By Melanie Padgett Powers, writer
The South Dakota Public Health Laboratory is located in the very center of the state in the capital of Pierre. The city of only 14,000 is the second smallest state capital in the US (No. 1 is Montpelier, Vermont, with a population of 8,000.)
Driving east to Sioux Falls, the state’s largest city, can take three hours. Rapid City is nearly three hours in the opposite direction. And that’s when the roads are clear. In the winter, there might be a foot of snow on the ground or roads may be covered in ice—or both. Weather and distance are just two of the interconnected difficulties public health workers in the state face.
Most public health laboratories across the US share the same challenges, such as lack of sustained funding and worries over staff recruitment and retention. But laboratories in more rural areas and remote locations, or in large states with sparse populations, have their own unique set of challenges. These circumstances often necessitate ingenuity, independence and creativity.
Before Tim Southern, PhD, D (ABMM), became director of the South Dakota Public Health Laboratory in 2015, he worked in the Omaha, Nebraska, state laboratory though a fellowship with the American Society for Microbiology.
“There are as many people in Omaha as there are in the entire state of South Dakota,” Southern said. “And the rural nature of South Dakota really changes the dynamic of service delivery. In South Dakota, we are highly resource limited, and our laboratory is geographically in the center of the state, hours from our major urban centers.”
Resource limitations have made the laboratory staff “fiercely independent,” Southern said. “We cannot order the kinds of supplies that other laboratories might order and get next-day delivery.” In addition, the staff tends to make most of their buffers and media and service their own equipment. “It’s very difficult to get technicians in Pierre,” he said. “They either have to drive a long way or they have to fly through our local airport that only has two flights a day.”
“When you’re dealing with a small state with a geographically dispersed rural population, you make do with what you have,” said Michael W. Edwards, PhD, HCLD(ABB), director of the New Mexico Department of Health Scientific Laboratory Division. “You typically have less money than everyone else. You get less money from the [federal government], and if you want to be successful, you have to sort of punch above your weight class. You just find creative ways to make things happen.”
Finding a Way to Reach All Citizens
Scott Shone, PhD, HCLD(ABB), director of the North Carolina State Laboratory of Public Health, can relate to the need for creativity. While North Carolina might not be as sparse as South Dakota, the state has a diverse geography and some very rural locations. “Some of the places we serve have a sizable population living in unincorporated areas,” Shone said.
Shone spent the first 12 years of his career in the New Jersey Public Health and Environmental Laboratories (including a year as an APHL Emerging Infectious Diseases Research Fellow). The two laboratories differ in a variety of ways beyond the population and geography.
“They differ just in the way public health is structured and how different groups rely on state public health for public health services,” said Shone, who joined the laboratory as director in 2019. “North Carolina has a decentralized system, so the local health departments are critical in the decision making and the provision of services for their constituents. The state public health laboratory perspective is we are a service provider to those local health departments who know and address the unique needs of the populations they serve.”
This requires the public health laboratory to embrace flexibility, he said, particularly because the Outer Banks islands, the Triad that includes the capital city of Raleigh, and the Blue Ridge Mountain communities in the west don’t have the same needs.
With this in mind, last year the public health laboratory and the state’s Department of Administration (DOA) created a courier service specifically for the laboratory. Historically, the laboratory was required to use DOA as its mail service courier, but that service wasn’t designed to meet requirements by the Clinical Laboratory Improvement Amendments (CLIA) or the US Environmental Protection Agency (EPA), Shone said. Plus, DOA was concentrated on the center of the state, so the laboratory used UPS to reach the farthest parts of the state. But UPS didn’t visit every location every day, and specimens didn’t always arrive meeting regulatory testing requirements.
Shone’s team approached the DOA in 2021 to see how to improve the system. “My goal is that no matter where you live in the state of North Carolina, if you rely on your local health department for care that the state laboratory of public health is going to provide the best possible laboratory service we can,” Shone said.
The laboratory was approved to contract with a private courier for about 18 months, as DOA and the laboratory partnered to build the laboratory its own courier service, which launched in 2023. “It has been a great collaboration between different agencies of our state government,” Shone said.
Now, DOA medical courier service drivers visit 109 locations in 99 North Carolina counties every single workday. The drivers collect the clinical and environmental samples, store them properly during transit, and deliver them to the public health laboratory in Raleigh by 11 PM the same day.
“That allows us to ensure continuity of that sample quality to comply with CLIA and EPA and any other regulatory entities,” Shone said. “It’s been great, and having it be part of a state agency is very helpful because there is a shared mission to serve the citizens of North Carolina.”
Working with Underserved Communities
By definition, public health laboratories are a part of the larger public health mission to protect and improve the health of all people. This includes working with and for underserved communities, which in more rural areas of the country often means people with lower socioeconomic status. Rural residents across the US have lower incomes than those in urban areas, and rural areas have higher overall poverty rates, particularly among racial and ethnic minorities, according to the Medicaid and CHIP Payment and Access Commission (MACPAC).
Rural residents also tend to be older, poorer and sicker. Access to care barriers include a lack of health care specialists and reliable transportation that is often needed to drive long distances to seek out care, according to MACPAC.
In Montana, many hospitals lack laboratory resources to complete the testing needed. “A lot of the rural hospitals are critical access and provide limited services,” said Deborah Gibson, MPH, laboratory services bureau chief for the Montana Department of Public Health and Human Services Laboratory Services Bureau. “So at the state laboratory, we do try to provide support to fill the gaps.”
For example, she said, many of the hospitals and clinics only provide basic microbiology. “They rely heavily on rapid testing with limited or no culture-based testing available. We often receive those isolates and/or specimens for further testing and identification. We also provide a lot of confirmatory testing services.”
And while Montana has a courier service, it doesn’t reach the most remote northeastern parts of the state. “The courier service can hit about 80% of the state, but there’s still areas that are so far out there that they can’t even provide overnight service. So, we miss about 20% of the state,” Gibson said.
For those areas, the laboratory provides prepaid FedEx or UPS labels for overnight shipping. However, that still presents challenges—sometimes hospital staffers have to drive to a neighboring town that has FedEx or UPS service. And in Montana, “neighboring” might mean an hour’s drive away or more.
In states such as New Mexico and South Dakota, laboratory scientists work closely with the Indian Health Service (IHS), indigenous communities representing 23 tribes and independent tribal health clinics. Nearly 11% of the population in New Mexico is American Indian. Every state agency has a tribal liaison, Edwards explained. The relationship between the tribes and agencies is unique.
“It’s not like you’re dealing with a local jurisdiction; you’re dealing with this autonomous group of people that don’t necessarily fall within your jurisdiction. It’s about offering partnership and being there for them,” Edwards said. “They don’t have the resources that we might have, so it’s about offering our capacity as an extension of theirs and sharing data and sharing our laboratory services.”
In South Dakota, where about 8.5% of the population is American Indian, 1 in 11 residents is served by one of the state’s nine tribes, Southern said.
“We try to provide services to those communities by reinforcing the scientists that work and live in those communities,” Southern said. That has included hosting packaging and shipping classes so the tribal clinics can send the samples to the state public health laboratory. “We try to provide options for them so that they don’t have to send their samples out of state to other laboratories.” One of the laboratory’s goals, he said, is to provide the tribal communities the highest quality testing at the lowest price possible.
These partnerships are particularly vital when there’s a public health crisis. In 2016, one of the largest foodborne disease outbreaks in South Dakota was traced back to a meal service at a powwow, a traditional celebratory gathering that includes dancing and singing. A total of 112 cases were identified in the Salmonella outbreak.
While IHS took the lead on the response, the South Dakota Department of Health (SDDOH) provided support, according to an SDDOH presentation at the 2017 conference of Council of State and Territorial Epidemiologists. SDDOH provided outbreak investigation guidance, laboratory testing, data management, data analysis and traceback.
Recruiting and Retaining a Workforce
Recruiting for public health laboratories, especially for clinical microbiologists, is a challenge across the country—especially as state laboratories can rarely compete with salaries offered by private laboratories. But rural or more remote public health laboratories may face an additional burden, as they need to lure people to states and communities with seemingly fewer amenities and resources.
It may not seem like it would take much to lure people to Hawaii, but the state has its challenges, including the high cost of living and the remoteness from the rest of the US.
The Hawaii State Laboratories Division is headquartered on Oahu and has district health laboratories on three other islands: Hawaii, Kauai and Maui. Some of the communities on the smaller islands are quiet, remote and isolated.
“We have a problem with recruitment and retention for the district health laboratories on our neighbor islands and for the hospitals on those islands,” said Edward Desmond, PhD, Hawaii’s laboratory director and State Laboratories Division administrator.
In addition, he said, “It’s gotten worse since the pandemic. We have noticed that young people graduating from college would prefer a job where they can telework and where they get a good salary. And we can’t offer either those things in laboratory work.”
One program that could help with recruitment is the medical technology program at the University of Hawaii John A. Burns School of Medicine, he said. The program, which is the only undergraduate program in the School of Medicine, begins with a medical laboratory technician associate degree at a community college and culminates in a bachelor of science degree in medical technology. In addition, the State of Hawaii announced in September 2023 the new Healthcare Education Loan Repayment Program, which will pay off educational loans for health care professionals who stay in the state and work for at least two years. Laboratory professionals are eligible.
To build the pipeline even farther out, Desmond’s team is working with the nonprofit ClimbHI, which aims to inspire students in Hawaii to finish high school by teaching them about a variety of career paths. The laboratory team has participated in several ClimbHI job fairs, which often serve marginalized communities.
The Hawaii laboratory also has a partnership with a medical technology regulatory group in the Philippines, which provides expedited licensure in Hawaii for medical technology graduates who pass a board exam and work first in the Philippines for two years.
Still, the public health laboratory is competing with private laboratories. But Desmond pointed out, “the new kid on the block” at a private laboratory might be assigned to work evenings and weekends. “We’ve got a Monday to Friday schedule that seems to be attractive to people who want a work-life balance,” he said. “And we have a defined benefit plan, while the private sector has defined contribution plans with an unknown value at the time of retirement.”
And if that doesn’t sell someone, Desmond bragged that his laboratory building has the best view of any of the 50 state public health laboratories. The state laboratory is high on a ridge overlooking a spacious lawn with palm trees, a nearby forest and Pearl Harbor in the distance.
Finding the right employees to work in more remote or rural locations might take some extra work, but once they’re there, they often stay, these laboratory leaders said. In fact, it’s often the geography and outdoor offerings that appeal to people, Gibson said.
After the height of the COVID-19 pandemic, the Montana laboratory had vacancies for six clinical laboratory scientists out of a staff of about 50. They’re fully staffed again. “We’ve been really lucky recently to hire a few good people,” Gibson said, “and those people who are coming to us from out of state are interested in living in Montana. It’s great for people that love the outdoors.”
Gibson is one of those people. She has worked at the Montana laboratory for 26 years. She lived in Missoula, Montana, as a child, but her family moved around a lot due to military service. She graduated from high school in Oklahoma but knew she wanted to get back to Montana as soon as possible.
Now, when the workday is done, Gibson—who is an ultrarunner—changes clothes and slips on her running shoes. Instead of walking to the parking lot, she runs to a nearby forest trail. Once in the mountains, she is surrounded by pines, with a gorgeous view of the Helena Valley in the distance.