OLYMPIA — In southeastern Washington's Asotin County, thinly staffed public health offices must balance COVID-19 contact tracing investigations with routine inspections of septic systems.
In North Central Washington, staff shortages impeded Okanogan County health employees reaching out to educate and test agricultural workers before a coronavirus surge for a time turned their region last summer into the hardest-hit place in the state.
And throughout the pandemic, former Washington Health Secretary John Wiesman lost sleep as the Department of Health (DOH) struggled to manage the COVID-19 data necessary to direct the response to the pandemic.
"I would wake up many nights at 2 in the morning, at 3 in the morning in a cold sweat ... panicked about how the hell are we going to get the data systems to work today?" said Wiesman, who left recently for a teaching position in North Carolina as part of a long-planned move.
The COVID-19 pandemic that marched across Washington encountered a public health system gradually starved of money, staff and attention over the past two decades.
Rural health offices — like in Asotin, Okanogan and Mason counties — have lost roughly half their full-time staff since the Great Recession, local officials say.
Meanwhile, DOH, which had for years pleaded with state lawmakers and Gov. Jay Inslee for funds to increase disease investigation, boost the public health lab and update information systems, wrestled to report and post COVID-19 data.
Those problems — which included troubles reporting the negative test results necessary to estimate the virus's spread — made it more difficult for the state and counties to respond to outbreaks and made it harder for the public to have faith in the system, officials and health experts have said.
Now, as Democratic lawmakers and Inslee draft a new, two-year operating budget, they're vowing to make amends. The governor has proposed hundreds of millions in pandemic health funding for the next two years. That includes at least $205 million for basic public health services that would be paid for by an assessment on health insurers.
No one in Olympia can claim ignorance to the problems.
In 2010, Wiesman — then the public health director for Clark County — co-authored a report that warned of a "severe funding crisis" and called for a predictable, stable funding source for health programs. Such programs include restaurant and wastewater inspections, administering vaccinations to children, helping new mothers and tracking communicable diseases like measles, syphilis — and COVID-19.
Similar reports in 2015 and 2016 by a group that Wiesman co-chaired called the system "woefully inadequate" and "unable to meet its basic responsibilities." The 2016 report called for modernizing public health data processes.
A 2018 report estimated that lawmakers and Inslee would need to provide more than $225 million in additional annual funding to DOH and local health offices to rebuild the system.
In recent years, lawmakers and the governor — influenced by other needs and priorities — have added just a fraction of that estimated need to the budget.
In a statement last week, Inslee acknowledged that public health has been "chronically underfunded" and cited the challenge of finding billions of dollars for K-12 schools after the state Supreme Court's order known as the McCleary decision.
"States have limited resources and their own unique challenges, such as our yearslong effort to find adequate funding in response to the McCleary decision," said Inslee in prepared remarks. "Our public health system has been chronically underfunded. However, no state, even with the power of hindsight, would have had all the tools at its disposal necessary to avoid COVID's impacts."
In an interview, state Rep. Eileen Cody said that before Wiesman departed she told him, "Everybody's been trying to tell us, and I think you should tell us you told us so."
"We can't fund the system to be prepared for something like COVID," added Cody, D-West Seattle and chair of the House Health Care and Wellness Committee. "But we should have been better prepared than we were."
Ballot measures, recession
The problem began, state and local health officials say, with a pair of voter-approved initiatives about 20 years ago. Initiative 695 removed the state motor vehicle excise tax, a dedicated source of money to public health programs. Shortly after that, voters approved Initiative 747, which limited property tax increases that helped fund local health districts.
Money problems festered as the Great Recession further hammered tax collections, officials say, and as federal funding became more restricted.
Those issues created a cycle where every budget brought cuts or difficult spending choices.
"Almost in every budget cycle before I came on board, there had been pretty major cuts," said Patty Hayes, who in 2014 became the director of Public Health — Seattle & King County. "And when I came on board six-and-a-half years ago we had a $12 million hole" in the budget.
She described a series of hard choices as funding dried up. Vaccine clinics stopped, home visits were trimmed back and planning for emergencies like a pandemic fell by the wayside.
Hayes described the loss of a program for identifying latent tuberculosis as a great example of how public health programs can save significant dollars.
If latent tuberculosis is identified, it can be treated for about $600, said Hayes — compared to $15,000 or more if the person develops the disease and later goes to the hospital.
Properly funded programs can generate savings to society for a host of ailments, said Anthony Chen, director of the Tacoma-Pierce County Health Department. And it's those same programs that will help communities recover from the pandemic.
"It's important for people to understand that, if nothing else," said Chen. "Public health is going to be pulling us out of this."
Chen started as director in 2008, at the height of the Great Recession, saying, "I walked in the door, they had already done a round of cuts before I started."
The department ended programs for tobacco-use prevention and enforcement, said Chen, as well as a domestic violence program: "That's how tight the money was."
Competing for money
As Washington's economy recovered, lawmakers spent dollars restoring impacted government programs, cutting college tuition, providing state worker raises after years of pay freezes and addressing big court decisions.
Front and center was the McCleary decision, which found that Washington was unconstitutionally underfunding K-12 schools by billions of dollars. Legislators also poured money into the state's troubled mental health system, which had drawn critical court decisions and federal inspections. They began directing funds toward Washington's homelessness and housing-affordability crisis.
Legislators and Inslee also raised taxes to fund free and reduced college tuition for low-income and middle-income Washingtonians, and implemented new programs providing paid family leave and long-term care benefits.
The low-profile mission of public health rarely attracts attention in the scramble for scarce budget dollars, said Sen. June Robinson, a Democrat from Everett who is sponsoring a pair of tax proposals this year to strengthen public health.
"The people who can make a real case of a crisis, 'we are in flames, we're going to go out of business or not be able to care for people if we don't get funding,' they just get more attention," said Robinson.
Funding for health data systems is not cheap, said Wiesman, and doesn't make for a compelling political victory.
"What legislators want is to be able to go back home and show people is, 'look, I got you this new service,' " said Wiesman. "They don't want to say, 'well we've invested hundreds of millions of dollars into data systems and epidemiologists to protect your health."
Since 2017, lawmakers have added some new public health funding: $15 million over the 2017-19 budget cycle and $28 million in the current, two-year budget cycle. But that is far short of the $225 million estimated annual need.
"Was it anywhere near adequate? Hell no, nowhere near adequate," said Wiesman, adding later: "It made a difference, it's just that it made a difference of a drop in a large bucket."
"We suffered because of it"
Temporary COVID-19 aid from the federal government has helped public health programs for now. But that money will fade away, officials say, and won't fix long-term problems.
Scott Lindquist cites himself as an example of how thin the agencies are stretched.
Washington's state epidemiologist, Lindquist is also currently serving as DOH's acting state health officer.
And he's helping to administer tuberculosis programs in Spokane and Yakima counties, he said, where interim health officers are filling in and don't have that expertise.
Lindquist also recently doubled — or quadrupled, or quintupled, depending on how you're counting — as Island County's local health officer to briefly help with a vacancy there.
"There's just such a lack of funding and a lack of skilled workforce," said Lindquist, adding later: "We can repeat this [scenario] for nurses, we can repeat it for information technology."
Since 2011, Asotin County Health Administrator Brady Woodbury has watched his staff of more than a dozen dwindle to six. The same staffers making calls for COVID-19 contact tracing must also still handle inspections and responses for septic systems.
"Contact tracing stayed the priority, but once you got enough, you break off and go get an inspection done," said Woodbury. If a septic system suddenly failed, he added, "we had to stop contact tracing."
Okanogan County Public Health over the years lost outreach staff who connect with agricultural employees — which include Mexican guest workers — who work with apples, cherries and pears, said Health Officer James Wallace.
"And we suffered because of it, we wanted to test more people, test our farmworkers, provide more communication and education as soon as this pandemic hit," said Wallace. "And because we didn't have the funding and didn't have the people we were behind the ball on that."
Wiesman said he's confident Inslee — who during the pandemic has seen the system's struggles up close — is committed to increasing funding, and cited the governor's budget proposal.
"Whether it was the decisions we had to make how to figure out how to slow the virus, or the data challenges," said Wiesman. "Whatever it was, he lived with it every day."