Barbara Kovacs is surrounded.

The director of York city’s Bureau of Health runs a 21-person department that takes reports of new COVID-19 cases, calls each one, finds out who they’ve been in contact with while they were contagious, then calls each of those people and warns them.

The practice, known as contact tracing, is key to keeping a lid on the spread of COVID-19, health experts say.

But her jurisdiction covers only the city’s 5.2 square miles, which are smack in the middle of the county’s 900 square miles. And the county doesn’t have a department like hers.

York County can’t track contacts, and instead relies on the state Department of Health’s regional office — an operation that Kovacs said has one nurse and one clerical worker, a staffing level far too small to perform the level of contact tracing experts say is needed.

“We are an island,” Kovacs said.

Four in 10 Pennsylvanians live within the jurisdiction of a county or municipal health department, but there are only 10 such departments in the state — six county and four municipal. They cover some of the state’s most densely populated areas, but are surrounded, like York city is, by counties that rely on a state health infrastructure that’s been thinned out by years of budget cuts.

“They don’t have contact tracing or anything like that,” Kovacs said.

Pennsylvania Health Secretary Dr. Rachel Levine announced Friday that although contact tracing had been halted when the department became overwhelmed by the increasing caseload, it is restarting in the 24 counties Gov. Wolf has authorized to tentatively reopen on May 8. Contact tracers will come from state personnel, local health systems, public health students, volunteers and, where necessary, new hires, she said.

Each of the state’s 67 counties and more than 2,500 municipalities have taken their own approaches to public health, creating a fragmented infrastructure.

Like the shortage of testing kits, this patchwork of capabilities poses significant challenges for Pennsylvania as its businesses and institutions try to safely reopen. While one person might be warned they’ve been exposed to the virus, a neighbor living just across a county or city line might not figure it out until they’ve carried — and spread — the disease for days.

Kovacs’ department, for example, has tied more than 40 percent of the city’s cases to places outside city limits.

“We’re trying to deal with that —How do we address that employer? —because they’re not in our jurisdiction,” she said.

Without any actual authority over businesses and institutions outside her city, Kovacs can only notify the facility and send a fact sheet she developed.

Early warning

Areas of the state covered by local health departments began mobilizing for the COVID-19 outbreak far earlier than their counterparts, and have attacked the virus’ spread more aggressively, an LNP | LancasterOnline review found.

Chester County, like most places with a local health department, began mobilizing in January, according to county commissioners spokeswoman Rebecca Brain. Neighboring Lancaster County didn’t start until early March, when warnings from Washington, D.C., and Harrisburg became more dire, said Josh Parsons, chairman of Lancaster County’s board of commissioners.

Even if Lancaster County officials had started earlier, in some key ways they would’ve been years behind counties and cities with health departments.

Some of the largest — Philadelphia, Allegheny County and Chester County — developed pandemic plans in the mid-2000s, and drilled on them regularly, officials there said.

Philadelphia’s health department, for instance, began planning a pandemic flu response after the SARS outbreak in 2003. The department updates its plan every three years, incorporating what the medical community learns from major outbreaks such as H1N1 in 2009, Ebola in 2014 and Zika in 2015, said Dr. Steven Alles, director of the Philadelphia Health Department’s disease control division.

“We have treated this as a serious risk for a long time,” Alles said.

Alles’ 180-person division within the health department began tracking potentially exposed residents more than a month before the state identified its first infection.

When the United States announced its first case, in Washington on Jan. 23, county health departments like his began receiving airline passenger manifests from the federal government showing which of their residents had been to China during the outbreak. Within three days, Philadelphia had about 100 names, Alles said.

Contact tracing

Local health departments — and, specifically, their infectious disease experts — can shape policy, marshal government and private-sector resources and prepare emergency managers for what’s coming.

The asset they bring, however, might be the telephone.

When the Allegheny County Health Department learns of a new COVID-19 case, a contact tracer or case investigator calls to ask a series of questions. Among the most important: Who were they close to (within 6 feet for several minutes) from the time of the call through the 48 hours before they felt their first symptoms.

Medical experts see that two-day, pre-illness window as critical to the virus’ spread. During that 48 hours, those infected begin shedding the bug, in a sense becoming public transportation for the virus two days before they get the first hint they’re carrying it.

Once Allegheny County has the names of those who had contact with the infected, tracers call them to warn them that they’ve been exposed.

Not might have been. Were.

“It feels personal to that person. ‘I have been exposed.’ And we think that keeps people following the instructions a little more closely,” said Dr. Debra Bogen, the director of Allegheny County’s health department.

Those instructions include self-quarantining. As of mid-April, the health department had asked more than 1,100 people who’d been exposed to the virus to stay home and watch for symptoms. That was 200 more than the total confirmed cases in the county at that point, all people who could’ve been carrying the bug through the state’s second-most-populous county.

“Everyone’s really paying attention to the fact that people shouldn’t go out if they’re sick, but it’s those two days before you become sick where you may be spreading the virus,” Brink said. “That’s where the contact tracing really does put a lid on those possible exposures.”

States around the country are trying to rapidly scale up their contact tracing capacity. Rep. Dan Frankel, D-Pittsburgh, plans to introduce a bill to fund at least 500 case investigators and more than 1,000 contact tracers at the state Health Department.

Allegheny County offers another route. Its health department enlisted about 30 fourth-year medical students who had enrolled in a public health elective at the University of Pittsburgh Medical School. The students had gone through clinical rotations, giving them some experience dealing with patients and the rigors of a clinical operation.

Several other medical schools have gotten in touch with the students, asking how to replicate what’s being done in Pittsburgh elsewhere, said Carly O’Connor-Terry, a fourth-year student and one of the case investigators.

“I think med students are a pretty important resources for this, just because there is some expertise that goes with interviewing someone — especially on the phone, especially during a pandemic,” O’Connor-Terry said.

The conversations are a delicately balanced combination of investigation, education and emotional support.

“I’ve been surprised by how those skills have been showing up again,” she said.

Endgame

Case numbers show that having a health department doesn’t equate to a lower infection rate. Regression analyses by The Caucus, a publication of LNP Media Group, show a county’s population density and proximity to New York City, long the epicenter of the country’s outbreak, are factors also closely associated with the virus’ spread.

“Anyone can drive from New York City to Philadelphia, and we’d never know about it,” Alles said.

But three similarly sized, adjacent counties offer some evidence that they do have an effect. Delaware, Chester and Lancaster counties have populations between 522,000 and 565,000. The former two border Philadelphia, epicenter of Pennsylvania’s outbreak. Only Chester has a health department.

Chester’s rate of infections per 100,000 residents is significantly lower than its neighbors, at 189. Lancaster’s rate is 250 per 100,000 and Delaware’s is a whopping 514.

It might not make sense for small, rural counties with limited resources and a diffuse population to create a health department, Alles said. “But there are counties in our state that I think don’t have sufficient public health infrastructure. Delaware County, my neighbor to the south, doesn’t have a county health department. It shouldn’t be that way. That’s 500,000 people, and they have to rely on state resources that aren’t even based in Delaware County; they’re based in Reading.”

In Parsons’ four years as a Lancaster County commissioner, the idea of creating a health department “never came up,” he said. They’ve relied on emergency managers during the crisis, and have been coordinating their response with the county’s three health care systems, he said.

Before Parsons’ time, however, Lancaster County saw several failed efforts to create a health department, which the state authorized counties to do in 1951. In 1967, a campaign driven by community groups got the question on the ballot, but the measure failed after the Republican Party urged voters to reject it. Members of Lancaster’s medical community drove another unsuccessful attempt in 2004.

When the crisis passes, however, “I’m sure we’re going to have that discussion,” Parsons said.

Health departments have already started planning for society’s eventual reopening, grappling with questions that haven’t yet made it into the broader public debate but could soon be the difference between life and death.

Take reopening schools, Alles said. Should children and teachers have to wear masks? Should kids with chronic conditions go? How do you maintain social distancing on a school bus?

“I just gave you one setting,” Alles said. Retail, restaurants, public transportation — every sector that reopens will have its own set of challenges, he said.

The pandemic’s scale has thrust Alles and his colleagues into the center of public policy and safety, but they’ve been in the background for, in some places, decades.

Even contact tracing — an idea new to most people — is a routine part of their job. If a measles case pops up in Philadelphia, for instance, Alles’ team calls everyone who shared the doctor’s waiting room with that person, often shocking those they contact.

“People are so surprised because nobody knows we exist,” Alles said. “Something like this is so big, we’re now at the forefront and people are paying attention. That’s good for us because we are important and we do work every day.”

which Pa. counties and municipalities have their own health departments file map

This map from spring 2020 shows which six counties and four municipalities in Pennsylvania have their own local departments of health. A list with links to the departments is here. Additionally, leaders of the counties announced in mid-March 2020 that at their request, the state Department of Health, had agreed to let Chester take the lead on Delaware's COVID-19 public health response, as Delaware did not have its own local department of health.