The Tri-County Health Department in Colorado is a marriage between three counties. But after 55 years together, the pandemic has them on the brink of divorce.
The relationship started with a devastating flood. Lora Thomas remembers it vividly.
“I remember sitting on Ruby Hill in Denver watching this wall of water coming down the Platte River,” said Thomas. “There were actually horses in that water that had come from a racetrack.”
Others standing on the same hill saw a house grind into a bridge.
After that, Douglas County joined forces with its neighbors, Adams and Arapahoe. All three hug the major city of Denver. Together they’re a mixture of blue and red, urban and rural.
For decades, the relationship went well, with the Tri-County Health Department handling public health emergencies ranging from measles to youth suicide.
But now, Lora Thomas is not a kid sitting on a hill watching a flood, she’s a county commissioner up for re-election. And she says the relationship just isn’t working. It’s time her county, which is rich and conservative compared to its neighbors, moved on.
“We’re not toddlers anymore,” she said. “We’re adults and we’re ready to move out on our own.”
The trouble began with a stay-at-home order.
“In March, when the first shutdown orders were put in place, the commissioners received several emails from citizens saying we need to have our own health department,” Thomas recalls.
The mask mandate a few months later made things worse.
“We wouldn't want some other state coming in and telling Colorado what to do. And that is where Douglas County is,” said Thomas. “We don't want Adams County and Arapahoe County citizens dictating to us our very personal, important public health decisions.”
As Thomas pointed out, and as confirmed by the health department, her county had fewer cases than the others, and a local survey showed her residents were doing better than others at wearing masks voluntarily.
But in July, the health department’s executive director, Dr. John Douglas, laid out the facts to the board of health. According to state standards, all three counties were experiencing at least “medium” viral spread. Cases were rising. Contact tracing efforts were being hampered by “reticence” to participate among the public. He made the case for a mask mandate, citing evidence that mask mandates help slow the growth of outbreaks and could benefit the economy.
“I do believe honestly that we would do better — because we live in a very highly interconnected metro region — if we were following similar prevention efforts in all of our counties,” he said. “But I do get the fact that we have different jurisdictions. I also get very clearly that I’m not an elected official.”
And, he added, it was clear to him that Douglas County would have “less” of an “appetite” for something like a mask mandate. Essentially, he said, the risk of causing political issues might outweigh the health and economic benefit of a mask mandate.
“I’m not really interested in superseding elected officials in circumstances where the situation is not as serious as it might be in an area with higher rates of incidence,” Douglas told the board.
As such, he suggested a mask mandate, but also suggested that Douglas County be given the option to opt in.
Yet, the board of health — which consists of nine people, three appointed by each county — voted to issue a blanket mask mandate across the region.
Now, Douglas County was given an option to opt out of the mandate. And shortly after, the Colorado governor issued a statewide mandate that rendered local ones redundant. Finally, from a population standpoint, Douglas County is overrepresented on the board of health. (If counties were awarded appointees based on population size, Douglas would only get two.) But to Thomas, those were just details.
“It became clear to us that this one-size-fits-all just did not work well,” Thomas said. “It became clear to us that this nine-member board of health was no longer effective at maximizing the governance and policy decision-making for Douglas County residents.”
So, in the summer they wrote a letter announcing they intend to break off and form their own health department.
They’ve since backpedaled a bit and are talking with the other counties. But going rogue is still on the table.
“If, after well-intended discussions with Tri-County Health and the two counties, we cannot establish a Douglas County-specific governance model, there will have to be an option to pursue our own health department,” Thomas wrote in an email October 1. (Health department woes are part of her campaign platform).
Emma Pinter chairs the county commission for one of the other members of the health department, Adams County. Compared to Douglas County, it’s lower income and more progressive. And Pinter is irritated by what’s going on.
“Historically, this has been very collaborative,” she said. “The issues were common...opioid addiction, youth suicide, mental health generally, access to public health, access to medical care, the cost of medical care.” (Lora Thomas, for the most part, agreed).
If Douglas County really wanted to leave, said Pinter, why didn’t this come up before?
“To have this conversation at a time when it is so critical that we are responsive and that our health department is responsive is a distraction,” she said.
Pinter has served in local government for seven years and she said this squabble isn’t about public health or about serving the needs of residents.
“I absolutely love local government and one of the things I really appreciated about it this whole time is that despite party affiliation, the work of local government is so pragmatic,” she said. “For partisan politics to have seeped its way down here, where one of our colleague counties would be in favor of rejecting science or rejecting the opinions of public health experts would be disconcerting to say the least.”
According to the National Association of County and City Health Officials, over half of local health departments share services in some way.
But there’s a broad spectrum for what “sharing” means, starting with just sharing data, supplies or equipment.
To compare this spectrum to relationships, that would be on the friends-with-benefits end of the spectrum.
“Moving towards tighter and tighter collaboration, the next would be contracting services,” said Charlie Hunt, an epidemiologist by training who is deputy director at the Center for Sharing Public Health Services, which is dedicated to getting health departments to work together.
That might be more like dating.
“And then of course at the very far end of that is a consolidation of mergers, where health departments literally come together and have a shared governance structure,” he said. “We see that across the U.S.”
The Tri-County Health Department is a full merger. It is like a marriage, but instead of planning a 55th anniversary bash, this trio is talking about divorce.
Hunt isn’t aware of other public-health marriages falling apart right now, but he says the system is under more strain than ever. And through studying examples across the country, Hunt and his colleagues know what elements spell success.
Health department relationships don’t work if the partners are just in it for the money.
“It really is more about being able to deliver more effective and more efficient services,” said Hunt, though reduced cost can be an added benefit.
And politics alone shouldn’t do the marriage in, he said, but it’s understandable how the pandemic may be prying them apart.
“One of the success factors — or prerequisites, even — is to have a shared regional identity,” he said. “I don’t know what the political landscape was like back when the health department formed, but it stands to reason that if there are differences in philosophies, differences in ideology, that there are going to be some tensions created because of that.”
Over the past few decades, the counties have indeed changed a lot, as many growing communities in the Mountain West have. According to the census, the populations of Adams and Arapahoe Counties have more than quadrupled since 1960. Meanwhile, Douglas County’s population is 72 times as big as it was in 1960. And the counties each contain a piece of Aurora, Colorado’s third largest city and now, according to U.S. News & World Report, one of the most diverse in the nation, with a 72% chance that if you chose two people at random in the city they would not share the same race or ethnicity.
As it stands, Lora Thomas said Douglas County is pushing to restructure the health department so that each county would have its own board of health and contract with the Tri-County Health Department for services. She called it a “win-win for everybody.” After all, creating a new health department would likely be expensive, and the split wouldn’t be official until July 2021, whereas restructuring could occur much sooner.
To Jennifer Ludwig, such a setup would not be a “win” at all.
“We are not set up to do contract-for-services. That's just not our business model,” said Ludwig, who is the deputy director of the Tri-County Health Department. “Being a three-county health department, there's a lot of economies of scale. We have one public health director that covers all three counties. It's cost effective...When you have one county or only two counties the cost per person goes up.”
She’s rooting for a different option: That the health department sticks together, with its usual board of health setup, but with a tweak to the bylaws that would give county commissioners a chance to counter a public health order if they think it would harm their residents, or if they can give evidence showing it’s unnecessary for their residents.
She said this pandemic has really yanked public health out of its happy place.
“What's happening here is not unique,” said Ludwig. “Nobody had ever seen public health in the light. We're always in the background. If you don't see us, we’re doing a good job. [The pandemic] put public health in the limelight front and center in the best — and worst — possible way.”
Ludwig said if Douglas County broke off, that would have a huge impact on their ability to respond to the pandemic, and she’s already spent too much time on this — including responding to employees worried about potential layoffs, and wondering how long the department will be able to retain the 125 contact tracers they just hired, let alone how they’d distribute a future COVID-19 vaccine if they’re a county short of funding.
“My time has absolutely been pulled from the pandemic to focus on this," she said. "And if we were to lose staff, even if it's next summer, we will still be in the middle of a response.”
Ludwig and her colleagues are rooting for the marriage to make it, so they can get back to work and public health can go back to being invisible.
This story was produced by the Mountain West News Bureau, a collaboration between Wyoming Public Media, Boise State Public Radio in Idaho, KUNR in Nevada, the O'Connor Center for the Rocky Mountain West in Montana, KUNC in Colorado, KUNM in New Mexico, with support from affiliate stations across the region. Funding for the Mountain West News Bureau is provided in part by the Corporation for Public Broadcasting.