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Five years ago, Melanie Richburg used a roll of duct tape, a HEPA filter and a portable fan to draw contaminated air out of a hospital room where patients were tested for the coronavirus.

Now, as the state’s largest measles outbreak in three decades sickens an increasing number of Texans in the South Plains region, the Lynn County Hospital District, where Richburg serves as the chief executive officer, is still without specialized isolation rooms to treat patients.

So, she’s prepared to bring out the duct tape again.

“If we see the volume of patients exceeds the number of beds available at children’s hospitals, we’re going to need a contingency plan,” said Richburg, whose county is 30 miles south of Lubbock and has had two measles cases. “The biggest struggle we have is the same struggle we had during COVID.”

The coronavirus pandemic underscored the need for robust public health infrastructure. And it brought to light a remarkable urban-rural divide in access to basic health services. In the months after the virus ravaged the country, federal dollars flowed to local public health districts, and policies targeting health care deserts saw a renewed push.

Yet as a disease that had been declared eliminated from the U.S. in 2000 makes a resurgence, rural West Texas communities and state officials are scrambling to respond. Aging infrastructure, a dearth of primary care providers and long distances between testing sites and laboratories plague much of rural Texas, where the measles outbreak has concentrated.

At least 198 people in Texas have been infected with measles since late January, and one child has died from measles, the first such death in the country in a decade.

More measles cases are expected, and the outbreak could last for months, state health services commissioner Jennifer Shuford told lawmakers last week.

Though different from COVID in many ways, measles is similarly revealing how a lack of public health resources leaves rural communities vulnerable. What’s left are local leaders forced to scrape together the few tools they have to respond to an emergency, contending with years of lackluster investment from the state and federal level to proactively prevent emerging public health threats.

“We’re in a public health shortage area,” said Gordon Mattimoe, director of the Andrews County Health Department.“ You have to think outside the box.”

Lack of infrastructure

Some 64 Texas counties don’t have a hospital, and 25 lack primary care physicians, according to the Texas Department of Agriculture. Twenty-six rural Texas hospitals closed between 2010 and 2020, according to a rural hospital trade organization, and although closures slowed in the years since, those still standing are often in crumbling buildings with few medical providers.

Swaths of Texas have scant resources for public awareness campaigns. And they lack sufficient medical staff with expertise to provide the one-on-one education needed to encourage vaccination and regular visits to the doctor.

“We have a difficult time in our area finding pediatricians for our newborns,” said Sara Safarzadeh Amiri, chief medical officer for Odessa Regional Medical Center and Scenic Mountain Medical Center. “That’s a problem. If you can’t find a pediatrician, then when a serious question comes up, who do you ask?”

Most of Texas’ measles cases are in unvaccinated school-aged children and are concentrated in the Mennonite community in Gaines County. Cases have also been confirmed in eight other counties spanning Dallam near the Oklahoma border down to Ector, south of Gaines.

To contain the illness, rural health care teams have cordoned off spaces to conduct measles testing, used social media to blast residents with information about vaccination efficacy and schlepped throat swabs across counties to ship them to a state lab in Austin — the only public state facility that was conducting measles testing until the Texas Tech University Bioterrorism Response Laboratory, part of a national network of CDC-funded labs, began measles testing last Monday.

Testing is critical for measles, experts say, because infected individuals can be contagious for several days and must isolate themselves to avoid spreading it further.

In Gaines County, runners have had to drive specimens up to 70 miles to get to a FedEx office where they could ship the specimen to the state laboratory. It could then take another 48 hours to get test results. During that time, public health officials would ask patients suspected of measles to quarantine — but they don’t know if they followed through.

“Some people need the test to say ‘I’m positive’ before they actually do something or follow the directions given,” Amiri said. “Having that testing available is very important.”

In Andrews County, just south of Gaines, Mattimoe is using the old City Hall building as a testing site because he doesn’t have a reverse pressure room.

Those rooms prevent contagious diseases from spreading to other people, and the Centers for Disease Control and Prevention recommends suspected measles patients are treated there when possible. In the absence of such spaces, rural counties including Lynn and Yoakum have improvised a room for measles testing, hoping they don’t get overrun with more patients they can handle.

Mattimoe, who said he is anticipating more cases, opted to open up City Hall for testing since that building happens to be vacant.

WIthout it, Mattimoe said, he’d have to “shut down the entire department for two hours between suspected cases.”

Reactive instead of proactive responses

Public health is based upon prevention, yet it’s emergencies that spur the most action, particularly in rural communities.

It was only after a school-aged child died from measles that state and federal support intensified. Twenty seven contractors were brought into the outbreak area last week to assist local health departments, Shuford, the state health services commissioner, said during a legislative hearing. A public awareness campaign with billboards and social media messaging was also launched. And, upon a request from the state, the federal CDC sent “disease detectives” to West Texas.

County officials also doubled down their efforts. In Ector County, County Judge Dustin Fawcett made media appearances to discuss the efficacy of the MMRV vaccine whose two doses provide 97% protection against measles. And the commissioners court approved the purchase of a $7,695 freezer to store measles test specimens — samples shipped after the date of collection must be kept at -70 degrees celsius.

In Andrews County, residents stepped up their communal responsibilities. Mattimoe saw a surge of people coming into the clinic to get vaccinated. “Unfortunately, the death of a child was one of the things that spurred many people to come in,” Mattimoe said.

Even as state and federal officials are sharing more information on vaccines, experts say those campaigns needed to come sooner. They have known for years that vaccination rates have been declining.

“We shouldn’t be doing it during an outbreak,” Amiri said. “We should be doing it beforehand to prevent the outbreak.”

Getting vaccines in residents is further complicated by the fact that Texas has a mostly decentralized system of public health. Cities and counties can stand up their own public health departments or districts, but the majority of rural counties can’t afford to have their own. Instead, they rely on one of 11 public health regions.

Those regions cover vast territories with limited dollars and don’t always know the ins and outs of local communities, especially on how to motivate residents to get vaccinated. The logistical challenges of traveling across counties adds another layer of difficulty.

“You have to call these tiny towns and figure out who can give you space for free to set up a testing clinic,” Wells said. “Then you’re driving from Lubbock to rural areas and that cuts how long you can keep the clinics open.”

And then, rural public health departments are having to contend with mixed messaging from the federal level as Robert F. Kennedy Jr., the health and human services secretary, has cast vaccination as a personal choice while downplaying the news of the outbreak.

“I think with the changes that are occurring at the federal level, we need to realize that we do need to strengthen our local public health,” Amiri said.

The power of funding

Years of underinvestment in public health left Texas ill prepared for the coronavirus pandemic in 2020. Hospital equipment was scarce, and state and local health departments had outdated technology that limited access to crucial data.

The pandemic also exposed the rural-urban inequities in health care access. Residents of Texas counties without hospitals died from COVID-19 at 20% higher rates than residents of counties with hospitals, according to an analysis by the Austin American Statesman.

An influx in federal funding helped shore up local public health departments and stave off more rural hospital closures. Texas received $35.5 million in grants for improvements in public health infrastructure in fiscal year 2020. An additional $221 million — the most of any state — is flowing to Texas through the CDC’s five-year Public Health Infrastructure Grant.

That funding has helped some local health departments address the measles outbreak, public health officials said. The Lubbock public health department has nearly doubled in size thanks to a $2 million grant. Those extra workers have been on the front lines of testing for measles and vaccinating children.

“It moved us from undersized to right sized,” said Katherine Wells, director of the city’s public health department. “It got us to the…health department we need for Lubbock.”

In Andrews County, Mattimoe has also used grant dollars to grow his health department. Four new employees, including an epidemiologist and a social worker, have helped the county complete a population health assessment that offers a snapshot of residents’ needs. And its year-round vaccine clinics have helped stave off the worst of the measles outbreak.

“Community immunity has really saved us,” Mattimoe said. “There will be a case eventually, but there’s something to be said about herd immunity.” Andrews County does not have any confirmed measles cases as of Friday.

The influx of dollars that rural communities received during the height of the pandemic showed the meaningful changes that officials could do with more support, but it still hasn’t been enough.

Texas spends less on public health per person than the vast majority of other states, according to the State Health Access Data Assistance Center, whose analysis shows Texas spent $17 per person on public health in 2023. A decade earlier, the spend was $19.

The low levels of state funding particularly hurt rural communities that have higher rates of uninsured Texans and more senior citizens with greater health needs, according to the Texas Organization of Rural and Community Hospitals. Deteriorating buildings and the shortage of medical professionals still persist in rural areas, while lower volumes of patients means higher health care operational costs.

In Lynn County, Richburg, the CEO of the health district, had hoped the makeshift contraption she made during COVID for a reverse pressure room wouldn’t be needed again in her rural community of 5,500 people. She attempted to pass a bond last year to pay for infrastructure upgrades, including a mini intensive care unit with four negative pressure rooms.

Voters rejected the proposed tax increase, though, a gut punch to Richburg.

“We wanted those four specific beds so that when we had situations where we needed to isolate patients, they’d be adequately cared for and not in a room with a broken window with a fan duct taped in it,” she said.

In addition to isolation rooms, Lynn County’s health care system is due for a major electrical upgrade, Richburg said. The facility’s backup power generator doesn’t cover the MRI machine or the CAT scan. In the meantime, Richburg and her staff plan to do their best with what they have.

“We’re still here, the lights still come on every morning, and patients still come in for services,” Richburg said. “We’re not going away.”

Disclosure: Texas Tech University has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.

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