How a hand-tied local health department is keeping up the fight against COVID-19

GREAT FALLS — Bowen Trystianson enjoys solving puzzles. These days, that proclivity is a good fit for his job.

Like many health officials in Montana fighting the COVID-19 pandemic, and trying to convince the public to help, deputy health officer Trystianson and his colleagues at the Cascade City-County Health Department are facing profound obstacles. In a community of more than 81,000 people, just about 46% of the eligible population has been inoculated against the virus. Among residents age 12 to 29, that statistic plummets to 28%. 

“I remember seeing that on a graphic that I get and I was like, ‘oh, cool,’” Trystianson said, followed by a sarcastic chuckle. “So yes, that is unfortunately very low.”

The knotty challenges facing the county’s health department are piled in no particular order. A slate of new state laws have seriously weakened the authority of local health officials. Department staffers are battling low morale. There’s widespread public skepticism and defiance about the available vaccines, despite their proven safety and efficacy. Misinformation continues to spread like weeds on social media. 

To be clear, Trystianson said, answering questions about public health is one of the most fulfilling parts of his job. He respects and even appreciates that Cascade County residents have stacks of questions they want answered before “everybody just jumps on board” with vaccines. 

“Their challenges are valid, their concerns are valid, and they do deserve answers,” Trystianson said. “What’s unique about this situation is that I have people who won’t necessarily believe the answer I give them.”

INFECTIONS INCREASE AS DENIAL PERSISTS

Cascade County does not have the lowest rates of vaccine uptake in Montana. Other counties, including neighboring Toole and Chouteau, report even smaller percentages on the state dashboard, with a similar drop-off for younger residents. 

The fact that Cascade County is average, located near the middle of Montana counties’ vaccination rates, remains a source of deep concern to its health care officials. As they explain, the median is not a happy place to be.

With less than half of the county’s eligible population vaccinated, the Delta variant is continuing to infect more people, said Trisha Gardner, health officer for the city-county health department. The vast majority of new cases are among unvaccinated residents.

“We are seeing this spreading in multiple different venues. Every place from workplace to family gatherings, barbecues, weddings, funerals,” Gardner said. “What we’ve found is that the people that are getting exposed had multiple opportunities to have an exposure.”

The most recent report from Benefis Hospital in Great Falls showed that the 28 patients hospitalized on Monday for COVID-19 took up a small but impactful portion of its total bed capacity. The motivation for Gardner and Trystianson’s work is that many of those hospitalizations could have been prevented if patients had received a vaccine and reduced their exposure.

“There’s a strong attempt to resume life as it had existed prior to the pandemic,” Trystianson said, referring to social events and gatherings that county residents are attending in droves. “I do understand people wanting to get back to normal. The only problem is that in order to do that, you have to overlook that things are still not normal. You have to ignore that risk.”

Oftentimes, awareness of risk emerges only after someone has started showing COVID-19 symptoms, or when their illness takes a turn for the worse, Trystianson said. That realization can be especially unpleasant for younger residents who consider themselves part of a low-risk population.

“My 20-to-40-year-olds kind of perceive themselves, like, ‘well, you know, people in my age range aren’t necessarily dying. So what does it matter? I’m going to have mild COVID. It’s not a big deal. It’s going to be fine,’” Trystianson said. “Then I’ll meet one of them in the clinic and they’ll have post-COVID syndrome. And they’re a little bummed about their choice. But hindsight is 20/20.”

‘BE WHERE THEY’RE AT’

Heading off preventable illness, death and regret among unvaccinated people requires local health employees to be in the right place at the right time. 

The goal, Trystianson said, is figuring out “how to be where they’re at” to offer the vaccine when it’s most convenient. That way, he said, “they don’t have to take an additional step to go get it.”

Critical to that strategy is making sure that people who are unconvinced about the vaccine can have their questions answered and then have immediate access to a shot. Despite the skepticism he often hears from Cascade County residents, Trystianson said he’s seen the approach work in real time.

When the department set up a vaccination site for nine days at the state fair in late July and early August, complete with a posterboard graphic outlining facts and fictions about vaccines, Trystianson recalled, some residents told him they had not gotten the vaccine out of fear that the shots would negatively affect their fertility, an idea that has gained traction despite being researched and debunked in recent months.

Trystianson said he explained how medical researchers have determined that theory to be false and, in doing so, convinced the women the vaccines were safe. 

“I gave them the vaccine right there,” he said. “They were on the fence until that point, and then after having that discussion, addressing their concerns, we gave the vaccine right there.”

There are still plenty of people who remain unconvinced about the safety and benefits of the shots, Trystianson said, many of whom have come to trust only limited sources for information about the vaccine, such as the anti-vaccination and anti-mask group America’s Frontline Doctors, which sells the parasite-fighting drug ivermectin to treat COVID-19, an unproven approach that Montana’s state health department recently warned against.

“I don’t have an issue with people continuing to question the vaccine. My issue is more when they won’t accept a fact-based answer. That becomes a hard thing to address,” Trystianson said. “And I’ve had that happen. I’ve had people tell me that where I’m getting my information from, regardless of the source, is somehow corrupted.” When that happens, he said, “I can’t convince that person.”

Figuring out who remains open to legitimate information, and who doesn’t, can be a time-consuming process. But the efforts at the state fair were not for nothing. After setting up a booth every day, the health department said, it vaccinated 124 people, more than half of whom were under the age of 40. 

REBUILDING TRUST

Even as the availability of vaccines has dramatically improved the toolbox for fighting the pandemic, Cascade health officials point to bills passed by the recent state Legislature as examples of new setbacks and blockades for local health departments.

Gardner highlighted a handful of bills supported by the Republican majority and signed by Gov. Greg Gianforte this spring. House Bill 702, which broadly prohibits discrimination or disparate treatment based on vaccine status; House Bill 121, which requires oversight and approval by local elected officials for any proposed public health department rules or regulations; and House Bill 257, which generally restricts local health departments from issuing fines and restrictions to businesses and customers, effectively gutting local mask mandates.

“I would say those are the big three that have really affected the authorities with public health,” Gardner said. “And, you know, addressing communicable diseases in particular.”

Without being able to ask someone their vaccination status, order someone to self-quarantine or isolate, require extra safety precautions for unvaccinated people, or mandate masks or proof of vaccination at businesses or public gatherings, Gardner said, much of the communication from the health department now comes in the form of recommendations.

“It’s disappointing, yes, from my perspective, because I don’t feel that there was ever a time that we overstepped our bounds with authorities,” Gardner said.

“I think there was a misperception of how we used that authority previously,” she said. “Even when we did mandates such as the mask mandate or different closures, our first goal was always, always education. We didn’t assign fees or fines to anybody.”

One of the ripple effects of the Legislature’s “additional restraints” on health departments, Gardner said, is that their communication, education and advice no longer carries the weight it did prior to the pandemic. Information coming from the department can only be effective when the community trusts the messenger. 

To that end, Cascade is shifting its public communication strategy. Starting this week, the department has revamped its partnership with other emergency responders, including Cascade County Disaster and Emergency Service, Great Falls Fire Rescue, and Great Falls Emergency Services, as well as local school districts, hospitals and other health care groups. The coalition’s mission is to share messages about how to fight the pandemic and ensure the public knows those statements have widespread support. 

“I think that’s the ultimate goal,” Gardner said, adding that many of the same community partners have been coordinating closely over the past year even if the public didn’t realize it. “Presenting that in a very unified voice and way to the community, I think, can help and just make a difference. It’s not just us alone.”

The coalition had its most recent meeting on Tuesday. A spokesman for the health department said the group’s first messaging focus will be to show appreciation for health care providers working to care for patients sick with COVID-19. 

COUNTERING MISINFORMATION

Even on days when the health department feels like it’s taking small steps forward, employees said, it’s critical to keep morale from crashing. As the months of pandemic living drag on and case counts surge again, Gardner said, it’s inevitable that local officials and health care workers can burn out.

“Even looking at something like fire season — it’s a season,” Gardner said. “This is a pandemic that we don’t know at all when it might end. And that uncertainty is a difficult thing, I think. For a lot of people, myself included. It takes its toll.”

Gardner’s strategies for retaining her current staff and protecting their well-being include creating better boundaries between work and home life and trying to curb staff from consistently working extra hours. In her personal life, Gardner said, she tries to stay off of Facebook as much as possible to avoid the stream of negative comments directed at the health department, public health strategies and the vaccines.

“It’s just not a good thing for me to go down that rabbit hole,” Gardner said. “You know, I check what I need to do and try to get off and avoid some of the more contentious pieces of it.”

Along with comments from supporters and people expressing appreciation for the health department’s work, the Cascade City-County Health Department Facebook page also draws plenty of ire from people who are opposed to the vaccines and the department’s efforts to distribute them. Responding with patience is sometimes easier said than done.

In a July 30 post promoting vaccine availability at the state fair, the health department offered a free wristband voucher for fair rides to anyone who got a shot. One commenter, out of more than 300, said the incentive and vaccination effort “reminds me of the eugenics programs during WWII,” suggesting the inoculations are deadly.

“Dude we offered to let people ride the Tilt-a-Whirl,” the department replied. “You can’t possibly compare those.”

Trystianson acknowledged the frustration he often feels about the vocal opposition the county is facing. He processes those emotions at home or with friends, he said, so when he comes back to work to answer more calls and find more answers for vaccine skeptics, he can continue to see those interactions as opportunities.

Most mornings, Trystianson said, he’s “not necessarily jumping out of bed” with excitement. “Snow White-style, having birds tweet all around my head while I get ready for the day,” he chuckled. “It’s not quite that magical.”

“Sometimes I require that shower and that cup of coffee to kind of reframe my head,” he continued. His ideal approach is “not to blame, not to just write people off, but to seek information and to see how I can actually improve it. And that’s usually what I come in here with. Just kind of a calmer determination to try to see if I can make things better.”

Asked what additional tools they could use to continue combatting the virus, Gardner and Trystianson both voiced the need for more staffing, including contact tracers and people to administer vaccines. But they also landed on a wish for the community: patience, understanding, and openness to learning about a rapidly evolving situation. 

“I hope the community knows that we are trying our best. We’re not trying to be frustrating, we’re not trying to kind of pull the rug out from underneath them,” Trystianson said. With the resources they have, he said, they’re working as hard as they can.