Ill equipped: Public health hobbled by lack of funding

Like countless public health departments across the nation, Cameron County Public Health was hobbled in its response to the pandemic by chronic underfunding and a reporting system mired in the 1990s.

The result has been a tremendous backlog in the reporting of COVID-19 cases and lengthy delays in getting test results back from laboratories, which has made tracking the spread of the virus nearly impossible.

Esmeralda Guajardo, the county’s public health administrator, said her department operates under the guidelines of the Texas Department of State Health Services, which operates under the guidelines of the Centers for Disease Control and Prevention. TDSHS funds the various health departments under its umbrella based on population, which works out well for places like Harris County and Travis County but not so well for smaller counties like Cameron, she said.

“One of the reasons we had a backlog — I can say that maybe bigger cities did not have the problem — was because we were not in a position to hire contact tracers,” Guajardo said. “You know that larger cities did, with the (CARES Act) funding that they received, they were able to hire contact tracers.”

The $2 trillion CARES Act passed by Congress and signed into law in March contained money for local governments to help cover costs associated with battling the pandemic. U.S. cities and counties with populations over 500,000 received the funds directly through the Treasury, though counties and cities with populations under 500,000 had to apply for the funds through their respective states. In the case of Texas, the governor’s office dispersed the money at a lower rate than the federal government, with the result that Cameron County received $55 per capita while Hidalgo County received CARES Act funding at the rate of $176 per capita.

“We got $5 million to cover the entire Cameron County organization,” Guajardo said. “How do you cut out so much to hire individuals to help us with contact tracing? It’s very, very difficult.”

She said it’s a special situation for health departments along the border in places like the Rio Grande Valley and Laredo that accommodate large numbers of visitors from Mexico as well as Winter Texans — factors not taken into account in the usual TDSHS funding formula, which may be the way it is because of CDC guidelines. Whatever the case, Guajardo said she and her colleagues along the border have been voicing their concerns about the situation for years.

“You can’t keep up with the regulations and the structure the state wants to implement … if they don’t provide the resources to be able to keep up with the bigger cities, the funding and the resources that they have,” she said. “There’s just so many factors other than just population. … We’re playing by someone else’s rules and requirements but we’re not given the resources to keep up. Someone might look at us and think that we’re not being able to perform well, and it has absolutely nothing to do with that.”

Health departments in large metro areas of the state, besides getting more funding through TDSHS and having huge tax bases, have a substantial resource infrastructure supporting them — hospitals and university medical systems, nonprofits and foundations for instance — compared to departments in less populated places, Guajardo said.

The upshot is that when Cameron County was hit with the COVID-19 tsunami her department was overwhelmed and had to apply to the state for personnel help, which arrived in the form of 10 epidemiologists and six data-entry people to help plow through the case backlog. The relief is temporary, though Guajardo has asked the state for an extension.

Disease preparation is just one of several types of services the health department provides, and she’s had to ask employees from other areas such as vector control and the Women, Infant and Children supplemental nutrition program to come in on weekends and after 5 p.m. on weekdays to help with COVID-19 paperwork.

“I’m pulling them in to help out,” Guajardo said. “It’s very tiring.”

“Touch and go” funding is how she describes the money her department gets to deal with emergencies.

“We don’t get funded unless there’s a problem,” Guajardo said. “You have a problem, they give you money, then before you know it it’s gone. The COVID funding we’re getting right now, it’s only good until about mid-March. It’s very difficult for us to utilize those funds and hire people that will want to take a job with us when they know it’s only good until mid-March. And while they’re here they’re looking for somewhere else to go work, so they can find something more permanent. This is very typical of public health funding.”

It means her department plans short term because it can’t plan long term, can only be reactive as opposed to proactive in case of emergencies, and won’t be prepared for the next pandemic, she said.

“Of course being along the border we take on the responsibility of protecting not just our community but the rest of the state from any kind of disease, and so it puts us in a very difficult position,” Guajardo said.

A related issue that has made it harder to deal effectively with COVID-19 is a skeletal statewide public health reporting system that still relies on fax machines in some cases. Guajardo said she doesn’t understand why a Texas Department of Public Safety trooper in another city can know within minutes if she gets a ticket on the way home from work, “yet in the name of public health I’m not able to access a clinical record on someone down the street that tested positive for COVID.”

“We need to be able to put that kind of priority in public health funding so we can have a robust public health reporting system in place,” Guajardo said. “I hope and pray that the silver lining in all this is the next pandemic, God forbid we have to go through one again, we’re prepared because people actually understood our problem and decided to help us.

“There’s no reason I shouldn’t be able to get a lab report immediately from someone being tested for positive. We’re the last ones to know, and we’re still receiving reports by fax machine. If that’s not antiquated I don’t know what is. Some doctors offices choose to go that route and we provide that option.”

The county also sorely needs laboratory infrastructure instead of having to ship virus specimens off to Austin and wait days for the results, she said.

“There’s so much that needs to be looked at, and if funding’s not provided to public health then we’re going to go through these problems again,” Guajardo said. “Not to whine about what we don’t have, it’s just that this needs to change. Public health is critical. It’s as critical as public safety.”

Having a real-time reporting system could have prevented COVID-19 from raging out of control in the state, she said.

“There has to be a system and I believe it can be done,” Guajardo said. “It can be done. We need to address this. It needs to be talked about.”