How a state’s defusion of public health led to vaccination chaos

ST. LOUIS – Missourians have spent hours finding vaccines in rural areas – at least those with cars and time. Tens of thousands of doses are waiting to be distributed and are slowly being rolled out into a federal long-term care program. Waiting lists are hundreds of thousands of people long. Black residents are left behind.

With the rocky vaccine rollout in Missouri, Missouri is one of the lowest states in the country. 23.7% of the population were vaccinated with at least one dose on Thursday, compared to the national average of 26.3%. If Missouri were on par with the national rate, that would represent roughly more than 162,000 additional people vaccinated, or nearly the entire population of the City of Springfield.

Part of the problem, according to health experts, is that the state bypassed its 115 local health departments in its first vaccine rollout plans. Instead, state officials have largely outsourced the work to hospitals, counselors, and federal programs as hospitals and mass vaccination centers had the manpower and facilities to deliver large numbers of vaccines.

Meanwhile, local health departments and state-qualified health centers, which typically reach the most vulnerable populations not connected to traditional health systems, initially had to share about 8% of the state’s vaccine supply. That allocation has since increased to 15%, but it hasn’t been enough to fill the remaining gaps.

“You get what we pay for,” said Spring Schmidt, former assistant director of the St. Louis County Department of Health, noting that the state’s public health departments have been underfunded for decades. “This is an infrastructure that is similar to government utilities or other services that our citizens expect to be provided to them and that they usually only notice when they drop.”

The local health authorities knew what to do. “We have drilled for it, we have plans for shelves that collect dust for it,” said Schmidt.

But that’s the problem with the health department’s long-standing underfunding: despite all the plans that have been drawn up in flu and H1N1 vaccination campaigns, health departments would still need the staff and facilities to do something on this scale, said Dr. Alex Garza, head of the St. Louis Metropolitan Pandemic Task Force, a consortium of key hospital systems in the region. And state and county governments don’t provide the resources to get the job done.

A 2020 study by Kaiser Health News and AP found that Missouri’s public health workforce fell 8% from 2010 to 2019, a loss of 106 full-time employees. Public health spending per Missourian was $ 50 a year – one of the top ten lowest states in the country.

When the pandemic broke out, local health departments only had 408 staff trained in vaccinations. That comes from a report released on Friday by #HealthierMO, a group that works for better public health in the state. This means that if only these employees had given vaccines, they would have to vaccinate around 15,000 people each – in many cases with two shots. Even in the most efficient scenario, where it would take five minutes for each person to be vaccinated, it would take over seven months for just one shot per person.

At the same time, public health officials are accused of taking pandemic safety measures. State lawmakers are discussing the limits of public health powers, and local officials have withheld funds from their health departments, thereby hampering their authority to act in the crisis.

A question of justice

Missouri public health officials said the outsourcing approach missed the public health brand: getting the vaccine to those who need it most.

According to the data available, only 9.9% of black Missourians are vaccinated compared to 18.3% of white Missourians. A series of reports from Deloitte, a large consulting firm advising the state on its rollout, showed a pattern of vaccine deserts in metropolitan areas where the state’s black residents are concentrated.

Non-Hispanic black Americans are 1.9 times more likely to die from Covid than white Americans, according to an analysis by the Centers for Disease Control and Prevention. Black Missourians make up 13.1% of the state’s deaths, over 11.8% of the population.

Some of the Deloitte reports in early March also found that nearly a third of Missouri residents were traveling outside of their county to get vaccinated. Democratic State Senator Jill Schupp and other critics said initial rollout data showed the geographic distribution of vaccines did not match population size.

“If you’re older and don’t drive like that, if you have a low income and don’t have access to transportation, if you’re a working person who can’t take the time to drive an hour and a half to get your vaccine – these people are on their own, ”said Schupp.

According to Dr. Randall Williams, director of state health and senior services, and Robert Knodell, assistant chief of staff to Governor Mike Parson, decisions were made to prioritize vaccines based on population size and risk factors. They say no single group would be happy with their allocation given the limited initial vaccine supply.

Adam Crumbliss, the state director for community division and public health, noted that state officials have concerns about data discrepancies that appear to be keeping Missouri behind. Missouri state health officials and federal government officials have argued over at least four data issues.

CDC spokeswoman Kate Fowlie said a state file recording over 34,000 doses administered was not uploaded to federal systems due to data errors in January and took the state two weeks to fix. She added that the CDC and Missouri had an ongoing discussion about missing data from a provider who had incorrectly reported the number of doses given.

Crumbliss also said around 76,000 unused doses are in the pharmacy program for long-term care facilities with CVS and Walgreens, slowing the rate of vaccination in Missouri. The federal initiative has come under fire because of its delays.

However, according to the CDC, only about 50,000 doses need to be administered in the pharmacy program in Missouri. “A handful of long-term care facilities in Missouri had a late start in their first clinics and are closing the third and final clinic,” said Fowlie, noting that the state could work with the federal partnership to redistribute any remaining doses.

A political matter

At the heart of the heartland, Missouri is one of the states that has never issued a mask mandate – even after the Republican governor and his wife signed Covid-19 in September.

Parson hasn’t shied away from fights with health officials either. After Garza called for additional doses of vaccine to be allocated to the St. Louis area in early February, Parson accused him of “spreading fear and panic” with false information.

But after weeks of outcry, the state began targeting the more populous areas of St. Louis and Kansas City. Parson has too started tweeting in support of the local health authorities.

Nonetheless, the anti-public health political animus continues in the Missouri legislature – as in at least 23 other states – where lawmakers are weighing bills to curtail public health powers. The use of quarantine orders and other longstanding public health powers to fight the pandemic is now up for debate as health officials battle for funding.

“Nobody wears masks in the Capitol and you are asking public health officials to testify personally against their own instructions,” said Will Marrs, a lobbyist with the Missouri Association of Local Health Agencies. “It’s very much not normal.”

However, the legislators did not fight for an urgent decision for companies and organizations to officially skip the vaccination line. At least 90 have applied so far. Records obtained from KHN show that the state health department approved at least 15 agencies to get the vaccines sooner, including health giant Centene and the St. Louis Convention and Visitors Commission, as well as libraries and companies involved in Covid testing and manufacturing Vaccines are helpful.

The financing question

Even amid a pandemic, it was a struggle to get money to local health departments. The state used $ 9.8 million, originally sent by the CDC last spring, rather than forwarding it to local health departments.

Last summer, state lawmakers ruled that district officials would decide whether local health departments would get funding from the CARES bill. Many commissioners were mad at their health departments for closing local businesses and therefore refused to raise funds, said Larry Jones, executive director of the Missouri Center for Public Health Excellence, a consortium of public health executives.

According to a survey by the state health ministry, at least 40 local health departments hadn’t received any of the money by early October. Those who reported an average of 8% of the county’s CARES money, rather than the 15% recommended by the state.

In Kansas City, over $ 226,000 in CARES funds was given to Cruise Holidays, a travel company, in the summer, according to Platte County’s Landmark newspaper. As recently as March this year, the local health department received nearly $ 228,000, ministry spokeswoman Natalie Klaus said, far less than the state’s recommended $ 1.8 million.

The state has been allocated $ 55 million by the CDC to roll out vaccines, of which Department of Health spokeswoman Lisa Cox said $ 20 million will soon go to local departments. More are expected to be included in the new federal stimulus package worth $ 1.9 trillion.

Jones worries that if vaccination funding doesn’t get where it helps most people, history will repeat itself. Brian Castrucci, CEO of the de Beaumont Foundation, which works for public health, is also not optimistic.

“How sure are we that states that are actively trying to restrict the public health authority will do a good job of spending that money appropriately?”

KHN data reporter Hannah Recht contributed to this report.

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