How chronic underfunding fueled Georgia’s Covid-19 vaccine woes

Advocates warn that federal support doesn’t offer a permanent solution, nor will it ease chronic understaffing

How chronic underfunding fueled Georgia’s Covid-19 vaccine woes
An emergency room nurse in Savannah receives a dose of the Pfizer-BioNTech COVID-19 vaccine in December 2020.

Photograph by Sean Rayford/Getty Images

When Amber Schmidtke was a medical school professor in Macon, she started a research project to better understand why so many of the state’s kids were behind on their childhood immunizations. In 2017, Georgia was the slowest state in the nation to get three-year-olds fully vaccinated against infections like measles and whooping cough. Schmidtke found that a major reason for the state’s poor performance was the Georgia Registry of Immunization Transactions and Services—abbreviated, obviously, as GRITS.

Created in 1996, GRITS was initially designed to ensure children statewide were benefiting from federal vaccination programs by tracking immunizations given mostly in pediatricians’ offices and by county health departments. It was built for “more of a trickle than a flood,” says Schmitdke, and was so infrequently used to track adult vaccinations that most internists had no clue how to use it.

Schmidtke wasn’t particularly surprised, then, to hear that during the state’s massive Covid-19 vaccination rollout effort, GRITS had become a particularly gluey cog in the public health machine, its crashes and delays leading to dramatically underreported levels of vaccine administration statewide. But she was stunned when, during a January 19 hearing before the Georgia legislature, health department director Kathleen Toomey requested only minimal additional funding for public health in the 2022 budget.

“It’s sort of a weird look to be asking for no real increase in expenditures when we know that there are so many areas where Georgia is deficient compared to other states,” says Schmidtke, who authors a daily newsletter on Georgia’s Covid-19 dynamics from her new home in Kansas City. Georgia has some of the country’s worst scores on maternal and child mortality, sexually transmitted infections, and HIV transmission. The state’s Covid-19 dashboard has been notoriously ineffective. And last August, mid-pandemic, the state’s Covid-19 data task force was dissembled due to a lack of funds.

But compared with other states, Georgia has spent relatively little on public health in the past 10 years—and Governor Kemp’s proposed budget for the next fiscal year includes a $7 million cut to state public health funding compared to pre-pandemic levels, leaving county health departments to rely deeply on federal funds for their Covid-19 response, said Georgia Budget and Policy Institute analyst Laura Harker during a recent presentation. “The state has not been contributing to making sure that there’s some long-term stability for those health departments,” she said.

“Public health is drastically underfunded,” says Michelle Au, an anesthesiologist at Emory Saint Joseph’s Hospital in Atlanta and a state senator newly elected to represent North Atlanta’s 48th district. That’s why, she says, in the face of a national pandemic strategy until recently characterized largely by the punting of responsibility to state and local health departments, “we’re having this very fractured, Balkanized, under-sourced response.”

The messy vaccine rollout is not the fault of health departments whose resources have been stripped away over the past decade, says Au: “You never think you need to pay the money in until you need it.” And now, she says, we do.

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On January 11, a glitch led to the appearance of three times as many vaccine appointments in Fulton County’s registration system as its vaccination-site workers had planned for. The staff got all of the immunizations done anyway, tweeted Dr. David Holland, Chief Clinical Officer of Fulton County’s Board of Health, but at an enormous cost.

“The solution isn’t to work people to death. It’s to make sustainable investments in public health so that emergencies don’t crash the system,” he tweeted.

In early November, Georgia began working on a vaccine distribution plan that allocated vaccines to county health departments in each of Georgia’s 18 health districts according to the districts’ vaccination capacity and numbers of frontline workers and long-term care facilities. It wasn’t only local health departments that could request vaccine: large hospital systems, nonprofit organizations, private-sector physicians, and community health centers also placed orders.

While the decisions about where to allocate vaccines were made at the state level, each individual organization that requested vaccine had to create its own appointment system and website, and manage its own logistics for getting shots into arms. For local health departments already worn thin by months of testing and infection-tracking efforts, it was an enormous lift, especially when they were left with skeleton crews after years of public health cuts.

According to Holland, Fulton County’s health department employed 120 public health nurses at its peak—but over the past two decades, that number has shrunk to 30. “You can’t strangle public health and then expect to have a rapid, robust response to an emergency,” he tweeted.

Local health departments are also not Covid-only operations: “People don’t stop needing public health even though coronavirus happens,” says Au. “People still need regular childhood vaccinations, and WIC is still happening,” she says, referring to the federally funded program that provides supplemental nutrition to women, infants, and children. Public health workers at these departments also provide testing and treatment for HIV/AIDS, other sexually transmitted infections, tuberculosis, and other communicable diseases that, if not prevented with vigorous public health programs, can mushroom into entirely new public health emergencies.

“Money is important,” said Toomey in her testimony. “But even more than money, a thank you, and appreciation for what they’ve been through, and not the negativity that seems to come.”

Schmidtke noticed that statement with some dismay, and in a recent edition of her newsletter, struggled to square Toomey’s words with the accounts she’s been hearing from public health professionals who have been in overdrive for nearly a year. “Bringing in reinforcements would help a lot. Money would allow them to bring in more reinforcements,” she wrote. “I can imagine it is incredibly demoralizing to the public health workforce to know that help is not on the way.”

Atlanta coronavirus update
Dr. Kathleen Toomey answers questions during a press conference in April 2020.

Photograph by Kevin C. Cox/Getty Images

Indeed, there appears to be no rest in store for some of Georgia’s weariest public health workers: in early January, the state health department issued a three-month moratorium on vacation to its employees. And while lawmakers plan to give the state’s public school teachers and staff a $1,000 “hazard pay” bonus this year, no such support appears to be on the table for public health workers. “It is extremely disheartening to others of us who have been hard at it for nearly a year now too,” commented one district-level public health employee on a Facebook discussion about Georgia’s pandemic response.

In many parts of the state, including most of the metro Atlanta area, demand for the vaccine is greatly outpacing supply. When the state expanded vaccine eligibility to those 65 and older in late December, Georgians attempting to use the state health department’s vaccine portal encountered imploding websites and phone lines overwhelmed by callers desperately wanting vaccine appointments. People have been vocal about their frustration with the disorganized effort, says Rebecca Mitchell, a freshman representative in the Georgia House from Snellville and a veterinarian with a PhD in infectious disease epidemiology. “Everyone who reaches out to me is mad about the portal and not being able to get access,” she says.

In addition, while both brands of the vaccine available are quite safe and well-tolerated, pockets of vaccine hesitancy among rural healthcare workers have been worrisome to Toomey and other public health authorities. While residents of long-term care facilities statewide have eagerly accepted the vaccine, Toomey noted in her January 26 testimony, only 25 to 30 percent of the facilities’ staff themselves agreed to be vaccinated—and the same was true in many rural hospitals both in North and South Georgia.

Polling suggests individual politics align with vaccine hesitancy, with willingness to get the vaccine generally higher among Democrats than Republicans, who make up the bulk of Georgia’s rural areas. Hesitancy is also more common among Black Americans than members of other ethnic groups. Amid inequities that have disadvantaged rural and Black people in so many other ways during the pandemic, these trends hint at future disparities in Covid infection unless serious investments are made in targeted community outreach and education, says Harry Heiman, an associate professor at Georgia State University’s School of Public Health.

Vaccine education is another domain where resources would help, says Shanti Akers, a pulmonary and critical care doctor at Phoebe Putney Hospital in Albany, where 40 percent of the staff initially declined the vaccine. “One thing we suffer from as a rural-based health system is that we just don’t have the people,” she says. Without an infectious disease specialist or a vaccine coordinator on staff, there’s no one to plan “town hall” meetings like the ones large metro Atlanta hospital systems use to educate their staff about vaccine benefits and safety.

Georgia’s rural hospitals were already under extraordinary strain prior to the pandemic, largely as a consequence of elected officials’ refusal to expand the state’s Medicaid program. Over the past 10 years, eight have closed, and the ones that have survived are under enormous financial pressure due to high community rates of underinsurance.

A representative for the state health department wrote in an email that Toomey’s budget complied with Kemp’s August 2020 instructions to state agencies, which instructed them to submit budget requests equivalent to the past fiscal year’s, and that Kemp also directed agencies to prioritize spending federal Covid-19 response funds, which for the health department amounted to about $1.1 billion. But according to Laura Harker, the health policy analyst, doing so relies on short-term funding to keep both state and local health departments afloat when, in fact, they confront growing need every year. “When the federal funding goes away, the local departments will essentially face a cut because the state kept their grant funding flat,” she wrote in an email.

In a House Appropriations Subcommittee meeting on January 26, Representative Butch Parrish of Swainsboro said federal funds were not enough, adding that the pandemic had exposed critical public health staffing needs. “Federal funds have been used where we have been able to do that, but we still need to put in some state funds to help,” he said, shortly before proposing funding in support of several public health leadership positions, as well as $18 million to modernize systems to monitor disease trends—including GRITS—and $15.4 million to support the increased need for HIV/AIDS care during the pandemic.

Although the absolute number of vaccines Georgia receives is up to the federal government, several moves by Toomey’s agency and others may soon improve vaccine accessibility statewide. The health department has developed tech “strike teams” to help healthcare providers document vaccinations in GRITS in real time; a centralized appointment system is reportedly in the works; volunteers are being recruited to provide both administrative and clinical assistance at mass vaccination sites; and Toomey said in a January 21 press conference that she expects the locations of additional mass vaccination sites to be announced in the coming days.

Schmidtke says she understands that Toomey is in an uncomfortable spot. “I think she does want to advocate for her people, but she’s constrained by the politics of her position, too,” she says. The state health department’s budget shortfalls could easily be made up with just a crumb of the $1.7 billion in the state’s Revenue Shortfall Reserve, which it preserves as a rainy-day fund—but Kemp has not signaled that he intends to redirect those funds toward public health or any other of the state’s strained agencies.

“When you see what their budget request is,” says Schmidtke, “it doesn’t seem that public health is a priority compared to other issues, even in a pandemic. . . . It’s not so much an issue of staffing or funding, although those things would help. Perhaps it’s more of an issue of motivation.”