While the Alamance County population has grown in the past two decades, spending by the local health department has not caught up, a Times-News analysis has found.
The Alamance County Health Department provides services such as health inspections, maternal health clinics and communicable disease prevention. Local health workers are the first line of defense against the spread of communicable diseases in and outside the county.
But spending on health hasn’t kept up with the huge population growth these past two decades.
From 2000 to 2020, the Alamance County population grew by at least 30 percent, but spending by the local health department during that time increased only by 2 percent when adjusted for inflation, according to an analysis.
“I think it’s reasonable to suggest that when your population increases, so will your services,” says Alamance County Health Director Tony LoGiudice.
Overall spending by the local health department increased by 2 percent during that period. But when taking the population change into account, the per capita spending fell 22 percent, an analysis showed.
In raw dollar amounts, Alamance County spending for public health in 2000 was about $59 per person when adjusted for inflation. But 20 years later, the county was spending about $46 per person when considering the population growth.
LoGiudice said the health department is constantly assessing the community needs through community health assessments conducted every year. Another one, the Community Health Needs Assessments, is done every three years. These assessments, he says, help officials identify – and address – —issues concerning the community.
“We are constantly assessing and then readjusting our programming or working with the community to adjust their programs to meet those needs,” LoGiudice said.
How is the population growth impacting the county?
The Alamance County Health Department currently has a team of four communicable disease nurses that investigate close to 2,000 reported diseases annually. Since 2014, there has been a 150 percent increase in communicable disease cases that the health department has investigated, and prior to COVID-19 there was a mumps outbreak in the community, LoGiudice said.
Last year’s budget for communicable diseases was $713,000. The county receives about $47,540 in communicable disease-related funding from the state each year, the rest of the money comes from the county.
But as the county population has grown — and on the heels of a pandemic – this level of funding for communicable diseases, LoGiudice acknowledges, should be increased.
If he had more funding, LoGiudice said he would add one more communicable disease nurse to his team.
“As Alamance County grows and communicable disease cases continually increase, we will need to expand the team in a controlled and calculated manner,” he says.
According to financial records reviewed by Times-News, the public health department had about 90 full-time positions in 2010. In 2019, that figure was 86. During that period, 2018 saw the highest decline in full-time positions, 84.
Specifically, the WIC and Dental Clinic programs, which are under the local health department, saw new positions created over the years. Perhaps, reflecting the population growth, the WIC Program, which is mostly funded by federal and state money, saw a 45 percent increase in new positions created from 2009 to 2019 from 11 to 16. The WIC program provides nutritional advice, breastfeeding support and other benefits for low income pregnant women and women with children under five years old.
The Dental Clinic program also saw an increase of two positions during that time.
As population grows so has food and other establishments
The local health department is also responsible for making sure drinking water, daycares, school cafeterias, and restaurants all abide by the health codes. They do inspections on facilities such as nursing homes, swimming pools and grocery stores.
The population growth is partly reflected in the number of food permits issued by the health department in the last five years. Since 2017, the health department has issued about 424 permits to food establishments. That number includes transitional permits, meaning permits issued when there is a change of ownership. It also includes some temporary food stands permits.
The total inspections completed every year on all facilities is 2,486, according to figures provided by the health department. Of those, 1,717 were inspections on food service establishments.
Environmental Health Supervisor Betsy Mills said the number of inspections can vary each year depending on establishments that are opened or closed at the time. She said this number typically increases from year to year as more places open and the county population grows.
The health department has a total of 22 environmental health employees, including six who are responsible for inspections of restaurants and other facilities in the county. Another 11 are responsible for wells and onsite water waste systems.
According to Mills, the last new position added in environmental health was July 2019. That position was for wells and onsite wastewater systems inspections. The last time a new position was added in the food and lodging inspections section of environmental health was in 2017.
A state and nationwide problem
Ann Meletzke, director of Healthy Alamance, a nonprofit group, says that Alamance County is not the only county facing this trend; it’s a nationwide problem. “I think that as a general rule, public health is just misunderstood by people,” Meletzke says.
In large part, she said, there has been more focus on individual health, choices and behaviors, and less of an emphasis on population health. This, she said, coupled with the housing crash in 2009, has contributed to the funding decline for local health departments across the country, “and there’s never been any restoration of that funding.”
Since 2010, spending for state public health departments has dropped by 16% per capita, and spending for local health departments has fallen by 18%, according to a Kaiser Health News and Associated Press analysis of government spending on public health. At least 38,000 state and local public health jobs have disappeared since the 2008 recession, leaving a very small public health system workforce across the country.
According to KHN and AP, more than three-quarters of Americans live in states that spend less than $100 per person annually on public health. Spending ranges from $32 in Louisiana to $263 in Delaware. North Carolina is the 14th worst, spending an average of $72 per person in 2018, their analysis found.
Access to services still an issue for some
There are many services on offer by the local health department, but most people don’t know about them or find it hard to reach those services. Stephanie Baker, an assistant professor of Public Health Studies at Elon University, says this is one of the areas where more investment is needed.
“One of the ways that we could increase spending is mobilizing access to care and services from the health department so that they’re more accessible to people who are not in such close proximity to where the physical buildings are located,” Baker said.
Meletzke agrees. She said there’s a lack of resources in marginalized and rural sections of the communities. The farther away you get from the interstate, the more challenging it is to have access. She said both minorities and white residents suffer as a result of access, “but I also recognize that that disproportionate rate for minorities has to do with systemic racism, and the challenges that our most marginalized communities face in trusting health care, even if they can access it,” she added.
Among others, access to services is one of the major concerns for community residents. It is a recurring theme in the Community Health Assessments done every four years since at least 2007.
Can community health workers bridge some of the gap?
These days Ebony Pinnix spends some of her time in and around her east Burlington neighborhood where she grew up. She approaches people in stores and at gas stations and goes door-to-door in her neighborhood to educate residents about how to get COVID-19 vaccinations.
Pinnix, who is one of three community health workers, is in a pilot program overseen by Healthy Alamance which aims to make it easier for community residents to access services.
“It’s just basically opening those doors up for people who want to do it, who don’t know how to do it, or maybe have even been scared,” Pinnix says.
“The more they see my face and the more conversations we have, the more comfortable they become with me,” Pinnix says. “I’ve built rapport with a lot of people around in the community.”
While the team is currently focused on vaccinations, Pinnix hopes this pilot program will continue well after the pandemic. She knows from experience the importance of such a program.
Years ago, as a young mother, Pinnix didn’t know about her local health department and the services they offered. She wishes she had known about prenatal care and nutrition counseling, and she wishes there had been a community health worker guiding her through that process.
As a single mother with multiple young children and no transportation, “it was a rough time for us,” Pinnix said. “I feel like if we would have had somebody going around saying this is available (and) if you don’t have a way to get there, then this can be provided for you.”
This community health worker pilot program is funded by Impact Alamance.
Asked whether such a program should be made permanent, LoGiudice, while he didn’t commit to the idea, acknowledges the program’s importance in the community. He said community health workers “can serve as a trusted critical link between the underserved and the often difficult to navigate health and social systems.”
“We’ll continue to monitor and support, where we can, the Healthy Alamance pilot CHW program for it to be a success,” he added in a follow-up email.
Can a proposed bill solve some of these problems?
According to The North Carolina Association of Local Health Directors (NCALHD), an organization made up of local health leaders, communicable diseases in North Carolina have increased by more than 200% in the last 10 years, while state funding for it has remained stagnant.
The organization is backing a bill that would increase state funding for local health departments across the state.
In the 2017 fiscal year, the cost of responding to communicable diseases in North Carolina totaled more than $20 million, with the state providing only 4.3% of that total, the organization said in a previously released statement. It’s asking for an additional $36 million to expand local infrastructure for communicable diseases.
Local health departments are responsible for tracking about 80 communicable diseases. “And that means the identification of it, the investigation of it, the mitigation and prevention, and the contact tracing,” says Stacie Saunders, president of the NCALHD.
Local health departments across the state have received a lot of state and federal funding to fight the pandemic, but those come with strings attached. Saunders said those funds don’t address the ongoing communicable disease needs and other reportable diseases that local health departments are responsible for monitoring and treating.
“I think that now is the time that we say communicable diseases are not going away and even before COVID local health departments were responding to emerging diseases,” she added.
Since the time she has been a health director – formerly of Alamance County and now Buncombe County – Saunders said there’s been Zika, SARS, MERS, and Ebola outbreaks.
“It just goes to show that those few thousands of dollars that local health departments get isn’t quite enough to really support the foundation and workforce infrastructure that’s needed for communicable disease,” she said.