Share Public Health Transcript: Rural Health, Stories from Local Public Health Leaders

Season 2 Episode 14
Hannah Shultz: Welcome to Share Public Health, the Midwestern Public Health Training Center’s podcast connecting you to public health topics, issues, and colleagues throughout our region and the country, highlighting that we all share in public health. Thank you for tuning into this series, which focuses on rural health in the Midwest. Over 10 episodes, we talk with people in a variety of communities about their experiences and perspectives on rural life, employment and health. Our aim is to deepen understanding of the complexity of rural life and celebrate rural areas. We’re so happy you’re listening and learning along with us.

Hannah Shultz: Welcome to this penultimate episode of our rural health series. Today we’re going to talk with three people who work in rural health departments in Iowa. Our first guest today is Becky Vonnahme. She is a board of health member in Carroll County in Western Iowa.

Becky Vonnahme: I’ve been the chair of the Carroll County Board of Health for several years. I think overall I’ve been on the board probably about 15 years. My background is pretty unique in that I started off in life as a sports writer and somehow ended up changing over to public relations working at a medical school in Wichita, Kansas, and then ventured over to the Department of Preventive Medicine and Public Health and started focusing more on research, grant writing. A lot of the projects that I worked on during that time period were specifically on public health, leadership and development. And then as I was finishing up a master’s degree in that time in Wichita, I came back home to Iowa, met my husband, moved to Western Iowa and really tried to focus more on healthcare not from public health workforce and leadership but more fundraising development, public relations for rural healthcare.

Hannah Shultz: Becky’s background combined with her tenure on the board of health is really interesting. She shares her thoughts on rural health.

Becky Vonnahme: Even though I think people have stepped up, they’ve come together to try to enhance the economic viability of the small towns, you still have that rural culture that is very difficult to overcome with the preventive messaging. It’s gotten much better with how, just for example breast cancer awareness month. There are more women getting mammograms in rural Iowa due to that month than there definitely were in the ’70s or ’80s. The message of prevention is getting out there in terms of those once a year exams. I’m seeing it more with colon cancer awareness too. People that never before would have thought to go in to get a colonoscopy. That message is now really getting into rural Iowa.

But overall other preventive messages with the healthy lifestyles, being more active. We are seeing more and more communities that are expanding trail systems trying to have some outdoor workout stations, really working towards having expanded rec centers. And again, that’s taking the health messaging there; understanding that the more active you are, the better your chances of preventing different types of illnesses down the road. But we still have work to do. We still have a very proud, hardworking population that has grown up with the mentality that unless I’m dying, I’m not going to the doctor. So there’s still work to do in rural Iowa to overcome that type of perception that you’re seen as weak if you go in for your tune-up or your preventive exams.

Hannah Shultz: Becky talks about how public health is set up in her county.

Becky Vonnahme: Our county is pretty unique in our public health infrastructure. Many years ago before I was on board of health, the public health nursing component was privatized. So it was pulled out from the county structure and it’s subcontracted to a local hospital. So they hire the public health nurse and oversee the day-to-day activities. And then we have environmental health and our home care aides is still underneath the county structure, all report to the board of health. And then we also have a community action agency, New Opportunities in Carroll, and they have the WIC program, they have I-Smile. So they have some public health components of their agency as well, and they’re regularly reporting to the board of health as well.

So with that, you have what could easily be a little bit of a siloed system. But I felt like the communication and collaboration has been excellent with all agencies. But to me, I really think what brought that collaboration up a notch in the last 15 years was the shift with the ACA when that was passed and when all hospitals had to start performing a community health needs assessment as
well inside their organization and needed to start tracking their community benefits and showing what community benefit they are providing, and to verify that is actually meeting an identified need. I felt like that really kicked just our regular every five years CHNA HIP up a notch because the hospitals became more engaged.

I think in the past maybe, I don’t want to say there was a resistance because there wasn’t a resistance for hospitals in public health departments to work together, but I think there was perhaps maybe a lack of understanding how they could help each other out. And I see that kind of broken down a little bit more in the last 15 years, for sure, because I think there’s more of an understanding how you need to utilize the data to the best of your ability and work together because you have the
same issues. Most hospitals are going to show that their community needs more cancer education or prevention. Well, that’s going to fall right in line with what IDPH, with what local public health departments are wanting to accomplish on their CHNA HIP as well.

I really think it’s broken down a few of those maybe invisible barriers. I don’t want to say that there was ever an inability to work together because I never saw that either. I think there just was a lack of understanding of public health. I think people hear that word and a lot of times don’t understand that really it just boils down to prevention, and we’re all on the same page. All hospitals out there, they don’t want patients to come in with a stage three cancer diagnosis. They do not want that at all. So I think understanding when hospitals needed to do their own health survey and they really had to start bringing in more staff, and I think people became more educated on, “Well, why are we putting this survey out and what do we have to do with this?” And, “Oh, okay. Well, yeah, that would make sense that we should be working with public health department because they’re doing something big during the month of October anyways.”

So I think that that has been very beneficial, especially in rural areas where sometimes that research component, it’s not that it’s overlooked. There’s just so much on these staff’s plate already. You have so many people that are doing multiple roles, and to try to really have that research component in there too is difficult. And if you can work together, which I think they’re finding that public health is just a little more versed in that area with the statistics and the reporting back to agencies. And so I think it’s been a win-win.

Hannah Shultz: We recorded this interview in the fall of 2020. Becky talks about the impact of the pandemic on public health and healthcare in Carroll County.

Becky Vonnahme: Gosh, our public health staff and our local hospital workers are so stressed out right now. The more support that we can give to them, the more that we can try to collaborate and take off of their plate. It is just mandatory right now that we do that because we’re still several months away from having any sort of time to breathe. So I am seeing that locally, our local preparedness coalition just outside of our mega coalition. We’re really trying to work together. We’re trying to find better solutions with contact tracing, anything that… I’ve even gone in and gotten trained and I’ve been making phone calls just because we want to stay on top of it and we do not want our public health staff working 12 hours a day every day. We need them to be able to breathe a little bit.

You take the pandemic away, and September and October are always stressful times for all local public health departments across the state. And this year, those flu clinics were probably doubled, which was good that the community is getting the message that if you haven’t had a flu shot before, please, please, please get a flu shot this year. Just try it out this year. Try to save yourself from complications that we can avoid. So they have just been overwhelmed with flu clinics, and that’s not even taking the worst worldwide pandemic that we’ve had for over 100 years. So put that on top of their plate, and they still have school immunization audits that are coming up and take a big time.

So we really have to do everything that we can to support our frontline public health workers right now because they have taken on a ton of stress and they have many more months ahead that they have to deal with this. And that again, in the state of Iowa, funding has not been good. Nationally funding has not been good, but in the state of Iowa, there have been so many significant cuts to healthcare. This is what we’re left with now, basically our county of 20,000, when it comes to public health nursing, we have about 1.25 FTE, that’s without a pandemic. So it’s tough.

Hannah Shultz: Becky talks about how the board of health has made decisions and supported public health during the pandemic and before, and what some of the challenges are in her county.

Becky Vonnahme: I would say that those agencies are probably driving how we’re making our decisions more so than even the board setting the direction because we go based off of the CHNA HIP, what we identify through the data that the community needs. But we have had instances in the past, we know just from our gut feeling, and I try not to ever have, I say all the time correlation is not causation. So yes, just because we think this is a big need, we’re not going to go off into that direction until we see the data that supports that this is a big need. But we had a staff member several years ago that we had discussed, how can people in wheelchairs, are they able to even maneuver and exercise? Are our streets even safe enough? Are the handicapped accessible?

So she had a program, we supported her applying for a grant for a walkability study, and some great things came out of that and really identified areas where the city could improve the accessibility for residents. So I think there’s probably things like that that we’re constantly taking into consideration. And again, we don’t have a lack of access. We’re lucky in our county that we’re not a health professional shortage area for primary care. We are for behavioral health, but the whole entire state is, so we’re not unique there. We do have a good network of specialists that are able to make it into our communities. Not as often, obviously, as we’d like to see, but we pretty much have all the specialties covered that are coming into our local hospitals.

We don’t have a lot of access issues from that regard, but we do have socio economic issues. We don’t have a lot of health disparities based upon race, but we do when you look at our rural nature, what I had kind of talked about before with trying to break through a little bit of that stubborn mentality of I’m not going unless I’m dying type of attitude. I would say that is really at the forefront too of a lot of the decisions that we make from a board of health perspective because we know that, yes, this is a great idea, but are we going to be successful? How are we going to try to tweak those messages to really have an impact to affect change? And I think that’s probably what the majority of people in all boards all across the state and the nation really struggle with is how do you flip that switch to really not just get the message out, but to affect the change from the message.

Hannah Shultz: I asked Becky what she wishes people understood about public health.

Becky Vonnahme: I think a lot of people, with public health right now, they’re only equating it to wearing a mask or not wearing a mask. And so they equate that with the government stepping in where it shouldn’t step. That is frustrating because if they understood the role of public health, they would understand that without public health in our country 150 years ago, we would be a third world country; because the government stepped in and researchers and practitioners stepped in at a critical time in our country where the industrialization was occurring. It was overcrowding. Sanitation was horrible. There was no control over the food supply, over drinking water. Public health came in and said, we can reduce deaths just by making sure that we are inspecting food before people buy it, that we are inspecting slaughterhouses, that we are making sure that our water supply is clean and without disease.

So public health has saved millions and millions of lives in our country. I think people don’t understand or don’t realize that, or don’t put those two things together. And then through the years, the fact that public health has noticed that, boy, we could really reduce the amount of people dying in car accidents if we just required seatbelts, and look at what a tremendous lifesaver that was. And
then going on and saying, boy, little kids are unnecessarily dying in car accidents; if they were just buckled in a seat that fit the size of their body. So there are all of these accomplishments that can be attributed to public health.

And I think, again, because of the world that we’re in right now with the pandemic, I think people are only equating public health with wearing a mask or not wearing a mask, and that is unfortunate that they look at that as a type of government control that they don’t want when they don’t realize that the interventions that have occurred through the last over 100 years are really responsible for them even being alive right now. We’re so lucky that we have had such a strong public health infrastructure and direction in our country because I have no doubts that that’s really shaped us and really made
America what it is where if we didn’t have that input and oversight from the government, it wouldn’t be anywhere close to what we’re experiencing right now.

Hannah Shultz: I really appreciate Becky’s perspective. As a many year board member and a nearly lifelong rural resident, she has a really good understanding of the work and challenges of public health in her community. We’re going to zoom in now to two women who are employed by local public health. We’re going to start with Tammy McKeever. Tammy is in charge of environmental health in Clay County in Northwest Iowa.

Tammy McKeever: When I started here, Clay County did not have an environmental health department. There was nothing. And so I really started this program from the ground and I’m very proud of what it’s become and how it’s impacted the community in the county. Every environmental health department in the state of Iowa and probably the United States and in the world is a little bit different. So we started
with core programs of septics and wells and grant counties. And then it’s kind of grown since then. We do radon, indoor air quality, lead, lead poison children, nuisances. Just over the years, the program has really grown and we’ve become a valuable resource to the citizens of Clay County when it comes to their health and how the environment impacts them.

Hannah Shultz: Environmental health and public health are separate departments in Clay County.

Tammy McKeever: Our public health department is contracted to Spencer hospital. That was done 30+ years ago. Like I said, we did not have an environmental health division of public health up until I started. The public health nurses and administrator were not equipped to deal with environmental health issues. So they basically requested that the board of supervisors hire someone. In hiring someone, they also wanted to find a zoning administrator. So when I started, I was the environmental health and zoning administrator. And so it remained with the county and public health is with the hospital. Since that time, I am now the safety director, the floodplain manager, the EMS coordinator. When you’re in a rural community, sometimes you end up getting tasked with things that you were never prepared to be tasked with. But I was always up for the challenge and they gave me an assistant. So we are able to do a very good job with all of those programs.

Hannah Shultz: Tammy is the first environmental health employee for her county. She shared what she was doing before that and how she became interested in environmental health.

Tammy McKeever: I was working for well water and was in contact with the Buena Vista County environmental health person and I just found it so intriguing. I just thought that’s what I want to do. And so I contacted the board of supervisors. They had been receiving requests from public health and the timing was good. They ended up advertising the position. I would get calls about garbage, sanitation and I’m like, “Well, I’m in environmental health.” There was that. Years ago, actually when I was hired, I was hired as a sanitarian. And so I always found it interesting that I would get calls about garbage and I would get calls about mental health. So I don’t know if they got that confused with sanitarium.

So there’s been lots of things that have surprised me, but what surprises other people when I tell them what I do for my environmental health position, some people who’ve never lived outside of the city limits and have always had a sanitary sewer might be surprised to hear that I inspect septic systems or might be surprised to hear that I do inspect septic pumpers. I think there’s, over the
course of the years, been a lot of surprised people of that that is something that I do, and sometimes they can even make fun of. There’s all sorts of fun, little quotes associated with septic systems. I think that’s probably the thing that probably surprises people the most that the first time they meet me or hear what I do, that I inspect septic systems. I think that surprises them.

I think that the expectation, and it’s definitely a stereotype, but the expectation is that that would be a man. That it wouldn’t be a woman who’s dressed in office clothing. So I wear business attire to work every day and when I go out and inspect, I’m not getting sewage on me typically, occasionally but not typically. The biggest challenge is if I got to step over a barbed wire fence or something. I have done that and I’ve caught my pants before. But I think that’s what the surprise is is that there’s this expectation that if you’re inspecting something that is a construction, that deals with septage, that that would be a woman. And 20 years ago I was a younger woman, so I think there was some surprise from contractors, surprise from people who just meet you. But over the past 20 years, more and more women have gone into this field.

When we talk about public health and environmental health, the public health side as far as nursing goes, you see a lot of women. Years ago, the sanitarian side as they called it, we call it environmental health now, was a lot of men. And so I think that is a surprise. Not so much now as it was. There’s a lot of women in environmental health doing septic system inspections and septic pumper inspections and lead investigations and nuisance investigations. But I think when I started in my career, that was definitely a surprise that it was a woman doing it.

Everything has become more technology-based for sure. I’ve been here, like I said, 21 years in December. When I started, everything was pretty much paper and mail. And now that pretty much is non-existent. Everything is web based and online. And it’s a good thing. As we all know, anytime you’re dealing with computers, if they go down, it can become challenging to even do your job. The other thing that has changed is as I stated before, when I started, we were very basic in our programs. We were doing some septics, and over the years, things have grown to, when I started, there was no such thing as septic pumper inspections. That was something that didn’t happen. But as we learn more and progress, that was determined by the state legislators that that was a needed service, that inspections needed to be performed on septic pumpers.

We didn’t have time of transfer inspections. Throughout the years, it was determined that this is an opportunity for us to be able to make sure that people have systems that are working. So the programs have all grown and matured and there’s been new ones added. The work has become more involved and the expectations of the public are higher. We just continue to try to make it better every day. Do the best you can every day, but make it better every day. I feel like we have. The public’s more educated than they were. They have access to information online and try to challenge rules and regulations, and you have to be very well versed and able to make them understand why we do things.

I think that’s probably one of the most important things about my job is when you’re doing what I do, making people understand why they have to do something is the greatest tool that you can use. If they understand why, then people are more willing to participate and do things in a joyful manner. And so that is just very powerful to make them knowledgeable about environmental health and the importance of why we’re doing things.

Hannah Shultz: Tammy says that over time, she thinks more people have seen the connection between environmental health and healthy communities. She goes on to talk about what it’s like to work with county government and county elected officials.

Tammy McKeever: One of the challenges of a county public health department or an environmental health department is that we have a board of health that regulates that is in charge of environmental health. But the purse strings are the board of supervisors. And so the challenges are that you have these bosses who are elected and these bosses who are appointed and they change, and their agendas are different and their philosophies are different. And so as an environmental health practitioner, you’re constantly dealing with the political arena, whether you want to or not. And so the most important part is that they understand the importance of your programs and what it does for the community and for the citizens of that county. Without that, environmental health and public health can be pushed to the side, there’s no doubt about it.

I think with the pandemic that we’re in, it has really brought forward the importance of public health. I would like to say that I have been very fortunate that I have been supported by my board of health. We had a board of health chair that was the chair for 30 some years. She recently retired, but there was not one board of health meeting that she didn’t tell me how much she appreciated everything that I have done. If there was something in the newspaper, she would cut it out and give it to me. So
very, very positive reinforcement for me that I was on the right track and doing the right things.

And like I said, the board of supervisors, who are the purse strings, I mean, they decide your bottom line of what your budget is going to be. There has been rocky times but in general very supportive, very common sense people and understand the importance of public health and environmental health and how that affects each other. So I’ve been lucky and I think that… I have heard stories from other counties, I’ve actually heard horror stories from other counties and have felt very blessed and very lucky that I was in the county that I was in. We have a medical director on our board of health. That is one of the most passionate people I’ve ever met in my life, and he’s hard to keep up with. So yeah, I’ve just been really blessed with people that have been supportive.

Hannah Shultz: As Tammy mentioned, she’s been a department of one for most of her career, which can feel a bit lonely.

Tammy McKeever: I did create the Northwest Iowa Environmental Health region. And so we meet on a monthly basis and talk about environmental health issues. The public health nurses have a regional coordinator and that regional coordinator brings them together on a monthly basis and basically gives them updates for an environmental health regional organization. So it mirrored what the public health
administrators were doing where they would meet on a monthly basis for their region and they would talk about emerging issues and things they didn’t understand. What we recognized or what I recognized early on in my career is that we deal with the DNR or the Iowa Department of Public Health.

I mean, there’s all these agencies that have these committees and I’m a one person office, and how do I stay involved and how do I get all the resources and information that I need when I am a one-person office? And so we created this region. We meet on a monthly basis. We try to encourage each person to be on a board, whether it be through the Iowa Environmental Health Association, or if the DNR has a committee they want somebody on, or the Iowa On-Site Wastewater Assistance, or
the Iowa On-Site Wastewater Association, the Iowa Water Well Association.

So we try to have someone sit on those boards and then we come together once a month and we share the information, and it was our way of being able to stay up to date on what’s happening and not have to be gone all the time. So I guess that I’m very proud of. When I’ve had other people start in other counties, they said it’s one of the most valuable things that they have. We’re able to reach
out and help each other. And so I guess that was kind of my brain child and glad that we’re doing it, and that we started at 20 some years ago.

Hannah Shultz: Tammy shares what’s different about doing her work in a rural area and how she’s overcome some of the challenges.

Tammy McKeever: Well, I think what is unique is that in an urban area, there’s usually an entire department. And so you may have, for example, I’ll use COVID. If I need to be quarantined, it’s going to be very challenging because we’re now a two-person office doing five different jobs. But going back to the days when it was just myself and environmental health, even taking a vacation day was challenging and unique because I had no one to fill in. So one of the things that we have done in our region and that is probably unique is we have created a 28D agreement with our entire region that if I’m suddenly ill or I have a vacation time, that I am able to go into another county and work.

I don’t know if that’s something that would ever be done in an urban area and may be not necessary in an urban area. But for us in the rural area, the contractors can’t quit working because I’m sick for five days. So who’s going to do those inspections. They can’t put the work off. Does it just not get done? There’s lots of challenging questions. We were able to, in our rural area, come up with this
and it’s worked fabulous. For example, if someone’s on vacation, they let me know that they’re on vacation. They try to arrange so that I’m doing as little as possible in their county trying to get as much done as they can before they leave. But if you have a contractor who needs to install a septic system and needs an inspection, then I can go over to 17 other counties and do their inspection. So we provide that service to each other.

I think it’s probably unique to rural versus an urban where you have a department. But basically what happened is when I first started I met with the DNR, I met with the Iowa Department of Public Health, and it just felt like, oh my gosh, there’s this association that I should be a part of and there’s this other association I should be a part of and this other association I should be a part of. And I’m like, well, how do I keep up to date on all this? And then I attended a training and I found myself talking to another individual. And we just kind of were like, maybe we should try to get together once a month and kind of just go over some of this stuff.

And that’s what ended up happening is we had the first meeting in Clay County. I kind of took over as the president and have been the entire time. There’s not really a president. We don’t elect anybody. It’s just a leader and I do the agendas every month. We haven’t been doing it because of COVID. We did some virtual. We skipped some months, for example April and October because that’s when our conferences are. But for the most part, we meet every month and we go to a different county every month. And so we’ve got to, sometimes we’ll do hands-on things where maybe we haven’t seen a new technology and that person will set up a training for us and we’ll all go there and see what that is, or we might do even a webinar all together in swimming pool or tattoo or something.

That way, if we have questions afterwards, we can kind of talk about it and how we interpreted it. We share information about contractors who say, “Well, this county doesn’t do that.” And we can say, “Well, I know that person in that county and I know they do because I talk to them on a monthly basis.” We last year met with the public health administrators in a large meeting and just kind of discussed things that different public health and environmental health departments are working on. One of the things that came up at that meeting was I always send in bat exposures. So if someone’s been exposed to a bat and they aren’t sure if they’ve been bitten, I have always, since I started, sent them in to be tested for rabies.

There was probably half the departments that didn’t even know that they could do that. And so that was one of those things that it was like, well, this was very informational. Now we know that if we get a bat call, we can send it to the lab to be tested for rabies. I mean, it’s really positive. We build each other up. It’s very nonjudgmental, like we are willing to admit if we’ve done something wrong as far as I didn’t even think of that, or what would you do in this case, or can you send me that letter that you sent? And so we’ve got a really good support group and I guess I’m proud that I was the founder of that.

Hannah Shultz: I love this story of camaraderie and support. Working in rural areas on a team of one or two can be so isolating. What a great way to get support from others in the same position. Our final guest today is Sharon Miller. Sharon leads the health department in Madison County. Have you seen Bridges of Madison County? Yep, it’s that Madison County. She’ll give us some context about what her community is like, but I really want to underscore that she is near Des Moines, the most populous city in Iowa, and is dealing with some incredibly challenging rural situations.

Sharon Miller: Madison County has roughly a little under 16,000 folks throughout the county. We have small towns that are less than 100 and we have larger towns. So we definitely are very rural. I have been the public health administrator for about two and a half years. I currently have eight staff. I have an office manager, an environmental health officer. I have a one part-time RN. I have two PRN RNs and I have three home health aides. So we are a very small health department. It’s nice to work in a rural community because you do have those key connections and everybody knows everybody, and it’s very warm and welcoming. When I started, it was just like being embraced into a family as a new member. So that’s nice. One of the challenges is we don’t obviously have some of the capacity that some of the larger health departments have such as Polk and Dallas. We don’t have the staff capacity, we don’t have the financial capacity. We need to do good work with the little amount of funding and staff that we have.

Hannah Shultz: Sharon shares some of the benefits, as well as the challenges of being a small rural health department.

Sharon Miller: Sometimes we want to be a bigger county because we want to have some of those bigger pieces of pie like Polk and Dallas do, but we really like the autonomy of being rural. We don’t want to be swallowed up by the bigger counties. We want to make sure that we stay small. Especially during COVID, it’s been kind of a blessing that we’re that close to Des Moines, especially when it comes to before they started shutting down the test Iowa sites. Early on, it was easy because we could get an appointment. Folks would drive a half an hour, not think twice about going into Polk County to get a test Iowa site test because especially early on when SHL kept the parameters of who qualifies for testing so tight, we didn’t have a lot of folks at the beginning of the pandemic fall within the strict guidelines of needing a test.

And so having that quick access to Polk County for test Iowa was truly a blessing. And I shouldn’t say just Polk County, because obviously there were some in Dallas County. It’s nice in regards to folks that can access those larger counties. The challenge is for those folks that can’t access those larger counties. We don’t have public transportation. We don’t have a busing. We have a lot of food
insecurity in our county. We don’t have big grocery stores like the Hy-Vees and the Fairways throughout all the county. Maybe in a couple of the bigger towns we do, but we have mom and pop grocery stores. We’ve got mom and pop pharmacies. We’ve got the Casey’s and the Kum & Gos, and those are the places that have to provide groceries.

And if you think about that, where are our fruits and vegetables and how can we afford sustainable food source when we’re going to run to the Casey’s to grab a loaf of bread. I’m not getting healthy meals. My kids are getting used to eating the junk food. And so having that obesity and diabetic issues, we have them. We have a lot of folks in our county that qualify as obese and a lot of folks that have diabetes, and it perpetuates for them and it was really… Obviously because of COVID, another thing, we knew we had food insecurity. We knew we had pockets of it, but we didn’t know the extent of that food insecurity until COVID came and kind of locked us all down and then all of a sudden we’ve got families that luckily all the schools in our county offered families to go and get meals there for that stopgap measure, but it doesn’t and it hasn’t solved that problem.

And then another shining, blaring spotlight is our mental health. We’re in rural Iowa. We don’t have the mental health services that we need. If you want to have mental health services, you’re going to have to go to some of those larger counties. We don’t have the capacity, and it’s not fair. On the one, we don’t have public transportation, how’s my family going to get there? They’re not getting
reimbursed. They’re in crisis situations. They can use the phone, but we also can’t do Zoom. And why can’t we do Zoom? Because not every single town in my rural county has access to internet. So how can I have a telehealth visit if I don’t have the capability to actually have telehealth, which also is a struggle for our kids to stay connected with school.

How can we properly engage these kids to help them with normal growth and development when they can’t do it on a screen? And especially in March and April and May when we shut the schools down, these kids were very disconnected because they didn’t have the capability to sit in front of a screen. That just wasn’t going to happen at some of these towns. Because sometimes I get a little
too passionate about some of the stuff, but this is rural Iowa. I mean, these are the things that we see on a consistent basis.

And then when you have folks that say, “We need to invest, we need to invest.” Well, do it. Figure out a way to invest the dollars to actually help rural Iowa. Don’t just do a blanket statement and say, “We understand.” How do you understand if you don’t actually see it. And don’t pick and choose who you want to talk to. If you want to have an open forum and a community meeting, that’s great. But
guess who comes to those open forums and those community meetings, the people that have access to transportation and the means to be able to financially afford to go to those meetings. And not everybody in the community can. And so you’re missing a large portion of people that need to have their voices heard.

Hannah Shultz: Sharon talks about how COVID-19 has threatened her community.

Sharon Miller: Well, I think COVID, the pandemic itself is a threat to our community. We don’t have the access to testing that we need. I don’t have the financial capabilities to give someone money to go get testing. There is no taxis, there are no Ubers, there is no public transportation. So when these poor individuals are ill, how are they going to be able to access the care to get tested to know? And then it goes back to, they can’t do a telehealth because they don’t have internet in these small towns. So by the time they do and are able to access care, they are sick. Whether they’re sick with COVID or they’re sick with their diabetes is out of control or they’ve had stroke-like symptoms for a handful of days, but they’re just not ignoring them, they’re trying to figure out a way, but they also can’t afford a $5, $6, $700 ambulance visit to either the one hospital that we have here in Madison County or any of the surrounding county hospitals.

And that’s also, I mean, it’s a blessing that although we are in rural county, we do have a hospital here in Madison County, but it’s in Winterset, which is the largest town here in Madison County. But it’s also not a 10 minute drive from all the other points in Madison County. It might be a half an hour, 45 minute drive from the farthest point south of our county. And so they may have to actually access
care in a different county. And does the other counties, and does Madison County have all the services that this individual needs? This individual may need to get a referral and have to go to the larger county, Polk and Dallas, to access care, or even to Iowa City. Or we have veterans here and so they have to go to Des Moines for their care at the VA.

And so it all just snowballs into a great, big… And then you have individuals that are feeling overwhelmed because they don’t know how to access the system. They’re not health literate. We know that healthcare has its own vernaculum. We all do, everybody that works in different pockets. So when you’re trying to explain to mom or grandma, we talk at a higher level than what they can
comprehend themselves. And so when we are providers, we need to remember how to talk to individuals in language that is easily comprehendible not just to the patient, but to the patient’s family, which is a huge disconnect right now because if the only person that can access care is the patient because of COVID, how is the patient going to articulate to its family members the help and the support that the family needs to give to this individual to actually make sure that he or she is taking care of its diabetes or whatever it is. They can’t because they don’t necessarily understand everything that has been said to them in that small amount of 15 minutes.

Hannah Shultz: Sharon has so many stories highlighting these challenges.

Sharon Miller: Pre COVID, that came in. They were an older family, they were accessing services. They had to go to Des Moines to get the services; chronic health, cancer, blah, blah, blah, needed some assistance with the medical cannabis card. The provider in Des Moines said, “Go to public health and they’ll help you.” Well, no, you don’t come to local public health. You go to the Iowa Department of Public
Health, and everything that you need to fill out is online. These individuals were past 50, they did not have access to a computer. They didn’t know what a mouse was, and what they heard was, “Go to public health.” So these poor individuals came into our office. This lady was older as was her husband. They’ve been married for 50+ years, are still happily married. The wife was in tears because no one could help her.

So we take time, which is what we’re blessed with in rural Iowa. We got to take time. I spent an hour and a half out of my day last June to help this couple understand how to fill out the forms. I downloaded stuff from my computer, printed things off, told them exactly where to go, what to send, what we needed to copy, everything. They had to go back to Des Moines to get a signature. Then they came back here with all these pieces of paper signed, did not know what to do next. I put everything in there. They wrote the checks, they got everything done. Then they got a notice that said that they had to go to the department of transportation to get this card. They couldn’t do it at the department of transportation here in Madison County. Again, they had to go back into Polk County to get this done.

All the amount of hurdles for this one small process that should have been an easy process was not an easy process. Luckily it all worked out. It was great. They had to get a renewal this year. So they came in when COVID numbers were low. Our office has been open during COVID because we are public health. They came in, they got this notice from the state. They got to renew, what can we do?
The blessing of all of that is that they made the connection to local public health so that they knew they could trust local public health, and we would help them.

The challenge was the amount of hurdles that it took this poor couple to get this card was ridiculous. How could it have been made easier? It could have been made easier by the provider who knew, just by looking at these individuals, that technology was not their friend. It could have been made easier by the provider and/or the nursing staff by saying, “Mrs. Miller, could we print these forms out for you? Could we help you?” You were already in the clinic, why could they have not done it? Well, because we only had 15 minutes. We’re running late.

The blessing of being in rural Iowa is we have those human connections that we can spend a little extra time. But the challenge is when you have insurance and other people’s driving those buses, we
can’t make those connections. And oftentimes people that can’t navigate the complicated healthcare system get lost in it. And therefore they don’t ask healthcare because they feel like they’re just a number. They feel lost in the system. They have no control, and they’re being told what to do when we don’t ask them what they need us to do for them.

And I’m talking about people that are blessed that had insurance. I’m not talking about these individuals, and we have a large number of folks that are under-insured or uninsured. And so then, yeah, I’ve been having chest pains for five days, but I can’t do anything about it because I’m either going to have to pay for gas, groceries, or a hospital visit. I’m going to continue to pay for gas and groceries so I can continue to work and feed my children, and I’m going to not pay attention to my own health. And so by the time I do pay attention to my own health, we’ve got a ton of health issues; instead of doing that preventative healthcare, which we know is so important.

But when you can’t afford it, you don’t do it, which is so hard especially right now during COVID. Families can’t afford to be quarantined for 14 days, especially if they’re not considered essential,
because somebody needs to pay the rent, they got to pay the mortgage. They’ve got to feed these kids. And if the only hot meal that these kids are getting on a regular basis is at the school, then it really is compounding the issues when we have to have these kids stay out of school because they are a close contact to a household positive.

I don’t have any magic wand to fix all of this, but it’s just really, really hard. It’s no wonder the communities are tired. Everyone is COVID weary. Local public health is beyond COVID wary. We are overwhelmed. We have cases coming through at an astronomical rate right now. I mean, we can’t even do our own proper contact tracing because we have so many cases coming in. What do you do? I don’t know. And then people are weary and they don’t want to tell you the truth because they themselves don’t want to be put in quarantine.

So when you ask them, “Have you traveled anywhere?” “No.” “Have you been with anybody?” “No.” “Have you been six feet for 15 consecutive minutes?” “No.” Even though we know that they have
been, but we have to rely on their honesty. And then it just perpetuates the numbers of positivity that we are getting. And now we have the challenge of it’s becoming winter. We’re closing these sites down. Not everybody has access to a stroke detection. There’s no stroke detection place here in Madison County. You’d have to drive to Des Moines.

The test Iowa sites have all been closed with the exception of one that’s on the north side of Polk County. So that’s going to be a 45 minute drive from Winterset. It’s going to be an hour drive from the
southern part. So they’re going to have to go to a different county and hope that they can get tested there. Ad we don’t have the luxury of having some of those Binax cards or those Abbott quick tests here in our county because they’re expensive and our local providers can’t afford to spend that much money on these apparatuses.

Hannah Shultz: A quick reminder, we recorded these interviews in the fall of 2020, which was before vaccination started and numbers of COVID-19 cases were rising every week.

Sharon Miller: Well, we are very tired. I will speak up for a lot of public health administrators. We are tired. Our staff are just tired. Our staff is overwhelmed. Our public health administrators have not had days off for months, even weeks. We’re all salaried. We’re not getting bonuses. We’re not getting overtime. We’re eating the hours. We can’t not answer the phone. We don’t know if that’s a positive or if it’s not a positive. We got to answer the phone. Folks look to us at local public health for all the answers. We don’t have all the answers.

We get the guidance from IDPH and the Department of Ed, just like the general public. And then when they talk to you, they’re angry, they’re frustrated. They’re angry because they’re positive. They’re frustrated because they’re positive. They’re angry they’re in quarantine. They’re frustrated they’re in quarantine. They’re angry because they don’t think local public health is doing enough. Why haven’t we flattened the curve already? You’ve been telling me since March to wear a face covering, wash my hands. I’ve been doing that, doesn’t seem to make a difference. Our numbers are spiking throughout all of Iowa.

We went from very few numbers in March. Now we are at 17.5% positivity as of today. We had 12 new cases overnight. I always tell my staff it’s like pulling back the onion. At what point are we going to get to the core of the onion? The staff are overworked, they’re tired. We got to take care of their mental health. They have families. They may have kids. They may have their own issues within their own families. And so folks sometimes forget to practice patience and grace, and they’re just concerned about their situation and they don’t think about maybe Sharon might have a situation at her household. How is her health? How many days has she worked? Has Sharon been in quarantine? Has she been positive? Why is Sharon so short with me? Why does she have to ask me all these questions?

I have to ask you all these questions because I have to do my due diligence to protect the other residents of Madison County, and I need you to do your due diligence to be open and honest with
me and tell me what you can about your case. People are tired and they’re wary and I’m not sure it’s going to get any better, especially as we are coming into the holidays. Folks want to see their parents, their grandparents, their new baby, new cousin, whatever. We can’t have folks do some of those activities. Will they do them? Yep, they will. Will it affect our numbers? Yep, it will. Was it worth it? I don’t know if it will be or not. Everybody will have to make their own decision.

It’s just, it’s a very frustrating situation in public health right now. It’s challenging because I appreciate that folks are trying their hardest to demonstrate that face coverings work, but the more we
demonstrate face covering works, the more it puts doubt in the minds of individuals. Why am I working so hard to show you the data that says that face covering work? Why can’t we just say face coverings work, because we’ve instilled now the seed of doubt about, “Hmm, Sharon’s working really hard to point out that face coverings work.”

And then on the other side, it’s a whole behavioral change, and that’s what public health works with is we work with behavioral change. If we can’t give folks the tools to change their behavior, then this is not going to go anywhere. I like to tell individuals that push back to me in regards to face coverings, I like to say, “Well, let’s think about it in a different format. It’s a piece of cloth. I put on a piece of cloth every single time I get into my car. I strap it across my shoulder, I buckle it in. It’s called a seatbelt. Now, will it protect me from getting into a crash? No. But it may save my life if I get into a wreck or it may decrease my seriousness of my injuries. But that piece of cloth protects me just like the piece of cloth I need to wear over my face and my nose.”

And so I think if we can change the message and the vernaculum to resonate with the public and make it as simple as those comparisons, maybe we’ll see some of that behavioral change. But right
now, folks are tired and there’s lots of data that they can find that says face coverings don’t work, even though we know they do work.

And then the other thing that’s really good in local public health when you’re in rural counties is you also get to transform the life of a young person. They can look up to you and say, “Wow, I want to be
like the local pharmacist or the local Bircher or the local mailman or law enforcement.” They already have a built in role model instead of having to try and think bigger; because the small folks, when we make an impact, we just don’t know we make an impact, whether it’s me going into the schools and talking about something that I’m passionate about, and then you get one person in that class excited. And maybe that one person is the next person that’s going to go into public health and change the world.

We don’t know, but that’s also the benefits of working in a rural community because we get to make those connections and there’s not such a disconnect. Before COVID, we could put your arms around you and give you a big hug and say, “Laurie, I can see that you’re upset. What can I do to help you?” Now we just have to trust that individuals can find their voice to ask for help, and that’s not always easy, especially right now.

Hannah Shultz: I asked Sharon one of my favorite questions. Is rurality a determinant of health?

Sharon Miller: Well, I think it is a social determinant of health. It can be a positive social determinant of health because I can have that connection with my local provider. They will see me at the grocery store. They can come up and ask me, how am I doing? Is my med working? So that’s good. It also makes that connection stronger in regards to the social determinants of health, but it’s also a barrier because if I live in one of those smaller towns, less than 100, and we’ve got towns like that here in Madison County, I don’t have the access that I need to be able to be health literate, to be able to access fresh fruits and vegetables. I don’t have public transportation. So it’s a mixed bag living in rural Iowa.

It’s also we have pockets of poverty, which I haven’t even talked about. Not everybody in the county has the luxury of having more money than they need. We have many individuals that work paycheck to paycheck, and we have many individuals that are working two and three jobs. And we have families that are multi-generational families because they need to be multi-generational to make the ends meet. We also have an Amish population here in Madison County. And so they take care of themselves. I’m also working with them. That brings other challenges in regards to how do we message the importance of vaccines when we know that they typically don’t vaccinate their children. How can we talk to them in a respectful manner and meet them halfway so that we can hopefully protect those young children against something as serious as a measles outbreak or Something like that.

So when we think about that, we also have to think about how can we talk to them in a respectful manner, but also what are they really concerned about and what health issues do they have and how can we build that bridge between what we think that they need and what they think that they need, because oftentimes those are two completely different answers.

Hannah Shultz: That is such an important point. Ideally, public health meets people where they are and through tools like the community health needs assessments, we know we’re working in tandem with community members to improve health. Unfortunately, that’s not always the case. On the opposite side of that coin is understanding what the public thinks of public health. I asked Sharon what she wishes people understand about the work of public health.

Sharon Miller: I think that I wish folks would understand the breadth of which public health really is. It’s not just giving shots. I mean, we do a lot of good work in public health. I haven’t even talked about our environmental health program. I mean, we worry about access to clean water. We worry about clean water. We worry about radon. We want to make sure your septic is working right. Dog bites. So
there’s a whole lot of stuff that we do in public health, one, that folks don’t know we do. So I guess that’s good if they don’t know that we do it, we’re doing it well, or it’s not good because they don’t know of all the services that we can provide.

And then the other thing is I don’t think folks actually know what public health is, because those are two big words. When you think about the public, you think about, I don’t know what. And then when you think about health, what do you think about? Do you think about your doctor? Do you think about your overall health? So when you put those two words together, that seems like a lot of stuff that people can’t unpackage. So how do you, as students, unpackage that public health? How can we message and sell ourselves better in public health? Everybody that I know that works in public health has a huge heart. They’re kind, they’re empathetic. They want to make a difference. But if the community then doesn’t know the impact of public health on their community, then how can we truly make that impact?

And then the other thing is that with public health, there’s not an abundance of resources for us. We are just like any other business where we struggle for financial security and resources. The grants are harder to write. They’re more competitive. Public health for the most part, especially in a lot of rural communities, we’re not a money making program. And so when the board of supervisors are looking at programs to cut, it’s not uncommon that public health and some of their programs is the first thing on the chopping block because we’re not a sustainable program.

And so how can we get folks to think about public health not balancing the checkbook in that way, but thinking about we make a huge difference in the overall health and wellbeing of the community, and that’s priceless. That’s not trying to balance the checkbook. That is trying to make you and your family continue to be a productive member of your community. We want our kids to grow and thrive. We want grandma and grandpa to grow and thrive. We want to keep them at home and healthy for as long as we possibly can. But if we have to worry about Xs and all in if I spend $5 here, I need to generate $10, then we lose the passion and the mission of public health.

I think we need to think about, in an advocacy perspective, how we can frame public health so that we are not vilified. And right now we’re being vilified. I personally worry about young people that are
looking at what’s currently happening within public health and are they going to have the conviction to go into public health, because right now it’s not a fun place to be in. It’s a very shark infested water, and you never know when you stick your toe in that water if it’s going to get bit or not. Will we continue to have young people with your talents to share in the future, and will we have that amount of talent and expertise in the future? I don’t know. I know the cohort of Iowa state kids that I’m working with now, they’re smart, they’re bright, but what is that going to do when you think about your major in four, five years. Are we going to see new blood?

And then the other thing is I very much worry about the individuals that are currently working in public health because they’re tired. We’re not exactly young. Some of us aren’t exactly young. We are getting ready to put that surrender flag up, and if they leave and we have a mass exodus of the workforce, who’s going to replace it and what does that look like if it is replaced? Is it going to be at the quality that we want it to be or will we have counties say, well, we can just do one component of public health and not that whole menu of public health that we do because that’s all we can afford, or will public health be swallowed up within another department or with the hospital, and then we lose the identity of public health.

I will tell you that I have a freshman at Iowa State. She went in as an open major and she has declared her major, and she has declared her major as public health. I have tried very hard to bite my tongue and tell her not to get into public health because this poor girl will have her soul crushed, but she very much sees what her mom is doing and the impact of some of the things that we are doing in public health and she wants to be a part of that. So I’m hoping that enthusiasm and that passion, whether it’s a political drive or an advocacy drive or just an overall drive to make a
difference and have your empathy and kindness show up, I’m hoping that that may continue to drive
the workforce, but I don’t know.

Not everyone realizes the impact of public health upon them personally. You have a working septic system, congratulations. That’s because when it was being permitted and then when folks were looking at it as your house was being built, we made sure that it was safe and that it would hold what it needs to hold. When your child gets vaccinated and you get grumpy with me because you want to send your kid to daycare but you need to have that other MMR shot before you send your kid into daycare, that’s all public health and that’s all trying to help you be the best person that you can be.

Hannah Shultz: Thank you for joining us today. I’m very grateful to Becky, Tammy and Sharon for sharing their experiences with us today and for all the work they and their public health colleagues across the
country do to protect our health every day, whether we’re in a pandemic or not. We have one more episode in this rural health series. Join us next week as members of the planning committee for this series reflect on what we’ve heard and learned over the past nine episodes.

Thank you for tuning into this episode of Share Public Health. Thank you to the Injury Prevention Research Center, Iowa Center for Agricultural Safety and Health, the Healthier Workforce Center of the Midwest, the Heartland Center for Occupational Health and Safety, the Great Plains Center for Agricultural Health, the Midwestern Public Health Training Center, the Prevention Research Center for Rural Health, and the Rural Policy Research Institute. The theme song for this series is Walk Along John. It’s performed by Al Murphy on fiddle, Mark Janssen on mandolin, Brandy Janssen on banjo, Warren Hamlin on guitar, and Aletta Murphy on bass. Al learned these songs from a Fiddler named Albert Spray, who is from Kahoka, Missouri. A transcript evaluation and discussion guide for
this episode are available at mphtc.org, and in the podcast notes.

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