongalia, introduced an amendment to direct $2.5 million in revenue surplus to local health departments, which she said would have fully restored their funding.
“They had half of the employees that they used to have,” Fleischauer said in a speech before fellow delegates. “And they were confronting something that they knew was a risk, but we didn’t. We did not understand how many West Virginians could die. They did.”
The House of Delegates voted down the amendment along party lines, except for Delegate John Mandt, R-Cabell, who voted for it. Opponents largely argued that counties were receiving new funding from federal coronavirus relief laws — like the CARES Act and the American Rescue Plan— that would support department needs. But they did pass a resolution to study how public health is funded; lawmakers will hear the results of that study during next year’s legislative session.
Susman, the lobbyist for the local health departments, said the problem with relying on the federal relief funds is that they’re temporary.
“They’ll build infrastructure for pandemic response,” Susman said. “But the real issue will come when they evaporate, which they will, because they’re not designed to be sustainable long-term funding.”
Health department workers said they understand health departments don’t need “peak staff” levels all the time.
But state officials also put no mechanism in place for health departments to ramp up staff in times of crisis.
Smith says that’s a major problem.
“If we’re only funding public health when there’s a crisis, then we’re being reactive,” Smith said. “Public health impacts every West Virginian. We’re talking about lives. We don’t want to be reactive, we want to be prepared.”
Smith said that COVID-19 may reemerge regularly, like the seasonal flu. And health departments need adequate funding not only to continue the work of ending the pandemic, but also to help address new health problems the pandemic caused and existing problems the pandemic made worse.