When a novel strain of influenza swept across the U.S. in 2009 and made its way to Maine, infecting thousands and causing outbreaks at 40 summer camps and 200 schools, 50 nurses employed by the state got to work.
Maine’s public health nurses helped to set up and staff 238 vaccination clinics across the state. They helped school nurses vaccinate students, and ensured vaccines were effectively distributed and safely stored. They educated others charged with vaccinating at-risk populations. With public health nurses’ help, Maine managed to vaccinate children and seniors — the populations deemed at greatest risk — at some of the highest rates in the nation.
“We were people with boots on the ground,” said Janet Morrissette, who served as the state’s public health nursing director at the time.
Since then, the number of public health nurses has been cut in half.
The remaining 25 nurses working in the field face a long list of public health duties: visiting expectant and new mothers in their homes, especially mothers with drug-affected babies; training local health-care providers on tuberculosis detection and vaccine storage; carrying out immunization clinics as needed; monitoring treatment for those infected with tuberculosis or latent TB; and contributing to emergency preparedness in Maine’s nine public health districts. Two other nurses work in administrative roles, handling referrals to nurses working in the field.
“I’m really worried, should something like [the H1N1 outbreak] happen now, where’s the public health workforce that’s going to be able to mount that response?” said Morrissette, who served as public health nursing program director from 2005 to 2011.
Maine’s public health nurses have been around since the 1920s, when their primary mission was to improve prenatal health among expectant mothers and prevent infant deaths. They were some of the first employees of the state’s Division of Public Health, which evolved into today’s Center for Disease Control and Prevention. Unlike most classes of state employees, their responsibilities are defined in state law.
But the number of public health nurses has steadily declined over the course of Gov. Paul LePage’s administration, even as legislators have provided funding for the positions in the state budget. The state has filled few of the more than 20 vacancies that have come up in recent years, leaving key population centers and rural areas with scant coverage.
Plus, at a time when Maine’s infant mortality rate has risen to 13th highest in the nation and more babies are born exposed to substances, the Maine CDC has shifted many of the nurses’ duties away from promoting maternal and child health and promoting the public’s health in general.
Documents obtained by the BDN, interviews with former employees, and CDC staffing charts from various points in time over the past 12 years paint a picture of a key public health program whose operations the LePage administration has largely hobbled.
State health officials have claimed internally and, on occasion, publicly to be reallocating “limited” resources to the people and areas who need them, “structuring the duties of public health nurses to ensure work is at the highest and best use of nursing scope of practice” and “aligning resources to meet priorities.”
But the disappearance of much of the state’s workforce charged with controlling the transmission of communicable diseases, promoting maternal and child health, and carrying out school health screenings has largely happened without publicity from the state, much less a broader explanation of the LePage administration’s ultimate plans for the program.
“I think this was looking at health care as a business, and it wasn’t profitable to have all these nurses,” said Ted Hensley, who served as public health nursing director from September 2012 until he resigned in March. “I think it was all money-saving. It was all about money, not providing health care.”
A Maine CDC spokesman didn’t respond to repeated requests for comment from the BDN.
Across the country, public health nurses typically form the largest segment of the professional public health workforce — whether they’re employed by state or county governments — according to the Association of Public Health Nurses.
Unlike nurses who care for individual patients, public health nurses focus on the health of populations. Traditionally, they pay particularly close attention to the health of newborns and their mothers. In Maine, about 30 percent of state public health nursing positions are funded by the federal Maternal and Child Health Block Grant.
Public health nurses visit expectant and new mothers at home — free of charge and regardless of income level — to help new parents settle into parenthood. They screen mothers for postpartum depression. They monitor and address potential health problems with a newborn, often connecting parents and infants with services in their community.
As certified lactation consultants, they help new mothers become accustomed with breastfeeding and address related medical problems such as thrush, a fungal infection that can develop in babies’ mouths, or the breast tissue infection mastitis. Nurses assess the home environment to help parents address safety issues. A public health nurse is also on the lookout for signs of abuse, neglect and family violence.
“You never knew” what to expect, said a public health nurse who left her job recently and spoke on the condition of anonymity. “If you went to a house where it was winter and there was no heat, or someone felt threatened, or there were active problems going on, people weren’t safe, that would take priority. That was our goal, that moms and the babies would feel safe.”
When refugees arrive in Maine, Catholic Charities — the state’s designated resettlement agency — refers the new arrivals to public health nurses in the Lewiston and Portland areas, who then examine the refugees’ health records and connect them with health care providers.
And when a patient has either active or latent tuberculosis, health care providers alert a local public health nurse, who then visits the patient at home to ensure he or she is taking the required medications, handling side effects and not showing signs of liver injury — a risk with anti-TB medications. With an active tuberculosis case, a public health nurse can also be responsible for a contact investigation: getting in touch with the people with whom the patient has had contact and testing them for TB, which is easily spread.
For a patient with latent tuberculosis, which has a 5 to 10 percent chance of developing into full-fledged TB, public health nurses visit monthly for nine months, said Ronnie Paradis, who worked 10 years as a public health nurse in Lewiston until retiring in June 2015.
There were 18 confirmed TB cases in Maine last year, including two that were drug-resistant, according to the CDC, and eight contact investigations that involved 241 contacts.
“As far as TB was concerned, if they had active TB, we would go daily and watch them swallow the pills, except for weekends and holidays,” Paradis said. “We had to watch them. With the TB meds, they were usually on at least four meds. There were a lot of side effects. We would communicate with the doctors all the time.”
When northern Maine saw a cluster of botulism cases in 2002, public health nurses connected with those who were infected and those at greatest risk of infection, helped them go through their food — as the poison is commonly spread through canned food — and collected samples for testing.
“They were the go-to people in the field on the ground,” said Jennifer Gunderman-King, who worked at the time as a Maine CDC infectious disease epidemiologist.
Whether it’s hepatitis, E. coli, salmonella, pertussis or Ebola, “when these things are reported and found, your public health nurses are the ones there who are making sure there’s adequate follow-up and containment of that kind of outbreak,” said Hensley.
That’s more difficult now with fewer nurses.
“We’re not living in as safe of a public health environment as we were several years ago,” Hensley said.
Erosion of the ranks
Annual reports dating back to 2004 show Maine’s public health nursing program consistently had 48 to 50 nurses in the field, four to five direct supervisors, four consultants involved with managing different aspects of the program, and one director. In 2004, the nurses were based out of 16 offices around the state. Most offices had staffers providing clerical support.
Maine CDC organizational charts obtained by the BDN show a program steadily shrinking over the past year-and-a-half. They also reflect the effects of the state budget that passed in June 2015, which eliminated seven nurse positions, two supervisor posts and one program consultant position — all vacant — as part of a larger elimination of vacant CDC positions.
An April 2016 organizational chart shows a scaled-back program with 43 nurse positions, but only 32 of them filled. Two of those nurses handled patient referrals and didn’t perform field work.
In the three months after that staffing chart came out, the BDN has found, five nurses departed, leaving a staff of 25 in the field (24.7 full-time equivalent positions), two nurses handling referrals, two supervisors, two management consultants and two office associates.
“This administration has been systematically decreasing our staffing and not filling positions when they become open,” Hensley wrote in an email. “Our ability to provide services has been compromised to have adequate boots on the ground and staff, to safely provide public health services.”
As director, Hensley said, he asked repeatedly for clearance to fill vacant posts.
“Basically, I was just told, ‘no,’ and I would request every week or every other week for those positions to be filled,” he said.
Demand without supply
The state’s public health nurses traditionally have filled in the health-care system’s gaps, providing maternal and child health services in rural areas where other services aren’t available and serving refugees in the Lewiston and Portland areas.
In the Bangor area, one full-time public health nurse and one part-time nurse cover a territory that includes Penobscot and Piscataquis counties and now, increasingly, Kennebec County. Before the current state budget took effect, the Bangor public health nursing office had six full-time nursing positions and one part-time position. (The city of Bangor separately employs two nurses who visit new and expectant mothers within city limits.)
Today, in the Lewiston area, three public health nurses cover a territory that stretches from Lewiston-Auburn through much of western Maine. Within the city of Lewiston, the nurses’ work largely involves TB treatment monitoring. In rural western Maine, nurses visit expectant and new mothers. The program’s Lewiston office previously had eight positions.
“We have people who can’t start their treatment for TB on time and can’t be monitored the way they need to be because there are no public health nurses available,” said Carolyn McNamara, a nurse practitioner at B Street Health Center in Lewiston, which is affiliated with St. Mary’s Health System.
“When it comes to active TB, they have to have all hands on deck, making sure that person takes their medication and is not in a position to transmit TB. That’s when it’s really emergent,” said McNamara, who estimates she has referred 600 patients to public health nurses over the past decade. “The potential that we could see a delay with that is very concerning.”
With Lewiston coverage limited, nurses based in the Augusta area are often called to Lewiston, said Rep. Gay Grant, a Gardiner Democrat who has advocated for the public health nursing program and who is in contact with nurses employed in the program.
“Right now, we have a 39 percent vacancy rate of trained public health nurses, and they’re stretched so thin they can barely keep up with their workload,” she said. “That’s without an emergency.”
The Portland area’s coverage is down to five public health nurses where it used to have eight. Another nurse is located in Sanford; Sanford used to have two.
Two nurses cover all of Washington County. Four cover Aroostook.
Public health nurses currently employed by the state declined to speak with the BDN, citing fear of retaliation, job loss or further damage to the program if they spoke out.
“Everyone is in fear — the climate and culture in Maine CDC,” Hensley said. “There was nothing but a culture of terror. Everyone was dancing to the tune of the commissioner’s office and afraid for their jobs.”
“Everything was secrecy, not transparency” as nurses watched the program shrink around them, Paradis said. “We didn’t know if we were going to be fired or let go or what. Everything was a secret. Nobody would tell us what they were doing.”
Target for cuts
The contraction of Maine’s public health nursing program has happened as a result of attrition rather than any mass layoff. But the LePage administration repeatedly has targeted the program for cuts.
In 2013, the governor’s Office of Policy and Management recommended cutting $500,000 from the program’s more than $3 million state-funded budget. Democratic lawmakers rejected those cuts and made up for a budget shortfall through other means in early 2014, said Rep. Peggy Rotundo, a Lewiston Democrat and House chair of the Legislature’s Appropriations Committee.
But even with the positions preserved in the budget, the LePage administration continued to leave vacant positions unfilled.
As 2014 drew to a close and flu season approached, Appropriations Committee members inquired about public health vacancies in writing on Nov. 13. “What is the Department’s plan to fill key vacancies at the CDC?” committee members asked of the Maine Department of Health and Human Services.
Health and Human Services Commissioner Mary Mayhew didn’t respond until Feb. 3, 2015. “The Department actively continues to seek qualified individuals for key public health vacancies,” she wrote. “While vacancies are being addressed, the CDC maintains a highly qualified staff of credentialed professionals who monitor infectious diseases and attend to other public health matters.”
When LePage presented his two-year budget proposal that winter, his administration proposed the elimination of seven vacant nurse positions, two supervisor positions and one program consultant.
“In our negotiations with Appropriations, we held onto them, we held onto them, we held onto them,” said Rotundo. “Then at the end of the budget process, when it became clear he would not fill those positions, we decided we would take the money” and put it elsewhere in the budget.
Even with seven vacant nursing positions eliminated, five nursing vacancies remained — and the number of vacancies has only grown since the budget passed more than a year ago.
“We’re supposed to believe that when we develop a budget or pass a law — a law, mind you — that that would be carried out,” said Grant, the Gardiner Democrat, who also serves on the Appropriations Committee. “That is not what we’re seeing, and we can’t do anything about it.”
The LePage administration has indicated on other occasions since that February 2015 communication to the Appropriations Committee that it planned to fill nursing vacancies, but it has rarely followed through.
On May 5, 2015, public health nursing managers were called to a meeting with CDC leadership and Sheryl Peavey, then the strategic reform coordinator in Mayhew’s office and now the CDC’s chief operating officer. They were given a memo that identified priorities for restructuring the program — a memo developed without input from nurses or their managers, according to Hensley, and after Maine DHHS leadership had already asked Hensley and his management team to devise restructuring strategies and paid “very little attention” to their suggestions.
“The data clearly shows that certain areas of the state have specific needs that require more staff resources,” the memo reads. “For example, nearly 20 percent of all babies born affected by substance were born in Bangor. But we did not adjust our service priorities to be sure those infants thrived.”
The memo also listed “filling vacancies to ensure appropriate staff levels” as a step for the program “moving forward.”
But neither change highlighted in the memo has happened. The Bangor area at the time had the equivalent of 5.7 full-time nursing positions. Today, the Bangor region has one full-time nurse and one part-time nurse doing field work. Nurses in that office have had coverage areas that stretch from Waterville to Lincoln.
Maine had 36.2 full-time equivalent public health nurses at the time of the May 2015 memo. Today, the program is down to 26.7 full-time equivalent nurses, including two who don’t work in the field.
The LePage administration did relent and hire last year when faced with public pressure from a Republican lawmaker.
On April 15, 2015, the Legislature’s Health and Human Services Committee held a public hearing on LD 1077, An Act to Ensure Access to Public Health Nursing Care and Child and Maternal Health Nursing Care in Washington County. The bill, sponsored by Sen. David Burns, R-Whiting, proposed to reallocate funds to provide for additional public health nursing capacity Down East.
“I have been told by the experts that we in Washington County have a very serious problem, in fact a crisis, in two specific areas,” Burns said in his testimony. “Washington County has only one public health nurse, and the county has been without any child and maternal nurses for the past four years.”
Indeed, the public health nursing program’s Calais office had long had two vacancies. The county’s only public health nurse was based in Machias in a rural county that covers 3,300 square miles.
“And having just come through one of the worst winters in decades, with the City of Eastport receiving over 14 feet of snow, can you imagine what travel has been like for our one public health care nurse?” Burns continued.
The Maine CDC’s then-director, Ken Albert, delivered testimony opposing the bill, but said, “We can commit to more aggressively assuring that our vacancies are filled in the Washington County area.”
The state budget that passed two months later eliminated one of the Calais office’s two positions, both vacant. But the CDC later filled the remaining Calais post, a CDC organizational chart from late 2015 shows.
Shift in focus
Research has consistently found that sending a nurse into a new parent’s home is an effective intervention. Coaching from a nurse can reduce the likelihood of pregnancy complications, pre-term births, infant deaths, child abuse and other negative forces in a child’s life.
Research also has connected nurse coaching to improved language development among young children and improved cognitive and educational outcomes.
In South Carolina, Republican Gov. Nikki Haley earlier this year announced a $30 million expansion of nursing services for first-time mothers in rural areas with historically high infant death rates.
For much of its history, Maine’s public health nursing program was available to any mother and newborn, regardless of income and regardless of whether the family had special health needs.
But over time, public health nurses began to visit primarily those mothers with children at greater medical risk — premature and low-birthweight babies, babies with disabilities and developmental delays, and drug-affected babies, including babies born to mothers taking methadone to treat an addiction.
Even more recently, nurses have shifted to seeing more adult patients, particularly frequent users of Medicaid services.
In 2004, public health nurses spent more than 45 percent of their time on maternal and child health. Under the reorganization presented to public health nursing staff in May 2015, nurses were to spend just 26.4 percent of their time on maternal and child health — chiefly focusing on drug-affected babies and children with disabilities and developmental delays. Nurses would spend 48 percent of their time on infectious disease, 11 percent on medically complex Medicaid cases, and 6.6 percent on elderly residents who are known to Adult Protective Services.
They were to spend 4 percent of their time on health promotion — essentially, the work of helping communities improve public health.
“We were getting more into adults and less into maternal and child health because that was more Maine Families territory,” said the nurse who spoke on condition of anonymity.
While public health nursing has been available for almost a century, the home visiting program Maine Families has evolved over the past 20 years into a statewide program that employs certified parent educators throughout the state to visit new parents at home. They can perform parent education, but they lack the training a nurse has to detect or address medical needs.
‘Compromised and decimated’
The loss of nurses isn’t the only factor to interfere with public health nursing operations. A number of program policies complicated program operations.
— For most of his tenure as director, Hensley was barred from communicating with his staff via email without approval from Chase Martin and Peavey in the DHHS commissioner’s office. “They would approve on one hand and on the other hand, would disapprove,” Hensley said. “It essentially interfered with my ability to do business and work with the program.”
— After the May 2015 restructuring meeting, the public health nursing program closed many of its regional offices — which were located in regional DHHS offices — and started dispatching nurses from home. Maine CDC also dropped most public health nursing administrative support staff, leaving more paperwork for nurses to complete, mostly in their cars since they no longer had desks, according to Hensley and former nurses.
“Public health nursing has always been an independent and an individual job,” said the former nurse who spoke anonymously. “That made it even more so: not having a supervisor as a sounding board, more paperwork, more expectations, more responsibilities and more challenging responsibilities, and fewer staff.”
— A blanket ban on texting among DHHS employees meant that public health nurses couldn’t communicate with clients using the medium that many of them used exclusively. “We lobbied for getting it back,” Hensley said, but nurses still didn’t have the ability when he resigned.
— For a program trying to get the word out to potential clients — namely, new mothers — DHHS leadership ordered public health nursing to remove its program brochures from circulation, Hensley said. And due to reduced staffing, public health nursing could no longer afford for nurses to spend time as ambassadors for the program, explaining their services to local health care providers and how and when to make referrals.
— In another sign of its contraction, the public health nursing program’s accreditation with the Community Health Accreditation Partner lapsed in 2015. The program first earned it in 2009 under Morrissette and renewed it in 2012. It was the only statewide public health nursing program to attain CHAP accreditation.
“Not all organizations achieve accreditation the first time around,” Morrissette said. “We did, with a commendation as well.” In 2012, Maine public health nursing renewed its accreditation “without a single ding,” Hensley said.
But in 2015, Hensley said, the program likely wouldn’t have met the required standards due to a diminished staff of public health nurses and few supervisors.
With the number of public health nurses continually on the decline, “the fact that they are an incredibly important resource for this state is not only not being recognized,” he said, “but is being completely compromised and decimated.”
Maine Focus is a journalism and community engagement initiative at the Bangor Daily News.