For five months, Dr. Olivia Kasirye has worked every day straight as the Sacramento County health officer as California faces the COVID-19 pandemic. But each day, she spends time focusing on how to keep her department, all running on the same fumes as she is, from coming apart in the face of unrelenting demands. Testing, contact tracing, communication with the public, enforcing county directives.

The glue, which has worked miraculously, has been two words.

“Thank you.”

She knows that’s no substitute for the vacations her staff would rather be taking or relief from the stress they’re under to hold ground against the pandemic while also trying to carry out the basic functions that are the bread and butter of a county public health agency.

Immunization, home visitation, health education, STD control and more have all taken a hit. The National Association of County and City Health Officials (NACCHO) have also found vector control, regulation and inspection of food service establishments have also suffered. Well before the pandemic, between 2008-2016, local health departments lost more than 2,000 full-time positions, NACCHO found.

“We were already dealing with a thin staff and not a lot of capacity for surging,” Kasirye said.

Sacramento County has been without a field nursing unit for Kasirye’s entire career with the county — the staff that would have been crucial for the surge capacity for communicable diseases — victims of the 2009 budget cuts.

“It’s tough because you think ‘thank you’ doesn’t cut it, but whenever I can, I like to show that I appreciate their work, and to work alongside them,” she said. “I communicate with them, address concerns they have, talk through problems with them and let them know I’m listening.”

And she’s conscious of the dozens of county health personnel who have left their jobs during the pandemic.

“I reassure them that I’m going to be with them until the end,” she said, meeting their curiosity head on. “I see how hard they are working when I get those fast responses to emails I send at odd hours.”

Those rank-and-file employees are seeing their own personal horror shows as they stretch to fulfill their mandated responsibilities while pitching in however they can with the pandemic response.

In Cook County, Ill., Dr. Rachel Rubin, senior medical officer and co-lead, said every unit of her department’s 160-person staff has seen COVID-19 response added to their responsibilities.

“Many staff are serving in emergency response roles while also juggling their everyday responsibilities,” she said. “Even in our everyday roles, we have seen dramatic impacts from COVID-19. One sanitarian received 300 messages over one weekend when there was a change in state guidance related to swimming pools.”

If the intrinsic challenge of facing a generational pandemic wasn’t taxing enough, public health staff are finding themselves the brunt of public anger if the public disagrees with their directives.

“It’s been hard, we’re not accustomed to being in the limelight and having this level of scrutiny,” Kasirye said. “There’s a sense that you’re hiding something.”

But she has been buoyed by supportive feedback from the public.

“We’ve gotten letters from people who are appreciative of what we’re doing,” she said.

Anoka County, Minn.’s Public Health and Environmental Services department has been forced to limit work on programs and projects that target long-term community health outcome improvements.

“We had invested a whole ton of resources into community health plans to look at where the disparities are in our communities, populations that need extra help and to try and reduce inequities,” said Director Jonelle Hubbard. “We still try to work through that lens — we’re trying to make sure we’re getting testing for people at high risk who really need it — but we’ve had to put things on the back burner that we really want to do as a department.”

With schools closed since mid-March, prevention programming has been off the table. The county’s chemical health collaborative is at a standstill while the world outside goes on.

“We’re seeing an increase in chemical dependency and overdosing, jail population is going back up,” Hubbard said.

And, while practitioners are able to still see some clients via telemedicine and safe time on the road, Hubbard said the medium leaves a lot to be desired compared to in-person meetings.

“You have to listen and pay attention more closely because when you’re in person, there are a lot of nonverbal things you can’t pick up on virtually,” she said. “You lose a little connection with stuff going on, so you need to be very vigilant, listening to what the people they’re working with are truly saying.”

Anoka County, along with the others, continues to provide essential services, but on a different timeframe for some.

“Sometimes instead of being able to schedule people the way we used to and see them soon, it takes three or four days because of our staff shortage,” she said.

That’s going to get worse, soon. The National Guard, which has been assisting with mass testing, is due to leave at the end of August, and the health department will pick up the slack.

“We’re having to do a lot of contracting to fill some jobs,” she said. “That’s helping us fill nursing and office staff, but it’s harder to find people to work in a lab.”

“We need to work on a contract with an outside entity to help us through that, get more manpower in to do clinics,” Hubbard noted. “We don’t have the manpower to do mass testing, the National Guard has been doing that but they’re done at the end of August — we’ll have to pick that back up.”

Like Kasirye, Hubbard has been focusing on her staff’s well-being.

“I’m making sure my staff has the support and resources they need,” she said. “They’re getting breaks and time to decompress.”

She has contracted with a psychologist to do biweekly sessions as a team, consulting with managers and supervisors one-on-one and doing two-hour group sessions once a month with other staff members.

“This is long, drawn-out trauma,” she said.

Cook County’s Department of Public Health brought in its Trauma-Informed Taskforce to assist personnel, and Rubin said the department was creating additional resources on self-care and for managers through the group.

“This has been a challenging time for our department and our staff,” she said. “COVID-19 doesn’t just impact us at work, the pandemic has disrupted and stressed our families, friends and communities. Some staff have become sick. Some staff have lost family or loved ones to COVID-19. There is continued uncertainty about the course of the pandemic and we are still learning about this virus. We are fortunate to have our livelihoods, but COVID-19 has had a substantial impact on us both personally and professionally.”

If this wasn’t enough, Hubbard was widowed in the last year, but she feels secure thanks to the support she receives from the county, her staff, her family and the strength she draws from her faith.

“Self-care is critical, I do hot yoga, keep clear boundaries where I can about taking time off, shut my brain down,” she said.

Kasirye notices and appreciates her colleagues checking in on her.

“If someone doesn’t hear from me for a few days, they’ll write or call and ask if I’m OK,” she said. “I try to take care of getting sleep so I can function.”