Did pre-COVID budget cuts affect Sonoma County’s pandemic response?

It seems almost inconceivable now.

In 2019, a year before anyone had heard of COVID-19 Sonoma County officials were exploring a proposal to close down the county’s public health lab to save money.

The idea was quickly scrapped when the pandemic hit, but former county staff members say the proposal reflected a pre-COVID mindset that sought a shift in the mission of county health services. In essence, community-based prevention programs would be sacrificed to pay for those the county is legally required to provide.

That shift, in part, led to an exodus of numerous top health care employees in the two years before the pandemic hit, as well as instability at the top of the organization.

And critics say a greater focus on public health prevention could have laid crucial groundwork for some of the outreach efforts in those communities that were hardest hit by the pandemic, including immigrants and Latino, black and other minority residents.

Sonoma County wasn’t alone. Despite ominous brushes with other epidemics like swine flu and bird flu and other rapidly mutating viruses over the past 20 years, local public health agencies across the country have been chronically underfunded for years, experts say, leaving many flat-footed in their response to the COVID-19 pandemic.

As California’s only public health lab between San Francisco and Humboldt counties, Sonoma County’s facility on Chanate Road in Santa Rosa is one of only 14 labs in the state that are part of a federal network of laboratories that can respond to biological and chemical threats and other public health emergencies.

Over the past two years, it has informed the lifesaving work of the local health officer, epidemiologists, public health nurses, medical workers, educators, local businesses and just about everyone else battling the virus.

And now, with the benefit of hindsight, county leaders are once again reciting the mantra of public health prevention, including plans to build a new combined public health lab and morgue, with major costs, projected to be $30 million, expected to be covered by the federal government.

New leadership

According to interviews with several former health services employees, much of the cost cutting happened under the leadership of former Health Services Director Barbie Robinson, who proposed the closure of the local lab before the pandemic.

Robinson, who left Sonoma County a year ago and is now public health director in Harris County, Texas, which includes Houston, did not respond to repeated requests for an interview.

Her replacement, Tina Rivera, who was appointed interim director of health services after Robinson’s departure last spring, said she was not part of the discussions to close the public health lab.

In an interview with The Press Democrat, Rivera, who became permanent health services director in February, acknowledged some of the department’s management problems, as well as lessons learned during the pandemic.

“In every single disaster, our communities of color, our marginalized communities, bear the greatest burden,” Rivera said. “This pandemic, like no other really day-lighted the health inequities that we saw in our marginalized communities.”

She said she is committed to strengthening her department’s presence in those communities, as well as changing the agency’s “top-down” management structure to one that is more inclusive of rank-and-file expertise.

“A top-down organization is so ineffective,” she said. “The voices of everyone in our organization is so important. And there must be a focus and a communication to our staff — that every position is important that their voice.”

A crisis foretold

The mission of the county’s health services department has evolved dramatically since the days when it operated the old county hospital on Chanate Road. In the late 1990s, Sutter Health took over the hospital under a contract with the county that required the medical provider to continue providing certain services.

Over the years, the county health services department moved away from providing direct medical services. The county’s long-term psychiatric hospital, also on Chanate Road, closed in 2007, and the Sutter-operated hospital closed in 2014.

Without such facilities, local health officials were faced with having to redefine their role in the community, said former Sonoma County Supervisor Shirlee Zane, a longtime health care advocate.

“We were asking if we’re not going to be a hospital, what are we?” she said.

In the years following the closure of the county’s general and psychiatric hospitals, the health services agency turned to local “community partners” to address such issues such as smoking cessation, maternal and child programs and initiatives aimed at curbing the sale of unhealthy foods.

In 2013, county health officials launched a survey that documented the health and well-being of the county's agriculture workforce. The survey found that many local farmworkers lived in costly and crowded housing; earned insufficient incomes to meet their family's basic needs; had limited health insurance coverage; had restricted access to preventive and medical care; and experience significant health disparities — exactly the conditions that fueled the spread of COVID-19.

Similar conditions were uncovered in the post-recovery era of the 2017 North Bay Wildfires.

According to several former health services staff, who asked to remain anonymous to avoid conflict and controversy, the county’s focus on public health prevention became less of a priority after Robinson took control of the department in 2017 after serving as its interim director for about six months.

After the devastating fires that year, Robinson faced the challenge of balancing the budget of the county’s second largest department, which at the time had 700 employees and a budget of $245 million. The budget for fiscal year 2021-2022, by comparison, was $330 million, with 582 staff.

Supervisor Lynda Hopkins said Robinson revealed that some health services programs were being kept afloat through “deficit spending,” with a reliance on one-time funds. Hopkins said Robinson prioritized health services that were mandated by the state or federal government.

“There was a conversation around how can we focus on ensuring we succeed on mandated services, focusing in on legal obligations that Barbie didn’t feel we were meeting,” she said.

Hopkins defended some of the tough choices Robinson had to make and credits her for her several initiatives that have benefited some of the “most vulnerable residents” in the county.

Among Robinson’s achievements, Hopkins said, are the development of a new psychiatric health facility, her support on the Measure O tax measure that enhances mental health and homelessness services, and the creation of a data hub, known as ACCESS Sonoma, that allows county agencies to share information and align their services to residents who are experiencing physical and mental health challenges.

“Her legacy in Sonoma County will certainly outlast her tenure here,” Hopkins said.

In her effort to reform the county’s mental health division, Robinson proposed a number of controversial cuts that were ultimately postponed or minimized through last-minute reversals by the Board of Supervisors. Under Robinson’s watch, at least 17 top officials, including two health officers and two assistant health officers, stepped down between March 2018 and March 2020.

Hopkins said she did not support Robinson’s plan to close the public health lab, even before the lessons of the past two years. The lab, she said, has particular value for rural residents concerned about such things as water quality. The “fragmentation” of the local health care system became apparent with COVID-19, she said.

“The county used to run a hospital — it no longer does. The question is, how much ownership does the government have in a health care system,” she said. “I’ve seen some of the pitfalls with the pandemic, with the privatization of health care. We assumed the private sector would be more nimble, quicker to respond … I couldn’t get a vaccine through my provider for my kids, through my doctor.”

Underfunding public health

For many in the public health arena, the arrival of a deadly pandemic was only a matter of time. Health care crises of the past — including most recently the SARS outbreak of 2002; the swine flu pandemic of 2009; and MERS-CoV outbreaks after 2012 — made it all too clear that a more dangerous global threat was inevitable.

In a 2021 academic paper, historian Amy Forbes, a professor at Millsaps College in Jackson, Miss., examined the historical context of the COVID-19 pandemic and lessons often ignored or forgotten from previous public health crises.

“Despite recent SARS, MERS, and H1N1 alarms, as well as damage from past epidemics, public health programs have been neglected in the United States. COVID-19 has revealed consequences of this inattention, exposing government failings and social vulnerabilities,” Forbes wrote in her paper, “Covid-19 in Historical Context: Creating a Practical Past.”

Dr. John Swartzberg, an infectious disease specialist at U.C. Berkeley, agrees. Swartzberg said the state’s Department of Public Health, or CDPH, and local public health agencies have been underfunded for decades, particularly in the 21st Century.

He said decades of public health underfunding or irregular funding meant that agencies couldn’t develop a long term staffing with institutional memory and experience. Swartzberg said many public health departments were running “bare bones” operations by the time the pandemic struck.

“Now, if there was a low probability of a pandemic, you could see where during more difficult financial times … someone would say, well, ‘we can't give public health so much money this year.’” he said. “But everybody, anybody who was sentient or had done any type of studying at all knew that another pandemic was going to occur, and knew that it was going to occur and not in another century, not in another 50 years, but it was going to occur pretty soon.”

Committed to a new public health lab

At the start of the pandemic, staff at the county’s public health lab were sending the first cases of local infection to the federal Centers for Disease Control and Prevention, which required filling out lengthy paperwork and shipping of samples. When a state lab in Richmond, Calif., gained PCR testing capacity, local samples were sent there for a time.

“We were sending (specimens) in to Richmond to be tested which was still a long delay, compared with having the test in house here locally,” said Rachel Rees, director of the county's public health lab.

Rees said that as one of only 14 labs in the state that are part of the CDC’s Laboratory Response Network, the local facility was one of the first local public health labs in California to receive the CDC’s COVID-19 PCR testing kit.

Testing quickly ramped up, she said, and by August of 2020 the lab’s testing capacity had gone from processing 250 daily PCR tests to 1,500 a day, said Lisa Critchett, a county health microbiologist.

Rees said extra staff, borrowed from the county’s environmental health department, were brought in to help with the processing of specimens and all the cumbersome paperwork. “Over the summer (in 2020), we had the National Guard here helping to process and check our specimens into the laboratory,” Rees said. “Without them, we wouldn't have been able to do it.”

Jon Akre, a public health microbiologist, recalls the long nights and weekend hours spent at the public health lab processing the test results that informed decisions affecting the lives of Sonoma County’s nearly half a million residents. Akre called it a “team effort” that involved lab assistants, lab technicians, microbiologist and the lab director, with many of them working 10, 11, or 12 hours day.

“My wife jokes that she would pack me breakfast, lunch and dinner and send me off to the lab,” Akre said, adding that the work was “fatiguing.”

“I have an eight year old son, he was eight years old at the time, and I felt like I was missing parts of his childhood,” he said. “So, not seeing him, not seeing my wife so much … definitely fatiguing.”

While COVID-19 testing and genetic sequencing have been key functions at the local public health lab in the past two years, the facility also performs a variety of other testing services that are key to public health safety. Staff provide specimen testing to Sonoma, Mendocino, Lake and Humboldt counties.

The lab also does tick testing for Lyme disease, and tests for tuberculosis cultures, salmonella, shigella, sexually transmitted diseases and rabies. Staff also conduct testing of drinking water; recreational water testing, as well as shellfish, meats and growing water testing. It is only one of four labs in the state that provide shellfish testing.

It also does dairy testing for businesses in Marin and Sonoma counties.

Rivera, the new health services director, said the pandemic was an eye-opener and that she is committed to building a new public health lab and figuring out how to support it, even after COVID-19 subsides.

“I see the public health lab as an important resource tool, an important tool not just for our county, but for other counties that we serve,” she said.

Rivera also said she’s committed to addressing the local health disparities laid bare by the pandemic. To do that, she said, the county needs a strong public health division that can engage with local communities and health care providers and advocates who have roots in those communities, particularly those that have been neglected.

“You're going to see our department engage with this community like we never have before,” she said. “I don't think we have been in the community enough. I’ve heard that from our staff … but we’re going to change that.”

You can reach Staff Writer Martin Espinoza at 707-521-5213 or martin.espinoza@pressdemocrat.com. On Twitter @pressreno.