Bob Swanson worked for 33 years to keep the people of Michigan safe from diseases that vaccines stop cold. He battled H1N1, inoculated soldiers against smallpox after 9/11 and curbed measles outbreaks.
He thought he had another few years in him, but COVID-19 burned through them.
As Michigan’s state immunization manager, Swanson’s COVID-19 days began with meetings before breakfast at 7:30 a.m. andwent through dinner. He’d grab food and return to the back bedroom he’d set up as his office and work until midnight. Seven days a week.
Finally, when his wife could no longer bear to see him working such punishing hours, he moved to the family’s summer cabin and worked there “almost totally isolated,” for months. He took off just three days in a year.
Then, like many other immunization managers around the country, he had enough.
Since the beginning of the pandemic, a third of the 64 people who oversee the nation’s vaccination programs have left. In the midst of the largest vaccination effort in the country’s history, the nation lost a staggering amount of institutional knowledge.
The turnover includes 14 who quit, four who were promoted and six who retired, most earlier than planned – 24 in all.
The yearly turnover is typically 10 people, said Claire Hannan, executive director of the Association of Immunization Managers.
“The retirement rate is double the usual,” she said.
Swanson promised himself he’d get 50% of Michigan’s population vaccinated with at least one dose of COVID-19 vaccine before he left. He made it, barely.
“That happened the day before I retired, on April 30th,” he said.
There are many reasons people are leaving the field, including exhaustion, new opportunities and, at times, frustration with the politicization of a once straightforward public health effort.
“It’s sobering to say there are a lot of new people who have never been through a normal year,” said Hannan. “Now they’re having to deal with a crisis while still turning in their grants, writing their annual reports and submitting their data.”
In the United States, immunization managers are the backbone of the nation’s vaccination system.Among their responsibilities are making sure every child in the U.S. gets four doses of polio vaccine between the age of two months and six years, keeping the debilitating childhood disease eradicated here since 1979.
“These people are why there aren’t measles every day. They epitomize the invisibility of public health – there’s a lot of work being done but not a lot of appreciation,” said Dr. Joshua Sharfstein, an expert in health policy at Johns Hopkins Bloomberg School of Public Health.
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Little known before COVID-19, the thinning of their ranks after a harrowing year is not unexpected but it is worrisome, said Dr. Walter Orenstein, director of the Emory University Vaccine Center and a 26-year veteran of the immunization Program at the Centers for Disease Control and Prevention.
Vaccination is about relationships, some of them built up over years. Immunization managers know their state and county health officials and community leaders, working for years and sometimes decades to stop diseases like whooping cough, rubella, diphtheria, measles and mumps.
Those relationships come into play during outbreaks and proved invaluable during COVID-19 when outreach was crucial, he said.
“What works and what doesn’t work in each community may be somewhat different,” said Orenstein. “That’s why it’s so important to have people at the state and community level who have experience.”
‘It just wasn’t sustainable for my family’
When she thinks about the past 18 months, Christine Finley has trouble believing everything that happened.
In fall 2020, her team was trying to get ready for COVID-19 vaccines, though nobody thought they would come as quickly as they did.
When the vaccines did arrive, the demands were instant and sometimes seemingly impossible, said Finley, who stepped down as Vermont’s immunization program director in June.
The CDC wanted data on every shot administered within 48 hours. In Vermont, “we had pharmacies that send in their data once a month,” she said.
Each week was a scramble. On Tuesdays, states found out what their maximum vaccine allocation was from the federal government. Their orders were due Thursday, making it difficult to plan vaccination events further than a week out.
They dealt with ultra-cold storage requirements, distribution issues and questions about who would get vaccinated when.
Some people wanted to be first in line, others flat refused. In January, anti-vaccine protesters shut down one of the nation’s largest vaccination sites at Dodger Stadium in Los Angeles.
In Vermont, staff took as many as 800 calls a day from people desperate to get the shot. “They’d tell you, ‘Do you understand what you’re doing to my family and my children?’” Finley said.
The pressure was compounded by the increasing politicization of COVID-19 and near-constant changes.
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“It became very political,” said Finley. “One of my friends said, ‘Within the past four weeks, I’ve had four people above me in leadership.’”
Communication was complex. On Tuesdays, the Trump Administration had a standing meeting with state governors where important information about the vaccine rollout was provided. The governors would then go before the media to pass along the news – often bypassing immunization programs entirely.
“They would be out saying things on TV we didn’t know. We literally had to have somebody assigned to watch the press conferences so we could bring the information back to the public health department,” Finley said.
By June, she’d had enough.
“It just wasn’t sustainable for my family,” she said. “You could be on six to eight hours of calls just with CDC every week. Then you had to work with your staff. There was just no way around a 12-hour day.”
Finley plans to go back to her original job as a nurse. But she still sees the last year and a half as one of the most important things she’s ever done. As of this week, 74% of Vermont’s population is vaccinated.
For now, she’s enjoying being between jobs. “I said to my husband, ‘I can’t believe that I won’t wake up at 3 a.m. worried about something.’”
‘I knew I was truly impacting people’s lives’
Being a state immunization manager is something of a calling, said Michigan’s Swanson.
“I knew I was truly impacting people’s lives, that we saved lives,” he said. “We’re dedicated to what we do.”
That dedication extends to helping others in the field. Through the Association of Immunization Managers, a robust system of mentorships and training allows new managers to learn the complexities of federal grants, national guidelines and requirements.
That system is already at work to bring new immunization managers up to speed, said Hannan.
The Association of Immunization Managers always held monthly general membership calls to share stories and pass along information. During the pandemic, the calls happened weekly and became a lifeline to many.
“We talked about how to handle the cold chain requirements. Where do you buy a dry ice maker? How do you write grants? What kind of staff are you hiring? How do you prioritize who gets vaccine first?” said Molly Howell, North Dakota’s immunization manager.
She’s come to depend on those with even more years in the field and will miss the guidance of people like Swanson.
“The last year and a half honestly have been insane,” Howell said. “It wasn’t like all of this started when vaccines became available. We were already tapped out when we started planning for the vaccine.”
Actually, they were worn thin before the pandemic. In a state of 760,000, she had fewer than 10 staff members to oversee federal programs that provide free vaccines for children, do surveillance for outbreaks of vaccine-preventable diseases, track overall immunization rates for the state and run flu shots clinics and information campaigns for adults.
In the early part of the pandemic, her staff was pulled into contact tracing, responding to cases in long-term care facilities and staffing a hotline. Howell became the lead for her state’s child care response to COVID-19.
For now, Howell keeps her spirits up with small wins. Last week, she held an event at a mosque in Fargo and 34 people got vaccinated, and one of the state’s Native American tribes took out a mobile clinic and got 88 people vaccinated.
“That keeps you motivated,” she said. “Though then I see the deaths coming through from COVID and they’re younger and younger. That’s hard.”