MASSILLON – For years, the eight members of the Massillon City Health Department had well-established routines.
Bethany Perkowski, the environmental health director, drove around town inspecting restaurants while Audrey Sylvester, the director of nursing, did community outreach and organized childhood vaccination clinics, among a range of other duties.
Those jobs were vital. They kept people safe and healthy.
Then, along came COVID-19.
The entire office switched from their regular jobs to pandemic response and contact tracing.
“It was 90% COVID and 10% cramming in everything else,” Sylvester said.
Health department employees across the region simply did not have time for all the things they normally did, so children did not receive standard vaccines, restaurant inspections piled up and attention to other contagious viruses had to be thrown frantically onto the back burner.
Even as contractors take over contact tracing, the most time consuming of COVID responsibilities, and health departments clear their backlogs of inspections and clinics, they are still too overstretched and exhausted to do everything they used to, prompting fears that other public health threats could crop up while officials are distracted.
Overwhelmed with cases
Data from the Canton City Health Department illustrate the problem COVID caused most clearly.
In 2019, 1,505 communicable disease cases were reported to the department. In 2020, 5,001 communicable disease cases were reported.
The work had more than tripled, but the department’s staff had not.
And of those cases, 3,366 required a second investigation of close contacts.
There were also 35 infectious disease outbreaks in Canton, all of them COVID related, at places like schools and business that often lasted three or four months and required even higher stacks of paper and dozens of hours.
The department’s first option was to pull its employees off other duties and projects.
In Canton, two people were assigned to contagious diseases pre-pandemic — an epidemiologist and a nurse. Since the pandemic began, three more people switched from other jobs to COVID epidemiology and nearly the entire nursing staff joined on from other roles.
“It’s kind of like the shell game moving people around,” said Diane Thompson, the department’s director of nursing.
At the Carroll County and Columbiana County health districts, more than half the staff switched to COVID response and the whole staff had to drop what they were doing for vaccination clinics, officials there said.
In Massillon, the entire office threw itself into the response.
That is not counting the hundreds of dedicated volunteers, especially Medical Reserve Corps members, who assisted the regular staff.
There was some hiring. Columbiana County recruited school nurses and some temporary workers, while Carroll County roped in two college students taking time off school as interns. Other departments did not have the money or the time to train new staff.
‘We started off with that adrenaline’
The second thing departments did to make up for the increased workload was to work more.
“Pulling people in for a 40-hour week is a lot but pulling people in for 60-hour weeks sometimes, weekends, every weekend (is something else),” said Amanda Archer, director of the office of public health information and an epidemiologist for Canton City Public Health.
Two or three nurses at Canton City Public Health were working every weekend during the height of the pandemic and the epidemiologists were constantly on call.
Perkowski, from Massillon, would come in early and leave late to squeeze in restaurant inspections around contact tracing. With a fourth grader and seventh grader at home and her husband working as a Massillon City firefighter, it was stressful.
Sylvester had her first baby in the fall of last year. She was back on the job after five weeks.
“I would’ve been on maternity leave, but COVID calls,” she said.
The burnout is serious.
“We started off with that adrenaline, doing everything we could to help everybody we could,” said Laura Fauss, Columbiana County’s environmental health director. “Over months, that wears off.”
Terri Argent, Massillon’s health commissioner, said that in Massillon, aside from the abbreviated maternity leave, no one in the department had taken more than three days off until this month.
Falling through the cracks
The consequences for public health have been real.
Though many programs like childhood vaccinations, distribution of the overdose-reversing drug naloxone, Canton’s needle exchange program or Columbiana County’s septic tank inspections have resumed, people may have fallen through the cracks.
Kelly Engelhart, Carroll County’s director of nursing, said children have fallen behind on their immunizations in her district, because the health district had to suspended outreach to families.
“We could see a surge in vaccine preventable diseases like Pertussis … or measles,” Engelhart said in an email. “We will not see these health impacts right away. It will be delayed for 5-10 years.”
Free clinics for mammograms and Papp smears were canceled, and Fauss worries about those.
“It was on their calendar, and then they forgot all about it,” she said.
Archer, the Canton epidemiologist, said her principal concern is data analysis.
“Your brain is so focused on COVID, and it’s just difficult to pull away and do any meaningful analysis on something else because the COVID is always coming at you,” she said.
Cases of syphilis and gonorrhea were up in the city in 2020, but the health department does not know why. Archer has not had the time to scour the data for answers.
Health departments do data analysis in part to see if their programs are effective so they can win state and federal grants.
The state gave departments a break on those requirements because of COVID.
Archer pointed to the city’s naloxone distribution program. Their initial grant application used data analysis to show where and how they believed their distribution would be most effective.
But when they renewed the grant during COVID, they have not had time and were not required to find out if they were right.
Maternal health has been a major success story of crunching health statistics. Canton’s infant mortality rate looks normal at first glance, but when the department broke the numbers down by race, it revealed a crisis for Black mothers and children.
Now, however, the epidemiologist who did much of that work is analyzing COVID numbers instead of infant mortality, Archer said.
The core of the problem is not that the health department will stop doing programming all together, she said, but that those programs will be less equitable and effective.
“We will lose the ability to target to the people who need it the most,” Archer said.
Canton City Public Health inaugurated a new division, which Archer leads, to focus on data and accountability in early 2020. Due to the pandemic, those efforts have barely gotten off the ground.
‘Public health is under looked until they’re needed’
Health officials say that the fact that they are now forced to prioritize which deadly disease to focus on or sacrifice their weekends and their families to make sure restaurants are not giving people food poisoning stems from a deeper issue: Ohio undervalues public health.
“Public health is under looked until they’re needed, and then they’re expected to perform,” Fauss said.
Ohio spends $14.01 per capita on local health department funding, with only three other states spending less, according to the Health Policy Institute of Ohio. That’s a tenth of the highest spending state, New Mexico, and double what the lowest state, Missouri, spends.
This is partially because Ohio’s health system is decentralized and local funding accounts for about 75% of health department budgets, but even among other states with such systems, Ohio ranks low, said Amy Bush Stevens, the vice president of policy at the Health Policy Institute of Ohio.
Argent wishes she could have doubled her staff to handle COVID. Engelhart remembers when budget cuts reduced Carroll County’s health district from 20 employees to 14 a few years ago.
In April 2020, Gov. Mike DeWine admitted what many in public health had been thinking for years.
“Not just in Ohio, but we’ve historically in this country underfunded public health,” DeWine said during one of his coronavirus updates in April 2020. “One of the lessons from this pandemic … there’s going to be a consensus. We’ve got to fund consistently year after year public health and do a much better job.”
Archer said Ohio lawmakers also need to go a step further: Get out of the way.
“Because they’re in the way,” she said. “All of a sudden, because it’s a pandemic they want to start passing legislation that limits public health’s ability to do their job, and that’s unfortunate.”
Despite the long hours, shoe-string budgets and a pandemic that never seems to end, the employees at the region’s health departments say they are not going anywhere. They do this work because they love serving the community in moments just like these.
Argent remembers when she helped administer the first few COVID vaccine doses to Massillon seniors. Many of them cried. She cried.
“It made all these hours we work worth it,” she said.