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Mar. 14—On Friday, another 101 manila folders were added to the stacks and boxes lining what was once empty space in a repurposed conference room now used for COVID-19 case investigations at the Hamilton County Health Department.
Each folder represents one of the more than 41,400 confirmed coronavirus infections detected in county residents over the past year. Each was compiled by hand by a "contact tracer" — a health department worker who's tasked with using a positive lab report to contact the infected person, gather information about them and retrace their whereabouts in hopes of preventing more infections and gaining better control of the pandemic.
Bev Fulbright, epidemiology manager for the health department, said folder No. 1 is likely tucked away somewhere upstairs along with other old medical records. The team ran out of space in the conference room months ago.
Almost the entire structure of the health department was upended since that first case was confirmed on March 13, 2020. Hundreds of new hires and volunteers were brought on to respond to the public health crisis that stressed the local health system, economy and community. Officials estimate around 95% of the department's original staff took on new responsibilities.
Some have come and gone as the pandemic changes and the department's needs evolve. Others built workstations wherever they could find an area six feet apart from another person — a breakroom, kitchen, the employee gym and in offices abandoned months ago when their typical occupants went out to the community to conduct testing and now vaccinations.
"Before COVID, I was singing and dancing with children," said Renee Craig, who used to direct "Little Sprouts," an early childhood nutrition program. "We knew as much about COVID as the general public at that point and just had to very quickly become experts on all this."
Since March 2020, Craig has been the supervisor of the health department hotline.
In that time, citizens' attention, fear and frustration turned to the health department — an arm of county government that often operated out of the spotlight.
Schools had closed. Many churches did the same. By the time the county's first case of COVID-19 was confirmed, the local coronavirus hotline, which handled a handful of calls at first, was flooded with panicked inquiries.
Managers were scrambling to find protective equipment for their employees. Doctors needed the latest recommendations on how to treat patients. Concerned citizens wanted a place to report unsafe business practices. People who were exposed, symptomatic and unable to find a place to get tested all turned to the health department for answers.
By March 16, the county got its first glimpse of what the next 12 months would look like. Local leaders, following guidance from the U.S. Centers for Disease Control and Prevention, called for the immediate cancellation of all large gatherings. No weddings. No concerts. No sporting events.
More than 560 people called the Hamilton County Health Department that day, a record at the time. The staff had to navigate the sea of changing, and sometimes conflicting, public health guidance, statewide executive orders and local orders.
Dr. Paul Hendricks, Hamilton County's health officer when the pandemic started, said the public was asking legitimate questions, but the biggest challenge was providing answers about a new virus as science was rapidly evolving.
"We were learning on the fly. It's a classic building-an-airplane- in-mid-flight kind of a situation," Hendricks said. "We were constantly behind the eight ball on what was going on and with the spread."
He recalled the early reports of people without symptoms spreading COVID-19 being the "game changer" in our understanding of how to prevent the disease. Before that, it didn't make sense to advise that everyone wear face masks, because people would know if they were infected and therefore stay home away from others.
"When we heard about asymptomatic spread, then all bets were off. Anybody could have it," Hendricks said.
As tensions ebbed and flowed throughout the pandemic, those answering calls on the hotline faced the brunt of anger and anxiety over mask mandates, school reopening and vaccine availability. Staff had to stop saying their names when answering calls for security reasons.
In the past year, the hotline has fielded more than 127,000 calls from across the community.
'We called in everyone'
Local leaders began meeting to discuss COVID-19 preparations in January 2020, not long after the novel coronavirus was first identified in China. They watched the outbreak as it tracked across Asia and Europe, knowing it had all the earmarks of a possible pandemic. Staff study previous pandemics, write emergency plans and conduct practice drills throughout the year in preparation for the day the next health crisis strikes.
On March 9, 2020, the Regional Health Operations Center in the health department was activated to respond to the public health emergency. The team has met every morning at 8:30 since that day, including on weekends during the early stages of the pandemic.
An incident report from the time details the immediate goals and challenges: identify and track infected people, provide guidance and counter misinformation, minimize social and economic impact, procure personal protective equipment, identify remote testing sites and locations and resources for alternate care sites.
Early on, epidemiology manager Fulbright and three others worked contact tracing — following up with every infected person every day to check in, calling all known close contacts.
"The first weekend we worked, I did seven cases myself," Fulbright said. " I interviewed them. I did all the contact tracing, I called all the contacts every day. I did all the data entry for that case. And then, once you do several, you've got a lot of contacts every day to be calling."
The contact tracing process was familiar to department personnel, mirroring what they do for cases of meningitis, hepatitis or salmonella.
But they had never dealt with such a high volume of cases.
The contact tracing operations of the early chapters of the pandemic had to be scrapped as case levels spiked. The county stopped putting out notices about possible exposure at large gatherings. Eventually, community spread of the virus was so high it was assumed that if people went to any large event, they should act as though they were exposed.
At one point, anyone who could pick up a folder and find a quiet part of the building was making calls, Fulbright said.
"We called in everyone. We hired people, we had people from all over the health department come in to help us," she said.
The epidemiology division underwent the largest transformation at the health department. What began with four people before COVID-19 swelled to 50 contact tracers during the winter peak.
With fewer new cases in recent weeks, the department can again focus on tracking individual cases, Fulbright said.
"What we see as our numbers now, we think it's nothing," she said. "I remember the first day I texted my husband and said, 'We have 100 cases today.' That was huge. Now, we get 100 cases and we're like, 'We only have 100 cases.'"
Laura Pick, an epidemiologist at the health department, is responsible for compiling and monitoring the plethora of data used to track the progression of disease locally. Though the public health and community's focus has turned to vaccines, she hopes people don't forget lessons learned from the past year.
"While our numbers are a lot lower, they're still about as high as they were at the end of July and August," Pick said. "It's still [the] considerable amount of spread in our community that we have to pay attention to."
The price of public health
Those who work in public health typically have long careers — years and sometimes decades spent building connections and institutional knowledge — said Becky Barnes, administrator for the Hamilton County Health Department.
That is why it was always sad to see someone change jobs or retire, Barnes said.
"Sometimes I would say, when the apocalypse comes, you are going to come back and help us, and they would always just laugh because we knew that public health is a relatively small staff," she said.
Barnes gets emotional talking about it, but when the call for help went out, people stepped up. Existing staff rallied to take on new challenges.
"People that have even left us, gone on to work as a school nurse, they're standing there in the line giving immunizations today," she said. "I think it just speaks to the heart of people who have careers in public health. They're public servants."
But those in public service have been asked to do more with less. Adjusted for inflation, the Hamilton County Health Department and the Tennessee Department of Health spent less per resident on public health in the year before COVID-19 than in 2007.
While the state health department has seen budget cuts in the past decade, the county health department's budget has stayed relatively steady when adjusted for inflation. But as the county has grown, those same dollars are spread out across a larger population. According to estimates from the US Census Bureau, more than 40,000 more people are living in the county than a decade ago.
Public health funding goes in waves, with a bump typically following a health crisis and cuts starting around three years, said Gerard Anderson, professor of health policy and management at Johns Hopkins University. When public health is successful, people are largely not aware of it, he said.
"It's only when either the public health system fails or the entire medical care system fails that you notice the lack of public health," Anderson said. "The problem is success does not bring more money. In most industry and most care, when you're successful you get more resources. Here, you actually get less resources for actually being successful."
Barnes said that while prevention efforts likely save money in the long run, it can be difficult to advocate for spending the limited available money toward stopping something that could happen, compared to spending money on addressing an immediate need.
"It's really hard when you're the one that says, 'Give me money and I'll keep people from getting sick,' and people are saying, 'But people are here, they already have this, they're dying, we need treatment of these people,'" Barnes said. "There's always going to be that fight for dollars like that, and it is really hard to keep funding for things that people don't see."
Hendricks, who retired as health officer in January 2021, spent much of his career working as an emergency room physician at Chattanooga hospitals.
When he joined the health department in October 2019, he said one of his priorities was to leverage his network of contacts to establish a stronger connection between the health department and the medical community, which have similar goals of improving community health but often don't communicate. The two can be a "forced marriage at best," Hendricks said.
"I'd seen it from the other side, that I didn't think there was enough interplay. The medical community needs to know more about what's available and what's out there," he said. "I really felt like that was something I could offer, because I had feet in both camps, and I was committed to both camps. But it's like you're either for us or against."
Hendricks said he's "been accused of being a Kumbaya person," but there wasn't much interest on the part of the health department to forge new partnerships or break away from old processes.
"With this being such a new thing, we all had to learn from each other. That was probably our biggest missed opportunity," he said. "There was not enough coordination and working together with some of the other agencies around."
Diana Kreider, director of clinical service at the health department and the COVID-19 chief of operations, said the health department listens to community partners, but public health must make decisions based on what's best for everyone. In other words, Hamilton County is the patient.
"When you talk to sometimes community partners, they're giving good input, but their input is focused on what they know and what they're responsible for," she said. "At the end of the day, we have to take that into consideration, but also that whole big picture."
Often, individual concerns don't mesh with what's best for large populations, Kreider said.
"Because if you did this over here, that negatively impacts this group over there, or impacts the whole big picture. We have to go back to, 'What are we here for at the end of the day?' It's the health and wellbeing of the whole community, not just this piece of it," she said. "That's hard, and people can't see that sometimes."
Barnes said it's too soon to assess the true impact of the past year and the future of public health. The health department is still too focused on the immediate task at hand.
Like thousands of others in Southeast Tennessee, health department staff have fallen ill or had a loved one die from COVID-19. Others navigated quarantine, raising children or were caretakers for elderly parents. They gave up weekends, contact with family, holidays, vacation. In the past year, a staff member got pregnant, had a baby, completed maternity leave and returned to the phone. Another got married.
Kreider, who handles staffing at the health department, said people have risen to the occasion to address the crisis but staff were forced to put on hold whatever they were working on before the pandemic. Many are also dedicated to those causes, she said.
"They're grieving that because we're not able to provide those services or that needed care out in the community," she said. "So not only are they doing this COVID [work], but they understand the loss of what they were previously doing, and that's been a real difficult thing."
Hotline supervisor Craig wonders whether she will ever be able to return to her previous role educating children about fruits and vegetables.
"What will the health department look like when this is over?" she said. "Will I ever go back to teaching Little Sprouts? What will the programs look like? What will the building look like?"
At the same time, Craig said she has formed incredible bonds with those she has worked alongside. The team showed up to make calls, enter data or deliver vaccines on weekends and holidays. Despite the anger the hotline staff faced, they also connected some of the people who called, Craig said.
Sometimes people who are sick call the county hotline before their doctor or 911, Craig said. She picked up the phone once to a woman Craig thought was crying. But as she struggled to understand the woman, Craig realized the person on the other end of the phone was struggling to breathe. Craig asked the woman if she had someone who could take her to the hospital but the woman kept repeating "I have nobody," she said.
Craig stayed on the line while she flagged another staff member to call 911. She had to be sure the woman made it to the hospital.
But the call left her shaken.
"I was really scared," she said. "I was like, I think I may have talked to someone who may not survive."
Several weeks later, Craig answered the phone to a familiar voice.
"She had made it," Craig said. "She still wasn't feeling good, but she did call."