Health districts in Virginia.

As COVID-19 continues to surge in Southwest Virginia almost two years into the pandemic, the region’s three westernmost health districts remain without a full-time health director. Because the Virginia Department of Health (VDH) has been unable to fill the vacancies opened by retired or departing directors, Dr. Noelle Bissell, who is in charge of the New River Health District, has also taken on the leadership roles – in acting capacity – of the Mount Rogers, Cumberland Plateau and Lenowisco districts, the latter being more than 150 miles from Radford, where Bissell is based. 

Dr. Noelle Bissell, director of one health district and interim director of three others.

For the affected districts, the lack of a locally based health director first and foremost can result in a disconnect from the community, local health officials say. “Every time you stretch out one individual over a large area, even the best technology will never replace the opportunity for folks to talk on the ground and get a feeling for what’s going on,” said Beth O’Connor, executive director of the Virginia Rural Health Association (VRHA), a statewide organization based in Blacksburg. 

Historically, all of Southwest Virginia’s health districts always had one director overseeing each district. But in 2016, Dr. Sue Cantrell, since 1991 the director of the Lenowisco Health District, was also named the permanent director of the Cumberland Plateau district, where she had served on an interim basis for several years. 

When Cantrell retired in 2020, Dr. Karen Shelton, health director of Mount Rogers, was placed as the acting director over the entire region. Shelton left in July after accepting a job at Ballad Health, and Bissell, the health director of the New River Health District, stepped in to take on all three districts, in addition to her own. “In that time, the VDH has failed to fill any of those positions, and we have seen this gradual transition from four to one health director,” O’Connor said.

Beth O’Connor of the Virginia Rural Health Association.

So why has the VDH been unable to fill these positions, especially in the midst of a global pandemic that has left almost 15,000 Virginians dead? Department officials say their ideal candidates are required to have advanced degrees in public health, healthcare management, business administration, or other related fields, in addition to prior experience with public health or population health services at the local, state or federal level. But what’s equally important is an interest in making a home in rural communities and understanding the way of life there – and candidates who can offer all of the above are not easy to find. 

“Most people really have to have a heart to do this, and I am hoping we can attract somebody,” said Teresa Tyson, president and CEO of The Health Wagon in Wise County, a nonprofit organization providing healthcare to the underserved and the oldest mobile clinic nationwide. “We were so blessed to have Dr. Cantrell, she was amazing and her shoes are hard to fill.” Tyson said that it is hard to recruit for a rural health director position from a pool of candidates seeking to work in larger urban areas. “People are more attracted to those metropolitan regions that have more to offer, but we have a lot of beauty and culture here in the Southwest, it’s the prettiest region of Virginia,” Tyson said.

Teresa Tyson of Health Wagon.

Bissell, the director for the New River Health District filling in for three additional districts, does not have a background serving rural communities, but she brought with her a wide array of other qualifications. A native of the Baltimore area, Bissell received her Bachelor of Science degree in Electrical Engineering in 1986 from Johns Hopkins University, and her Doctor of Medicine degree in 1990 from the University of Maryland, followed by an internship and medical tour with the U. S. Navy, and was stationed in Iceland and Japan. After getting married, Bissell and her husband moved to San Diego, where she completed her internal medicine residency with Mercy Hospital/ University of California at San Diego. The couple relocated to the New River Valley in 2003 and has lived there since.

“To be a successful health director you have to engage with the community, you have to understand where people are coming from,” Bissell said in an interview Monday. “Obviously somebody who grew up in or who is from that community kind of has one leg up in that regard. But that doesn’t mean that somebody coming from outside the area can’t be successful, it’s just a matter of coming in and meeting everybody and establishing those relationships. If someone is aware of what the unique challenges are they will be successful,” she said. 

Virginia was already more than one year into the pandemic when Bissell took over three additional health districts at a time when the state’s Southwest had been hit the hardest by the spread of the novel coronavirus. And in much of the region, the new infection rate currently is well over 200 new cases per 100,000 residents and, in some places, well over 300 per 100,000. Wise County and Buena Vista top the list with 420 and 602 new infections. While public health officials say those numbers are slowly declining, at least for now, they remain more than double the statewide averages, according to new data released earlier this week. 

But Bissell said that there is no correlation between the COVID-19 surge and her overseeing a much larger area than any other health director in Virginia. “It’s no secret that the more rural areas of the state have lower vaccination rates in general than the urban areas. There is also a lot that follows along political lines as well,” she said. “While it is challenging to provide supervision from afar, I got local folks who are right there on the frontlines just like I am here with my staff.” 

Bissell said that she has “very sound leadership teams” in all four districts, from business managers and nursing supervisors to environmental health experts and public relations specialists. She is coordinating the region’s pandemic response mostly by phone and on Zoom calls, and is checking in on a regular basis with the boards of supervisors, community partners and school officials. “In the New River district we were doing weekly superintendent calls, and when I took over the rest of Southwest Virginia we just invited all of them,” Bissell said. “We now have 21 jurisdictions on our weekly call, where we have time to discuss how things are going and how people are doing things, what the challenges are and how we can address those, and it’s actually worked very well.”

Parham Jaberi

Yet, Dr. Parham Jaberi, the chief deputy commissioner for Public Health and Preparedness at the VDH, acknowledged that it “clearly is an unusual scenario” to have one health director overlook such a large area. Jaberi said that after the departures of prior health directors, initially “there wasn’t a lot of interest” among potential candidates to step in and fill these vacancies. “There were some physicians with a practice ongoing in urgent care settings or primary care that were looking at public health as something that they could do in addition to their practice, but it just wasn’t feasible, especially in the middle of a pandemic. So looking at who is available and able to come in and take on a large challenge, we were very limited,” Jaberi said in an interview Monday.

Hiring for positions in deeply rural areas has proven to be especially challenging, Jaberi added. “When you look at Southwest Virginia, it needs to be somebody who understands the community, it’s best to have someone who has practiced at least in a part of that area, so we can make sure that the public health director speaks the voice of that community,” Jaberi said. “You have to make sure the understanding, the approach and the philosophy matches, in addition to having the qualifications.” 

In the absence of health directors, the VDH has begun hiring chief operating officers without medical degrees. The agency has also taken a more aggressive approach and tasked a private recruitment firm to find qualified candidates nationwide and get them interested in coming to Virginia. 

“The challenge between the pandemic and between the fact that there aren’t many public or academic health programs turning out public health residents in that area forces us to look to recruit public health positions who were perhaps practicing not only in Virginia, Tennessee, and North Carolina, and that’s the direction we have taken,” Jaberi said. The VDH recently had a first round of interviews for the vacancies in the Lenowisco and Cumberland Plateau Health Districts, Jaberi added. “I acknowledge that without a full time director, somebody else is going to pick up the bill, whether it is the staff or the neighboring health director,” he said.

Jaberi, too, underscored that despite the department’s staffing issues, the coronavirus surge in Southwest Virginia is unrelated to the additional strain put on the leadership of the region’s health districts. “The reason why we are seeing those higher rates of illness despite the vaccinations – and Southwest Virginia has one of the lowest vaccinations rates in the commonwealth – is that we know that if your communities aren’t vaccinated, then you are prone to illness, and if you’re prone to illness you’re prone to hospitalizations and death,” Jaberi said. “In order to prevent the pandemic from getting worse, certainly we want to have competent and capable public health professionals. But the way to get ahead in a pandemic, in addition to having a robust public staff, is for individuals to simply get vaccinated,” he said.

Jaberi hopes that his department’s efforts will continue as the new administration under Gov.-elect Glenn Youngkin steps in. While he said that he has not been part of conversations with Youngkin’s transition team, “we expect these to occur over the next several weeks.” 

A spokeswoman for Youngkin on Tuesday declined to comment, but provided a transcript of a Q&A hosted by the AARP in September, where Youngkin vowed to prepare Virginia for future pandemics and address the need for healthcare professionals. “We have a massive shortage in staffing, and we need to reevaluate how we are recruiting and training people into this profession,” Youngkin said. 

O’Connor, the executive director of the VRHA, said that instead of focusing on recruiting healthcare professionals from areas outside of Southwest Virginia, the state and localities needed to invest locally to address the shortage of qualified candidates. “We need to think about what we are doing now to encourage our young people to think about healthcare careers,” she said. “What is Virginia doing to encourage these kids? Healthcare should be on top of every jobs wantlist, it’s a well paid profession with job security and that is needed in every rural community.” 

The VRHA is currently working with the Claude Moore Charitable Foundation, which helps provide and expand educational opportunities for underprivileged youth, to look at “what needs to be done to address these gaps, whether it’s doing more to encourage middle schoolers to think about healthcare as a career or scholarship,” O’Connor said. “We need to think very hard about how we address these issues. Especially since the population in Southwest Virginia continues to age, we’ve got to have competent people in these positions to address our public health needs,” she said.

Markus Schmidt

Markus Schmidt is a reporter for Cardinal News. Reach him at markus@cardinalnews.org.