A picture of the state of Wisconsin, red with tiny white illustrations of the COVID-19 virus

Understaffed, Underfunded: Wisconsin Public Health and COVID-19

An interview with Beth Borkowski by Dayna Long

This interview has been edited for clarity and length.

DL: Tell me about your educational and professional background.

BB: My first degree is in psychology. Then I worked in the senior living world for about a decade before going back to school for my nursing degree. I graduated last year and have, up until pretty recently, worked in public health.

DL: Oh, senior living. So you have a lot of experience in one of the settings that have become known for COVID-19 outbreaks. 

BB: I still talk to some of my friends that I worked with, and it’s not been very pretty there. Even thinking back to when I worked there, there’s just not a lot of familiarity with various types of PPE. People know what it is but you’re just not used to working with it on all the time, though I’m sure they’re used to it now. And then just the insidious nature of COVID – just the way it can transmit makes it very dangerous in that kind of setting. A fairly large portion of the deaths – I want to say almost half of them – have been in long-term care settings. And the hard part is you can’t control where workers go after hours, so if you have even one employee that doesn’t take it seriously, your entire population is at risk. That makes it really hard for them.

DL: During this pandemic, you were working in public health outside of Dane County. What can you share about how the pandemic has been playing out outside of Madison?

BB: I was in a more rural county. What the challenge usually is in rural counties is that their hospitals tend to be smaller, with fewer ICU beds and a lot less speciality care in general. I worked in the communicable disease program before the pandemic, and I would call anyone who had a new hepatitis diagnosis. We didn’t have one hepatologist in the entire county, so [patients] would always have to go to Madison or Milwaukee.

When you have a new illness like [COVID-19] that needs very specialized care, a lot of times [patients] end up being transferred to Madison or Milwaukee anyway. So when more rural areas write it off as a Madison problem or a big city problem, they do that lacking the knowledge that their own local areas can get overwhelmed very quickly. And then if the “big cities” are overwhelmed, their communities will have nowhere to send people.

The other thing that was really hard is the pandemic has become a political issue. We would call each person who tested positive and try to do contact tracing and give them guidance. And when the existence of the pandemic or encouraging people to wear masks is a political thing, those calls are very difficult. At least one person I called literally did not believe [the positive test result] because they did not believe the tests were accurate. I had to try to ask all of the questions I was supposed to ask, but it was like, “Well why did you go get tested if you won’t even believe the results when they come back? What’s the purpose of going and getting your nose swabbed if you weren’t going to listen?”

We ended up running into that a lot. People would refuse to give us any contacts or they would say, ‘Well I don’t feel sick, I don’t have any symptoms,” so they would refuse to quarantine. Or they would give contacts but then those contacts would be like, “Well, I’m not doing that,” or they’d say, “Yeah, okay,” but you could tell they weren’t going to follow the instructions. 

It’s also kind of hard because – like with [tuberculosis] patients, in my time there, I didn’t have anybody who actively had TB, but the other nurse I worked with had had a number and if there was anybody who refused to isolate while they had this very contagious condition, they could rely on local law enforcement to enforce quarantine orders. A lot of times once you had a quarantine officially imposed, people would follow it. You had mechanisms to ensure people were not putting others at risk. I feel like, because it’s become politicized, we’ve lost any ability to enforce for the public protection. I think that’s really caused it to spread a lot further than it would have otherwise.

DL: What about testing? In Dane County we’ve got this drive-up test site at the Alliant Energy Center where anyone can get tested for free throughout the week. Was there a site like that in the county you were working in?  

BB: No. The local hospital we worked with – their testing was free. But they would not test anyone who did not have symptoms unless they had the specific instructions from public health, for instance like if a group home worker had an exposure or this is somebody with immunocompromised family members who had an exposure. So we could usually authorize initial testing. But the way the Alliant Energy Center [test site] works, where you can just show up with no questions asked about why you think you need testing, that didn’t exist. There were multiple times when, even though for some people in our county it was an hour drive, we still presented Alliant as the only option where they would be able to get tested in their situation.

We do tell people even if they get a negative test, because you can just not have a high enough viral load, you’re supposed to quarantine for fourteen days. So sometimes in medicine we ask, “What will be different if you’re tested?” For a lot of people who don’t have symptoms who have been instructed to quarantine, being tested wouldn’t necessarily change anything. But there are situations where, you know, if you have two parents and they have a child they’re caring for and they were both exposed but asymptomatic, knowing if one tested positive or not would be helpful in knowing who can care for the child. So it is useful. But I know that a lot of places don’t have the access Dane has to testing.

DL: Most of us are aware of the rising case counts, hospitalizations, and deaths in Wisconsin. I think we’re less aware of how public health professionals and health care  workers are holding up in this crisis. What can you share about that? 

BB: It’s something I’m very concerned about. I think the public – and even other health professionals – don’t really know what public health does. I applied [to be a public health nurse] having done like a rural immersion where we went up to a Northern county and worked in their public health area for three weeks. And even having that experience I didn’t know all the things that our health department would be doing when I was hired. Like making care plans for kids in the low-income pre-k program called Head Start. We’re involved in training teachers if an EpiPen is needed for a student. I did the jail vaccine program where we’d go in and offer different vaccines to people who were incarcerated in the local jail. Honestly I think I miss that more than anything else because, having a positive interaction with people who were maybe having the worst month of their life, and giving them a positive interaction with somebody in health care when most of their interactions had probably been negative preceding it was really validating of what I was doing or of what public health could do. Even doing things like fluoride varnish to help prevent cavities in kids who maybe didn’t have access to dentists.

So I think what’s most upsetting to me is, I’d say in most health departments across the country, these things are not being done now because it’s all COVID, all the time. Public health is always a hard sell for why it should be funded. People see why you should fund treatment but they don’t always understand funding prevention. So public health is chronically underfunded at a national and a state and a county level. They were very staff-strapped and cash-strapped before the pandemic. I know our county didn’t staff up.  There was like a skepticism at the administrative level that such things could be afforded even though it’s like a pandemic, and there’s statutory requirements to respond to a communicable disease. It felt kind of exploitative. When you’re also in a community where half the community doesn’t think the pandemic is real, you can see where that’s coming from.

I think we’re going to see a mass burnout of public health workers. You’re working all the time for a really extended period of time. As a more direct-level worker, I didn’t really see it, but I know that on the management and the Health Officer level, the public facing people, they’re getting death threats. I know our health officer got death threats. The Madison-Dane County officer got death threats. She’s had protests at her house. There’s public meetings where the county boards vote on expanding actions to prevent further spread during the pandemic and people show up, won’t wear masks, cram in to speak about something, and then get very threatening and make threats at the Health Officer or other people who are just trying to take steps to protect lives basically. 

We’ve already seen people leave over that. I know a number of states have lost their top health officer for the state and a lot of counties, I think, have or will lose their health officers. I know Sauk County’s health officer just quit. I don’t know if I’ve specifically seen names in other counties but I know it’s got to be a rough time for everybody involved.

DL: When people think of overwhelmed hospitals, I think most of us imagine hospitals running out of actual physical space, but you’ve pointed out that the number of caregivers is also a factor. 

BB: When I was in nursing school I did a brief research project on the healthcare worker shortage. It’s better in Madison and Milwaukee and surrounding areas, but pre-pandemic there was a shortage of nurses, providers, and Certified Nursing Assistants (CNAs) in most rural areas, like particularly up North. It’s particularly bad for psychiatrists or people who can prescribe psychiatric medications. 

The CNA shortage is actually pretty bad. A few years ago the Democrats in the state tried to increase the pay rate for CNAs at state-run facilities, in the hopes that it would also rise in private industry, and that was shot down by the Republicans in the state legislature in favor of trying to reduce the number of hours of training required to get a CNA. So they thought that was the barrier for people wanting to go into the field. 

You can start surging spaces, you can put two patients in a room if you have to, but you can’t just conjure up more nurses or doctors.

Having been a direct caregiver before, when I worked in senior living, it’s a very difficult job, especially if you’re working in a place where people have memory loss or cognitive issues or a psychiatric diagnosis. I would work in our memory neighborhood and you get people who are physically aggressive because they’re not aware of what’s going on. You’re dealing with bodily fluids. You could probably make more money at Target down the street. It’s not like a living wage where you can sustain a family off of it. It’s very difficult for people to stay in the field long-term. Even in Madison there’s a CNA shortage but it’s particularly bad in rural areas. King VA actually started closing beds in the Veteran’s nursing home just because they couldn’t find enough staff to actually care for people. 

You can start surging spaces, you can put two patients in a room if you have to, but you can’t just conjure up more nurses or doctors. I think that’s kind of going to be one of the barriers if we keep seeing hospitalizations.

DL: You’ve talked about this a little bit already but how has the politicization of COVID-19 changed the public health response to the pandemic in Wisconsin? How are things supposed to work compared to what’s actually happening here?

BB: It became a very big concern for me when things were presented as a choice between either economics or saving lives. There’s definitely a middle ground where you can help people who are struggling economically from the impact of the pandemic but also protect people. But you had people on one side saying “Every measure possible to save lives,” which I think makes a lot of sense, and the other which was like, “No, we shouldn’t do anything because that will hurt the economy.” But if people are dying because of a pandemic running rampant, you’re still going to have economic impacts. People aren’t going to want to go shopping or to a movie or out to eat when they know they can catch a deadly virus. By keeping the virus under control, you’re also providing some of that economic protection. 

I would have liked to see the government step in more to help people who are in tough economic situations as well. One of the places we would see a lot of cases before things got pretty bad recently would be in workplace settings, because people wouldn’t want to call in sick. Or we would basically have employers telling the workers like, “No you have to come in to work anyway. We need you here.” And then when we would call and say “Hey, you have an outbreak in your workplace, you have to take these measures,” They would say, “Oh yeah, yeah, we do all that, we have people stay home, we mask, we distance,” I think because people feel like forced to go into work, we’ve seen it spread a lot more, and when people don’t have some of the economic support as a business, they’re more likely to pressure people to work in situations when they shouldn’t. So it’s all kind of a self-fulfilling prophecy almost. 

Making that political, like “We need to prioritize business. We’re not going to support those businesses with policy but we need all businesses open as much as possible,” furthered the spread and made things much more difficult in our country than they had been in other countries. 

It’s not just the way we’ve politicized the virus, but the way our political system is set up. We never were going to handle the virus well here.

In Europe, for all the businesses that paid people to stay home, that kept people on the payroll, still paying some portion of their income, the government subsidized those businesses instead of having businesses lay off a bunch of people and then the government paying unemployment. I feel like that would have been a much better way to handle everything and it’s a reason we have seen fewer cases in Europe, one of many reasons. We also don’t have any universal healthcare, so we’re also at a disadvantage because if people lose their jobs, they lose their healthcare and then they delay going in for care if they do get COVID. 

It’s not just the way we’ve politicized the virus, but the way our political system is set up. We never were going to handle the virus well here. Back in February when you could kind of see how this was spreading and becoming a pandemic, I think one of the things I was most afraid of is that our country would be uniquely unable to handle this because of the poor policies we have at a ground level. 

There are a set of powers that a health officer has for protecting their county in case of a communicable disease. A lot of them have been in place for a really long time, since before the advent of a lot of vaccines and antibiotics that have helped protect us from pandemics being a regular thing. For a lot of public health professionals, you can point to the moment when the state Supreme Court struck down the Safer At Home order as the moment everything turned for our state. After that happened, I know a lot of counties wanted to issue their own Safer At Home orders and you had the legal bodies of counties saying, “Well no, now it’s been deemed against the state constitution, our state laws,” And so health officers don’t have that power even though it’s right there in the state statutes. 

I think a lot of health departments also know that even if they’re in the right, they weren’t going to be able to [issue new orders] for lack of political will in their community. And it made people err too far in the other direction. They didn’t want to issue any kind of orders for fear that the whole chapter [of the state statutes] itemizing health officer powers would be deemed invalid and that they’d get sued and taken to the Supreme Court.

DL: We know that there are big COVID-19 outbreaks in some Wisconsin prisons. What can you share about the risks incarcerated people are facing right now? What should the state be doing differently? Why do you think the DOC isn’t being transparent about COVID-19 deaths in prisons? 

BB: I have a particular interest in correctional health. It was an area I considered working in as a nurse before I realized you have a lot of peer pressure to follow institutional rules that maybe aren’t in the best interest of the patient – I’ll put it that way. I had one of my clinicals in the state infirmary which is at Dodge Correctional. So I have some experience providing nursing care in a prison setting. 

It’s actually very hard to find nurses, doctors, psychiatrists, who want to work in prisons. So they’re actually pretty short-staffed, too, even pre-COVID. I was able to use that fact to shadow nurses in quite a few settings, so I’ve been to the one federal prison in Wisconsin, a couple of state prisons, and at least three county jails. I know a little bit about how they provide care in a pre-pandemic setting and I can only imagine that it’s really hard to provide adequate care in this kind of situation. Even quarantine and isolation. Really the only way you could [have someone quarantine] is to have them stay in an individual cell for basically the entire time. So anytime you see that they’re quarantining or isolating somebody in a correctional setting, I don’t see how they could do it aside from solitary confinement. They would call it something different, but they’re basically having that person stay in a cell that entire time so that they’re not around other prisoners or guards or staff. 

I have tried to read as much as you can from the outside and I’ve heard a lot of reports that people aren’t being allowed masks in prisons. I was actually reading through the mask mandate today for work and individuals who are incarcerated are actually exempt from the mask mandate. So I found that exception very interesting. I know it’s very difficult to have things like hand sanitizer in the prison setting because there’s always the fear that people will drink it to try to have some kind of intoxicating effect from it, whether that’s a likely outcome or not. It can even be hard to have adequate access to other hygiene products. So I just imagine it kind of spreads very quickly in those settings. 

Our prisons in Wisconsin are overcrowded under normal circumstances. I think basically every prison we have is over capacity, so that doesn’t allow for very much social distancing. I’ve been in some of the general population areas where there’s basically bunk beds packed in a room. I don’t think you could get six feet apart in most places like that. Some places have tried to be better at releasing people who are incarcerated. Dane County was more successful than others. At the state level, they only released like a thousand people but we have somewhere around 25,000 people incarcerated normally. So I don’t know that they made that big of a dent. 

The industry is very reluctant [to release people] because then the question gets asked, “Well, why were those people incarcerated if there were other options?” and so there’s a counter incentive to being aggressive about finding people that could safely be outside of prison and jails.

A lot of the prison population is at a higher risk for adverse outcomes anyway because people that are incarcerated for a life or a long-term sentence – basically they appear ten to fifteen years older than their chronological age because you just see an earlier onset of old age diseases. You’ll see heart disease much earlier, diabetes much earlier, heart attacks, stroke much earlier, just like general worse health partially because of not very nutritious diets, a lack of exercise, a lack of space, and I would think despair probably factors in there. A lot of people have a history of smoking before they’re incarcerated so there’s a lot of chronic lung disease. You would expect worse outcomes compared to other people who aren’t incarcerated at the same age. 

It’s pretty well-documented that there’s kind of a graying of the prison system. So there’s a lot of people who are in their fifties or sixties because they were given a life sentence. You know, if you were arrested in your thirties because of the three strikes rule during the nineties, you’re approaching your sixties at this time. That was a lot of what we saw during my clinical there, a lot of people who just had chronic conditions related to being in prison for so long.

DL: Imagine for a second that as a country we had the political will to make any changes we wanted to make people safe starting tomorrow. What things would make the biggest difference right now to keep people healthy and safe? What do public health and healthcare professionals need?  

BB: Our lack of a universal healthcare system is a big thing. There’s nothing more heartbreaking as a nurse than calling and counseling a patient about what to do and who then says, “Would I have to go to the hospital if I’m having trouble breathing? I don’t have any health insurance and I can’t afford it.” You know? Trying to figure out what to tell them and trying to explain, “Well, if you’re having these symptoms, maybe you can wait a little longer but definitely if your fingers are turning blue, go to the hospital. So if we had a system of healthcare that covers everybody so that affordability is not a worry, you would see people seeking care sooner, you’d see people getting treatment sooner, being diagnosed sooner. I think that would’ve really helped. 

Similarly we have no universal sick leave for workers. And if you think not having universal health care and sick leave policies doesn’t affect you, go to any fast food restaurant where people work part time at minimum wage and can’t afford to take off work, you’re going to be exposed to whatever they have. It really does affect everybody if you’re looking at it from a purely selfish point of view. 

There’s nothing more heartbreaking as a nurse than calling and counseling a patient about what to do and who then says, “Would I have to go to the hospital if I’m having trouble breathing? I don’t have any health insurance and I can’t afford it.”

The whole way the US is set up, really, made us so susceptible for this to spread. The fact that our minimum wage is not liveable – I would have people begging me not to have them quarantine because they couldn’t afford to miss the paycheck or they’d say “I don’t know how I can get food for the rest of the two weeks,” or, “I have to pay my rent. What do I do?” When such a huge portion of our country is living paycheck to paycheck we’re just not going to weather this as well. 

I don’t know if there’s a way we could policy our way out of the politicization of a crisis like this. Having better leadership would help. We did have a pandemic playbook. It’s funny – as we saw how this could be playing out back in February, I’d go home from work and on my own time I would print out “How to Mass Distribute a Vaccine,” what are non-pharmacological interventions, so like social distancing, and masks, and closing schools if needed and stuff like that. We have had a lot of those [plans] for a long time and they just were not utilized. Instead they were mocked and made fun of and I don’t think that helped anything. We threw out the whole playbook so funding for public health and funding for public education around public health are both really essential. 

As of 2016, Wisconsin was the third worst funded state for public health. So public health funding so that we could have a robust workforce would also really help. If you don’t have enough staffing to even keep up with the cases coming in. Public health does so much stuff to prevent childhood illness, maternal mortality, preventable illnesses and spread of communicable disease normally that funding it properly would also be pretty high on my policy request list. 

For healthcare workers in general, I’ve thought a lot about how we get more people into healthcare. I have to say for nurses one of the biggest issues is that there’s actually a shortage of nursing instructors. To be a nursing instructor at UW and at most nursing schools, you need to have a doctoral degree in nursing, a DNP. It’s the same degree you need to be a nurse practitioner. So you would have to go back to school, get that degree, and you could become a nurse practitioner and make $90,000-$100,000 a year or be a nursing instructor and make $60,000 a year, which is not that dissimilar to what you were making before going back to school for that degree and going into debt. So paying nursing instructors more, incentivizing becoming an instructor. Student loans in general are a huge problem, but health care workers self-sacrifice a lot on a normal day. So having mechanisms of student loan forgiveness, especially during a pandemic, would help keep people in the field but also maybe bring more people in. 

I think there are a lot of policies that would improve the country that would also have a positive effect on preventing the spread of a pandemic.

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