Missouri is nearing five months since its first case of COVID-19, more than 1,000 people have died and the infection rate is increasing in many places. And still, according to a letter sent to the governor by the Missouri Public Health Association on Wednesday, the state hasn't made contact tracing a priority.
"It is as if the State and many County Commissions have simple decided to abdicate from this responsibility," wrote Bert Malone, MPHA board member and retired deputy director of the Kansas City Health Department, in the letter.
Malone implored the governor to put pressure on county commissions to funnel funding towards their local public health agencies for contact tracing.
As of Friday afternoon, Malone said the association had not received an official response from the governor.
It's not the first time the association has asked state legislators to allocate additional resources to local public health agencies. In April, the association asked that legislators revise their $6.2 billion COVID-19 relief bill to earmark funding specifically for local public health departments. They didn't do it.
Missouri's decentralized public health system has made its response to COVID-19 disjointed and difficult. County health departments have struggled to scrape together the funds to manage the pandemic.
At the core of the problem is the localized approach to public health funding in Missouri, which ranks at the bottom nationally for public health funding per capita.
Lynelle Phillips, an assistant professor for the MU School of Health Professions, said she often contrasts Missouri's system with Vermont's.
Public health agencies in Vermont receive funding entirely from the state and, therefore, are subject to its orders. In Missouri, the 114 local public health agencies receive the base of their funding from the state but also require outside funding through, for example, federal grants.
Because they are not completely reliant on the state for their funding, Missouri's public health agencies have the power to supersede the authority of the Missouri Department of Health and Human Services, she said.
This structure allows the state's public health officials to pursue more progressive public health policy, she said. The downside is that this structure also has made it difficult for agencies to receive consistent and adequate funding.
In the case of the funding from the COVID-19 relief bill, if Missouri's system looked more like Vermont's, the money would be distributed directly from the state public health department to local agencies. Instead, each public health "fiefdom," has to request funding from its county commission.
Scott Clardy, assistant director for Columbia/Boone County Public Health and Human Services, said that when state legislators sent the money to the county commissions instead of directly to the local public health agencies "that was not supportive of local public health."
But there's good news: The department has been told by the Boone County Commission that it will approve a request to hire 30 new contact tracers and disease detectives, Clardy said.
The 'DIY' pandemic
Administrator for the Shannon County Health Center Kandra Counts said that though leaders in her county have been easy to work with, she was frustrated by the money going to the county first because it meant it slowed her department's response.
"A lot of money in the beginning should have come directly to the local public health agencies," Counts said.
"We were the lead agency dealing with everything, with the (stay-at-home) orders and the enforcement and the contact tracing."
Melanie Hutton, administrator for the Cooper County Health Department, said the lack of contact tracing is just another example of what she is calling the “DIY (do it yourself) pandemic.”
Hutton said every local public health agency is forced to navigate its pandemic response with little direction or assistance from the state.
"It's ... do it yourself. Build it yourself," Hutton said.
Hutton said her department is helping local schools develop a safe plan to reopen this fall but school officials, like local public health departments, have received little guidance from the state.
Counts expressed frustration about the lack of consistent guidance from the state. She said this has made it difficult for her department to clearly communicate with the public.
"We tell them one thing. And the next day it is something new," Counts said. "And it makes us look like we don't know what we're talking about."
The weak spots
Malone said the pandemic has exposed weaknesses in the state’s public health system. He said many of the problems stem from the general public not understanding how Missouri’s system works.
Since 2007, the average number of dollars each state invests in public health per person has increased. Missouri is an exception to this trend. According to data compiled by the State Health Access Data Assistance Center at the University of Minnesota, the Show-Me state ranks 50th in public health funding, dropping nearly 30% in the past nine years.
Missouri spends $7.07 per person on public health funding. The national average is $42.04.
“They (the public) think that by having the funding go to the state public health department it’ll (trickle) its way down ... but that is not the case,” Malone said.
How much a state spends on public health affects many facets of life.
The rates of tobacco usage among adults and adolescents are both common benchmarks for a community’s overall public health.
According to a 2016 study by the Centers for Disease Control and Prevention, Missouri has one of the highest rates of tobacco usage among pregnant women with 15.3% of pregnant individuals having used tobacco. This is nearly double the national average of 7.2%.
Phillips said public health advocates are “a victim of their own success,” and that many of their responsibilities are taken for granted by the general public. She said no one thinks about who's making sure their kids don’t come home from school with a rash or who is making sure their favorite restaurant is following proper safety protocol.
"I think they need to be seen and I think they need be heard," Phillips said. "They are doing a thankless job with little help from the state."
Anna Sirianni contributed to this report.