Amid Pandemic Recovery, Local Health Departments Grapple With Historic Turnover

Before last year, Dr. Jennifer Bacani McKenney’s full-time job was practicing family medicine with her father at a private clinic in Fredonia, Kansas, the 2,500-person town where she grew up. As a side job, she served as the health officer for Wilson County, a government-appointed position that paid $600 per month and consisted mostly of overseeing medical protocols, submitting a quarterly report to the board of commissioners, and helping with grants and public education campaigns.

When Covid-19 arrived in the United States, and as it eventually took hold in Kansas, McKenney’s side gig grew in scope. She held county-wide meetings every week to apprise leaders and stakeholders of the status of the pandemic in the community. She held question-and-answer sessions on Facebook Live. And she advised the Wilson County Commissioners on health guidelines, including mask mandates, school closures and other safety measures. By the end of last year, her role had grown to a second full-time job—one that eventually courted controversy, as the community grew weary of business closures, social distancing recommendations and virtual learning.

As a result, McKenney, who decided to practice medicine in her hometown specifically to care for the community she grew up in, faced harassment, including threatening comments on social media and, once, someone showing up outside her home to take photos of a socially distanced outdoor gathering she held to thank her staff for their hard work.

“They came to my house, filmed my house, and then five minutes later, people were on social media saying that I didn’t think the rules applied to me,” she said. “I remember thinking, ‘OK, you can say bad things about me on the internet, but I have little kids. Do not show up at my house. That’s over the line.’ That was a low point.” 

Since then, Kansas state legislators have stripped local health officials of their already limited powers, making it impossible for appointed leaders like McKenney to enforce things like mask mandates or stay-at-home orders. Still, she remains in the job, with no plans to step down.

“This is my hometown. I was born and raised here, and I decided to come back here, and I will always take care of the people of this town because they’re my people,” she said. “Those are the important people. Not the county commissioners, not the loud people who decide not to wear masks—it’s the people that do need somebody, and want help, and support me, and the science, and staying safe.”

Not all public health leaders have weathered the pandemic so well. At least 248 state and local health officials across 41 states have resigned, retired or been fired from last April through March, the largest exodus of public health workers in history, according to ongoing research by the Associated Press and Kaiser Health News. 

Some, like Dr. Gianfranco Pezzino, former health officer for Shawnee County, Kansas, resigned due to exhaustion and the feeling that their public health recommendations, based on science, were being ignored for political reasons. The county is home to 177,000 residents.

Some, including McKenney’s former supervisor, left for better job offers. Others departed because of burnout, the result of months of 60-hour work weeks with little or no time off, many of them juggling full-time careers with what had previously been part-time appointed positions.

Those numbers don’t include the departures of lower-level staffers, who also left health departments in droves. In Kansas alone, 60% of health departments lost between one and six employees, according to the results of an internal survey from the Kansas Association of Local Health Departments.

“Morale, in general, is pretty bad,” said Dennis Kriesel, the association’s executive director. “Many of these people have worked in public health for decades, and from what I have heard, this has been the worst year of their professional lives.”

"How Did This Become Political?"

There are myriad reasons for those departures, said Lori Tremmel Freeman, CEO of the National Association of County and City Health Officials. Some of the turnover is due to retirement among an aging workforce, but much more of it stemmed from pandemic-related stressors, most notably the politicization of public health guidelines.

“The No. 1 reason is politics,” she said. “Then there’s just complete fatigue from the pandemic—being worn down and worn out, long shifts, lack of workforce, lack of resources. There’s a lot of pressure on local health officials, and they’re sort of in this interesting position, where they’re at the frontline of the frontline but they don’t make up the guidance or the rules. In most cases, it comes to them and they have to enforce it. And they’ve gotten a lot of grief for those efforts.”

The politicization happened at every level of government, seeping slowly into the everyday lives of residents. States that lifted stay-at-home orders earlier in the pandemic, for example, overwhelmingly voted for Donald Trump in 2016. Democrats were more likely to wear masks than Republicans, including Trump himself, who often dismissed face coverings as ineffective and unnecessary. Once, speaking off the cuff at a coronavirus briefing, Trump suggested that introducing bleach and other disinfectants into the body—“by injection inside, or almost a cleaning”—could serve as a cure for the virus.

McKenney, alarmed, took to Facebook to debunk that claim, posting a warning from a cleaning manufacturer that customers should not ingest their products in an attempt to ward off Covid-19. The backlash to that post was immediate, she said.

“There were like 300 comments claiming that Trump didn’t say that,” she said. “So I responded and said, ‘Here’s the transcript, here’s the video,’ and that’s when people accused me of making it political. That continued for months, and I was shocked. How did this become political? Why? This is science, and it’s people dying, and it’s health, and it’s what I went to school for. I think we all thought, naively, that it was going to be about the science and the research—and then it wasn’t.”

Public tussles between elected officials and health experts became regular events across the country. In September, Dr. Aimee Sisson resigned as public health director in Placer County, California, which has about 400,000 residents, after the board of supervisors voted unanimously to end the county’s Covid-19 health emergency declaration, in direct defiance of her guidance. In November, a four-person health department serving a 6,000-person county in Montana resigned, citing a lack of transparency and support for contact tracing and other pandemic-related efforts.

That same month, Karen Koenemann, then the public health director for Pitkin County, Colorado, which has about 17,000 residents, left her post after months of vitriolic emails and what she categorized as inadequate support from county leaders. The burnout came to a head during a meeting with the county manager and the sheriff, when she “felt alone and so I just started to cry,” she told NPR.

In meetings with her board of commissioners, McKenney said, she and her supervisor were routinely referred to as “girls.” Once, during a discussion about whether it was safe for kids to resume playing sports, a county official told McKenney that she seemed to think she knew everything, just because she was a doctor.

“I just said, ‘Well, I think I know more than you about this, because I am a doctor,’” she said.

Threats, Harassment and Confrontation

In some places, those battles spilled over into health officials’ private lives, a particularly troubling trend for leaders who are accustomed to working more or less anonymously. Thrust to the forefront during the pandemic, many health department employees were subjected to threats and harassment simply for doing their jobs.

“Most health administrators directly work for a government, and they are not used to their department being a political tool, a hot topic, anything like that,” Kriesel said. “Normally, they’re pretty forgotten. Outside of a pandemic, no one knows who the local health officer is.”

Covid changed that. Thirty-eight out of 59 health departments surveyed by the Kansas Association of Local Health Departments reported receiving verbal harassment that was motivated by the local response to the pandemic. Ten departments said that staff members had been physically confronted or injured. One department had its power lines cut; another official said someone threatened to shoot her in the head. In Wilson County, sheriff’s deputies began attending board meetings to escort McKenney to her car; once, after noticing cars driving by her home, she moved her children to the back of the house during remote learning in case protesters attacked the front windows.

“I remember thinking, ‘I’ve never not felt safe in my own hometown,’” she said. “There were just times where it was so overwhelming, with regular work and health official work, that at the end of the day I would wait for my staff to leave, shut my door, put my head on my desk and cry for a little bit before I went home to my kids.”

Those types of interactions—public and private—were increasingly common over the past year, Freeman said. For most officials, it was a jarring departure from the norm, where residents and community members typically trust the guidance of their local health department.

“They’re used to being really trusted messengers in their communities, and helping the community understand why they need to do something to keep themselves safe,” she said. “If someone from the health department said to them, ‘Your water is now unsafe and you need to boil it,’ most people wouldn’t ignore that. It’s been a long, hard year and a half for them. It’s really hard to see and hear how they’re feeling right now. I worry for them. And I worry for the future.”

But not every relationship was that contentious. In Dallas County, Dr. Philip Huang, director of Health and Human Services, was able to work productively with his elected officials, securing, among other things, increased pay for department staffers who were working overtime throughout the pandemic.

“It was sort of crazy, that we were putting these people through these grueling hours and couldn’t even pay them overtime. It requires a lot of dedication to the mission,” he said. “Luckily, our county commissioners recognized the extraordinary circumstances.”

"It's Hard to Replace That Leadership"

It remains unclear how local health departments will fill the growing number of vacant positions. Recruiting for those jobs is difficult—private-sector health jobs at hospitals and clinics pay much more, often with better hours and benefits—and public health, in general, has been understaffed and underfunded for years.

That could worsen now, with so many public stories of threats and harassment, lingering burnout and poor mental health effects still to come. Nearly two-thirds of local health departments in the United States are in small or rural communities, according to data from NACCHO, where staffs are comprised of fewer people and recruiting new administrators is likely to be particularly difficult.

“It’s not easy to rebuild leadership in a health department,” Freeman said. “They don't have a bench or a deputy to draw from to create succession planning. It’s a leadership loss, and it’s personal, because these people have been working their hearts out. It’s also tragic for the communities, because it’s hard to replace that leadership.”

Amid the backlash and the ongoing pandemic, even officials in the public health field have struggled to muster encouragement for potential job candidates. Earlier this year, Kriesel said, a state health staffer called to ask for advice on what to tell someone who was considering a local health officer position. 

“I told her, ‘If someone called me and asked me, I’d tell them not to do it,’” he said. “Because there’s no upside right now. Every decision will be criticized, by people who do not understand the field, and you will probably face some level of harassment. I could not envision a scenario where it would be worth it to an individual.”

But others are more optimistic. Public health has been integrated into mainstream medical school curriculum in recent years, Huang said, and the real-life experience of the pandemic could help motivate students to consider it as a viable career option.

“Public health isn’t a glamorous area or anything, but this past year has certainly shown everyone how important it is,” he said. “I think people now can understand and see how this affects everyone. I’m hopeful that it will attract those people who are wanting to do something meaningful and worthwhile, because that’s what it is. That’s what I love about the job—what you’re doing is so important.”

McKenney agreed. The upside of her very public battles with elected officials and residents, she said, was an outpouring of support, including some from medical students who said her story influenced their decision to pursue public health as a career.

“That’s been kind of cool to watch, because they’re the ones reaching out saying, ‘I see what you’re doing. I want to fight like you fought, I want to do what you do,’” she said. “I am seeing interest in public health on the medical side of things, and that’s exciting.”