On June 2 Jessica Pearson, an epidemiologist with the Missouri Department of Health and Senior Services, sent a concerned but business-as-usual email to local health officials in the northwest corner of the state.
Pearson took note of the highly contagious COVID-19 delta variant, which had surged in some northern Missouri counties.
“Just a reminder that there is nothing additional that needs to be done as far as public health action for variant cases,” Pearson wrote, recapping a conference call earlier that day, “but we emphasize the importance of a timely investigation and implementation of control measures.”
One month later, as the United States as a whole experiences the fewest cases and hospitalizations in months, Missouri is in crisis.
Delta is rampaging through the unvaccinated, spurring rising cases and threatening to overwhelm Springfield hospitals. Missouri now has the second-highest rate of new cases per capita, according to data compiled by The New York Times, and among the lowest adult vaccination rates among all states.
What went wrong?
A joint investigation by The Kansas City Star and Columbia University’s Brown Institute for Media Innovation reveals how June became a lost month in the fight to slow the spread of delta across Missouri. Thousands of pages of internal emails and other documents from 19 local health departments trace the growing alarm and a sense of near-resignation among officials about their chances of halting the advance of the variant.
The consequences of the squandered month will last well into summer. CoxHealth, a major Springfield hospital, told The Star it’s bracing for hospitalizations to rise for weeks to come. Delta is still spreading and has now been found in the Kansas City and St. Louis areas, though state officials hope higher vaccination rates in those places will limit increases in cases. Schools will also begin next month with some parents in open rebellion against imposing mask requirements, even with delta all but certain to continue circulating.
The emails, obtained through records requests by the institute’s Documenting COVID-19 project and shared with The Star, paint a portrait of local health officials eager to vaccinate their communities but encountering resistance from residents, apathy from some politicians and a milquetoast state-level response. They document rising frustration with everyone from DHSS to elected officials to the public. An official in one county even privately mocked a video released by DHSS explaining the delta variant.
“I feel like we’re on an island, all alone in the COVID fight, but I know others in the state are feeling the same way,” Laclede County Health Department Administrator Charla Baker wrote to a DHSS official in late June. “With our community leaders and residents not wanting to take any remedial actions to protect themselves and others, we are just very frustrated and concerned with our current situation.”
The emails also show local leaders sometimes going to extraordinary lengths to win even modest advances in vaccinations, in the absence of new state initiatives. In Joplin, the city manager sought an incentive program for municipal employees but urged city council members to minimize their comments about it to not arouse public anger.
“We’ve alerted our local elected officials and decision makers with very little interest in discussion of mitigation measures,” Taney County Health Director Lisa Marshall wrote to health officials across the state on June 17.
“Our last election cycle saw a turnover in many of our elected officials resulting in a ‘pro-recovery’ focus. We are also seeing low uptake of vaccine in our county despite education and clinic offerings,” she wrote. “Without local support and continued low interest in vaccines, coupled with the welcome sign, I anticipate our numbers will continue upwards.”
This week, Taney, which includes the tourist destination of Branson, was among the top 10 counties in the United States for new cases per capita.
Missouri’s cases remain below their winter peak but are steadily trending upward. But even as health officials desperately try to engage the public, the messages from the state’s leadership remain mixed.
The Republican-dominated Missouri House in June debated a measure to undercut vaccine mandates for hospital employees. Some lawmakers have also repeated baseless theories that the vaccine affects pregnancy.
Gov. Mike Parson hasn’t used the same alarmed language of senior officials elsewhere to prompt residents to get shots. Instead, he has highlighted data points such as the higher rates of vaccination among seniors. His agitated response to the arrival of federal assistance that his administration requested provoked a rebuke from the White House. This past week, he stressed the state “is not in crisis mode.”
“I think we’ve took every action we could possibly take in the state of Missouri to prevent this,” Parson told reporters on Wednesday. “You have a vaccine that’s out there, and frankly it’s been out there for seven months now. … Everybody has access to it.”
While fully containing delta was likely impossible, health officials across the state quickly ruled out new mask mandates or other restrictions as politically taboo. Local leaders felt the state didn’t provide enough information to easily track where delta was showing up. And June passed without Parson announcing a vaccination lottery.
On Friday, State Epidemiologist George Turabelidze acknowledged a lack of precautions and low vaccination rates have fueled delta’s rise. He told reporters that even before the current surge, epidemiologists had predicted future outbreaks would occur in vulnerable areas.
“Unfortunately, Missouri turned out to be among those several states that do have those vulnerable spots,” Turabelidze said, “and those are spots where people are undervaccinated, people have low natural immunity levels, and some communities that assumed that pandemic was already behind us, and mitigation was dropped too quickly.”
“All those factors made us vulnerable, as a state. And that’s what happened, as it was predicted,” he said.
Asked about Pearson’s comments at the start of June, DHSS spokeswoman Lisa Cox said public health strategies are the same for all variants and that the Centers for Disease Control and Prevention had confirmed this to the agency.
“The same prevention methods apply regardless of the variant,” Cox wrote in an email. “Vaccination is the best defense against all variants, and we encourage all individuals age 12 and up to be vaccinated.”
Whatever happens next, Missouri is probably in for weeks of rising cases, hospitalizations and ultimately deaths — the vast majority likely avoidable if the deceased had been vaccinated. Going forward, a decline in vaccine hesitancy or behavior changes such as more voluntary mask wearing will take weeks to reach their full impact.
As the rest of the country keeps a wary eye on Missouri, the state offers a grim prophecy for other regions where vaccination rates remain low.
“It looks to me as though Missouri is the tip of delta’s spear,” said William Schaffner, a professor of infectious diseases at Vanderbilt University in Tennessee.
Warning signs as June begins
Missouri emerged from Memorial Day weekend with cases at their lowest levels in months.
On June 1, the 7-day average of confirmed daily new cases was 239, according to DHSS. In November, the average exceeded 4,500.
But something was wrong in Joplin.
Admissions were rising at two of its biggest area hospitals, Freeman Health System and Mercy. Devin Blankenship, assistant director at the Joplin Health Department, wrote in a June 2 email to city officials that he had talked to infection control nurses at the facilities.
Freeman had reported a COVID-related death each of the last three days. Blankenship relayed that the hospital “may need to flex” their COVID unit, closed since March. He wondered whether Mother’s Day and graduations were contributing and expressed concern about what Memorial Day could mean.
“Doesn’t seem to be any rhyme or reason to the admits,” Blankenship wrote.
In central Missouri, Stephanie Browning, director of the Columbia-Boone County Health Department, was thinking about contact tracing. Browning had been asked by a University of Missouri researcher whether it was still occurring.
Because of the up to 14-day gap between infection and symptoms, contact tracing was a difference maker in Missouri — and across the United States — in slowing the spread. But interviewing positive cases and reaching out to their contacts was a time-consuming task that burned through employee hours.
Contact tracing was still happening in Boone County, Browning wrote back on June 5. But a number of other counties “have stopped altogether,” she wrote.
The day before Browning sent the email, Boone County had reported just seven new cases. On July 6, there were 104.
In an interview, Scott Clardy, the department’s assistant director, said the number of cases rose so quickly that the department couldn’t call every contact anymore. Workers call who they can; everyone else receives a packet in the mail.
Missouri residents have also grown increasingly uncooperative with tracers. As delta spread, the reluctance or outright refusal of many to participate limited the effectiveness of an indispensable tool for public health officials.
Debra Bradley, director of the St. Joseph Health Department, disclosed in an email later in the month that about half of those called “do not answer their phone or refuse to give us information.”
In Jackson County, health officials initially ran into resistance as they tried to investigate an outbreak tied to a camp hosted by Crown Pointe Church in Lee’s Summit. Charles Cohlmia, an official at the Jackson County Health Department focused on communicable diseases and public health preparedness, wrote to DHSS on June 17 that it had been trying to get a roster of participants from the church.
“So far, we’ve gotten radio silence until a few minutes ago when the church lead said they would not be cooperating,” Cohlmia wrote.
Crown Pointe Lead Pastor Dennis Luce told The Star that the church did cooperate via its parent organization, which hosted the camp.
“Our concern was turning over personal information from our students and families, so in consultation with our District Office, they communicated all of that information on our behalf,” Luce said in a statement. “We have always cooperated and complied with the Health Department to reduce the spread of Covid and keep people safe.”
Officials weigh incentives
By mid-June, it was clear cases were rising again.
The state’s 7-day rolling average of new cases had surged to 411. Wastewater samples detected delta in all corners of the state.
Local health officials, facing stagnating rates of vaccination, asked the state to encourage hesitant residents to take the shot, according to notes of a meeting DHSS held June 8 to address COVID hotspots. The notes were prepared by a Joplin health department nurse who attended.
Among the questions asked at the meeting were: “The demand for vaccines continues to decline and we are not seeing much in the way of marketing from our leaders to change the mindset of people. can our elected leaders do more to support or promote vaccines? Haven’t really heard anything from Governor.”
“Thanks for the input,” a Parson administration official responded, according to the notes. “The most impactful means by which to drive engagement and reduced hesitancy rate is through physicians, public health, and medical providers based on the data.”
It’s not clear from the notes which official made the remarks.
At the same meeting, Adam Crumbliss, director of the state’s Division of Community & Public Health, discouraged local officials from sharing a state virus hotspot map with the public. He told them to “use discretion” and share it with partners “in an appropriate and thoughtful context,” according to the notes.
The following week, Parson told reporters he was skeptical of implementing a vaccine lottery, as other states had done.
He’s since changed his tone. On June 25, the health department told local officials the state was considering rolling out a sweepstakes program with the Missouri Lottery. On Wednesday he said the state was still working on a potential incentive, but he remained unsure.
“I’m not a huge fan of that, but I also want to move the needle in this state,” he said. “If it helps, I think we need to try it … At the end of the day, you know, I’m caught between that decision, do you really pay somebody to go get something they need that protects people and protects them?”
On Friday, state health officials promoted a $5 million ad campaign and other efforts to inform the public about the benefits of vaccination.
“Fear is not the means by which to move forward in Missouri,” Crumbliss told reporters. “The way to move forward is an aggressive action plan and engagement at the very individual level, and then having trusted voices on the ground.”
Emails show local officials weighing their own incentive programs. In Joplin, City Manager Nick Edwards wrote to the city council on June 15 floating an extra vacation day for city employees who are vaccinated by September.
He wrote that the city was facing staffing issues because of sick workers. At the time, 19 fire department employees were out due to the virus.
He estimated the cost of the vacation incentive at $30,000 and suggested that federal funds might pay for it.
But even as he tried to convince the elected officials, Edwards also urged them to minimize their comments if it was discussed at a meeting.
“Knowing the strong feelings on COVID, and further the use of taxpayer dollars to incentive vaccinations because some employees have not made the safe decision will likely be a divisive topic,” he wrote. “This conversation has the ability to negatively impact the election conversations.”
Edwards didn’t elaborate in the email on what he meant by election conversations, but in August the city will vote on renewing a sales tax for parks and stormwater improvements. He wrote the next day to colleagues that he had heard from the mayor and that the council unanimously supported the incentive program.
The initiative was rolled out before the end of the month. Reached for comment, Joplin community health director Ryan Talken said the program “has had success” but “the final results have not been realized yet” because it is ongoing.
‘I don’t want any of you ... caught unaware’
On June 17, Springfield-Greene County Health Assistant Director Jon Mooney decided the time was right to send a warning to colleagues across the state.
Over the past month, the average of daily new cases in the county had grown from 18 to 78. Perhaps even more alarming was the corresponding rise in hospitalizations, from 34 to 94 in a month.
Variant testing in the last week had shown 91% of cases were delta.
“While I could certainly be wrong, I don’t want any of you to be caught unaware or dismiss the rise in cases that we are experiencing as something that is unique to our area or is likely to remain localized here,” Mooney wrote.
Kelley Vollmar, director of the Jefferson County Health Department, asked in response whether Missouri would consider travel advisories for areas experiencing case growth. In the past, COVID spread across Missouri along Interstate highways.
In an interview, Vollmar said nothing appeared to come of that idea at the state level, though that has now changed. DHSS issued its first “hotspot advisory” on Wednesday for Camden, Miller and Morgan counties — the location of the Lake of the Ozarks.
Vollmar said as of Thursday no delta cases had been identified in her county, but she was confident it was already present.
“Probably within this next week we’re going to see numbers start to explode in many more areas because people have brought it back,” Vollmar said. “That’s why a travel advisory earlier would have been much more helpful.”
As the case surge gathered strength in mid-to-late June, local officials privately conceded that resistance from the public and elected officials would make it impossible to reimpose any meaningful mitigation measures.
Many of the largest metro areas issued mask mandates earlier in the pandemic, but Parson never implemented a statewide order. Since the CDC loosened its mask guidance in May, new rules appeared out of the question.
After a CoxHealth official informed Webster County officials of rising cases on June 17, Logan-Rogersville R-VIII School District Superintendent Shawn Randles wrote that vaccinations and masking were in “the same category as Religion and Politics.”
He suggested reducing the number of days children must quarantine after testing positive, and said the district is testing out not wearing masks during summer school.
“I’m just telling you the storm that is brewing in the parents,” he wrote. “They are not going to tolerate continued masking and quarantines. No matter how hard and often we try to explain that we masked last year to stay in school and avoid quarantines.”
A district staff member said Randles could not be reached for comment because he was on vacation. Webster County Health Director Scott Allen wrote to Randles that he appreciated the feedback, but wrote to Springfield officials with concerns.
He told The Star his department will help the schools implement whatever the state COVID guidance would be in the fall.
“I think folks are just ready to be able to move beyond this,” Allen said of the public. “The virus isn’t moving anywhere unless we do something to mitigate it.”
In northern Missouri’s Livingston County, one of the first to see the recent spike in cases in May, officials considered reinstating a mask mandate but feared one mitigation strategy would interfere with another.
“If you put on a mask mandate some people could say, ‘What’s the point of getting a vaccination?’” presiding county commissioner Ed Douglas said in an interview. “There was kind of the consensus in there being a backlash, it would do more harm than good.”
On June 24, Marc Johnson, a University of Missouri professor leading an initiative to test wastewater in the state for COVID, dashed off a quick email to Browning, the Columbia-Boone County health director, noting that Missouri had the most new cases in four months.
Browning wrote that it made her “sick” to think about it. The next morning, Johnson offered a poetic take:
“Vaccine in a year
But that does not help us to
Save them from themselves”
Delta may ‘ruin our summer’
Missouri’s surge was drawing national attention by late June. But even when the state did muster a response, some local officials were leery.
In Laclede County, Baker, the health administrator, on June 22 turned down an offer from a state official to get the county CDC-funded epidemiologists or case investigators.
“I never want to turn down assistance, especially when it seems that Laclede County cases are skyrocketing,” Baker wrote. But when the county got DHSS help last year, Baker wrote, “it caused my staff and I more work.”
In an interview, Baker said there was poor communication between DHSS and the county on which cases they were investigating last fall.
In other quarters, DHSS’s efforts were mocked. The agency posted a nearly 10-minute Q & A video to YouTube on June 23 of Turabelidze, the state epidemiologist, talking about delta. The video shows a picture of his face and the text of the question he is answering.
“Ya, he has a thick heavy accent and is kind of boring...bla bla bla. Just him talking with the view below. It is on our website anyway,” Andrew County Health Department Administrator Andrew Hoffman wrote to a colleague.
Hoffman told The Star that his statement was inappropriate and shouldn’t have been made and apologized.
Some local health departments also spent late June in a dispute with DHSS over whether they can use federal preparedness dollars for COVID-related expenses. Columbia-Boone County says the state gave multiple indications that the funds could be used for that purpose. At stake in Boone County is nearly $200,000 in grant money.
“I think what is most frustrating here is if we can’t spend preparedness dollars on the worst public health emergency in over 100 years, what should we be expected to spend it on,” Clardy, the department’s assistant director, wrote to top DHSS officials on June 30.
Cox, the DHSS spokeswoman, said Friday the agency can “only authorize funds be spent by the federal authority.” She wrote in an email that the preparedness funds are no longer applicable for COVID expenses.
As June gave way to July, hospital leaders entered near-panic mode. CoxHealth CEO Steve Edwards told leaders spreading vaccine misinformation to “shut up.”
The White House announced the creation of “surge response teams” for areas struggling with delta. DHSS quickly confirmed it had requested help, only for Parson to later tweet that he wouldn’t accept federal officials going door to door to “compel” vaccinations of residents — a mischaracterization given that vaccinations are voluntary.
Meanwhile, hospitalizations continue to rise. Earlier this week, hospitals were treating more than 1,100 virus patients, the most since March. Mercy Hospital in Springfield ran out of ventilators and was looking for more respiratory therapists to cover for the exhausted staff over the July 4 weekend. On Friday, the state reported the most new cases in a single day since January.
Lana Zerrer, chief of staff at Harry S. Truman Memorial Veterans’ Hospital in Columbia, wrote on June 28 to other VA officials that the best time to get vaccinated was three months ago — but the second best time is today.
“The Delta variant may prove to ruin our summer,” she wrote.
The Star’s Katie Bernard and the McClatchy Washington Bureau’s Bryan Lowry contributed reporting