When Sandra Robinson started working as a public health nurse for the City of Chicago in 1986, she was one of about 200 full-time nurses.

Back then, the city’s health department oversaw a network of more than 30 clinics scattered across the city. They provided primary and mental health care to low-income and uninsured people — services that are now largely provided or covered by federally qualified health centers, community health centers and the Affordable Care Act. 

Over time, Robinson said she started to notice a shift: the city appeared to be investing less money in public health and transitioning away from direct care.

“Eventually you knew it was all going to go,” she said.

In 2009, Mayor Richard M. Daley began closing several city run clinics, blaming the state for a lack of funds. Soon after, in 2012, Mayor Rahm Emanuel consolidated the remaining 12 mental health clinics down to six, saying it was more cost effective to partner with nonprofits and federal health centers.

By the time Robinson retired in the summer of 2019, she was one of only 40 full-time public health nurses serving the most vulnerable.

And then the pandemic hit.

“And it was all hands on deck, but the only hands was 40 (nurses) or less than that,” Robinson said. “Now mind you, we had told them a year in advance, ‘We are out of here. June 2019. What are you going to do? How are you preparing?’”

Faced with critical staffing needs at the health department, the city did what it had been doing for years when it did not have enough nurses or clinical staff to handle the work that’s usually done by full-time public health nurses like Robinson.

It contracted the work out with a for-profit medical temp agency. This time it was one based out of Florida called Sunbelt Staffing.

The city awarded a four-year, $4.9 million contract to Sunbelt in 2019, a year after it issued an open request for proposals seeking temporary medical services for various federally funded health programs and initiatives. The contract is entirely funded through federal grants.

City Public Health Commissioner Alison Arwady said these kinds of contracts are standard — and even critical — when there’s a surge in need, like during a pandemic.

“The Sunbelt contract itself is really meant to be temporary workers. It’s not a replacement for permanent staff,” Arwady told WBEZ.

She said there are 16 nurse vacancies that the health department is currently trying to fill, but the onboarding process through the city takes a long time — even longer when new positions are created.

“And so we’ve used Sunbelt before COVID; we’ll use Sunbelt after COVID,” she said.

But in the months leading up to the pandemic, temp nurses from Sunbelt were filling timesheets for work that would have normally been done exclusively by public health nurses.

The health department relied on Sunbelt for its HIV and sexually transmitted diseases testing and prevention efforts, viral hepatitis testing, substance abuse program, and behavioral health services at neighborhood mental health centers. Those initiatives have continued during the pandemic.

Sunbelt nurses also conducted home visits for the city’s lead poison prevention program, an initiative funded through a grant from the Centers for Disease Control and Prevention to help Chicago test and identify children living in homes with high levels of lead in the water.

After the pandemic hit, the city relied on Sunbelt nurses and clinical staff to handle public outreach.This was in addition to emergency contracts the city entered into to staff the temporary hospital at McCormick Place.

Hundreds of temporary clinical workers hired through Sunbelt staffed city shelters, conducted telemedicine services, contact tracing, and even social media and neighborhood outreach.

The Chicago Police Department also relied on Sunbelt to provide nurses and telemedicine services. A CPD spokesperson said the city hired about half a dozen nurses to work exclusively with the department, handling testing, home visits and verifying workers compensation claims for 3,256 police officers. One nurse was still with the department as of July 8.

In the first week of June alone, the city paid Sunbelt more than $52,000 to staff nurses at Hotel Julian, a temporary shelter reserved for city employees who contracted coronavirus. Nurses were paid an hourly rate of $62.50, plus overtime, according to vouchers WBEZ received from an open records request.

With its existing contractual obligations and new pandemic-related expenses, the city paid Sunbelt more than $11 million since the contract began in 2019, more than twice it was budgeted for. The city spent $4.2 million in 2020 and $6.3 million for the first half of 2021. In March 2021 alone, when the city began mass distribution of the COVID-19 vaccine, the city paid $3.4 million to Sunbelt.

Increasing dependence on temp nurses

Chicago’s growing reliance on temp medical workers is part of a larger trend in the health care industry. While companies such as Sunbelt have played a huge role in filling critical staffing needs at public health departments and hospitals across the country during the pandemic, there was an increasing reliance on them well before COVID-19.

“Hospitals already use them so much,” said Julia Bartmes, the executive director of the Illinois Nurses Association. “And hospitals that don’t have unions … I mean they use them more and more and more.”

The reliance on agency nurses is controversial for union nurses. Fights over proper staffing levels tend to be the biggest issue in contract negotiations, Bartmes said. And the burden of training temp nurses falls largely on full-time staff, she added.

Agency nurses are paid by the hour and don’t receive benefits, making them a cheaper alternative in the short-run. And City of Chicago nurses are among the highest paid in the state of Illinois, another reason Bartmes thinks Chicago leaders may prefer the Sunbelt option.

“You know, they are trying to plug holes and the sad reality is that if they were properly staffed initially, they wouldn’t have to rely on the agency nurses and they would be relying on the people who have the expertise and experience,” she said.

Bartmes and Robinson have been working with aldermen in the Progressive Caucus who’ve been calling on Mayor Lori Lightfoot to invest in more full-time nurses. They say the city should use federal COVID-19 relief dollars to pay for it.

They also want the city to reopen the mental health clinics that were shuttered under Mayor Emanuel to address what they are calling a growing crisis caused by ongoing violence.

Robinson said rebuilding the old network of city-run clinics staffed by public health nurses is the only way the city is going to make real progress in addressing critical health needs — particularly when it comes to mental health.

“Nurses are in the community. They know what’s going on in that community — not because of something they heard or read but because they are in the trenches,” Robinson said. “But you need resources, you got to have places to send them.”

If the city had a more robust network of public health nurses, that possibly would have helped Chicago address equity issues that were heightened during the pandemic.

Instead, the city hired two Sunbelt temp workers to oversee its Protect Chicago Plus Program, a public health initiative to ensure vaccine equity; and one temp worker to conduct “Latinx Outreach,” according to public records obtained by WBEZ.

Robinson said the city was already in the business of mass inoculations well before the pandemic and would have benefited from having public health nurses at the table when it was devising its COVID-19 vaccination plan.

Between flu season and back-to-school meningitis shots, the city vaccinates thousands of people every fall. Before the pandemic, this was largely done by a roaming van of two to four nurses, depending on availability.

Arwady said the city is investing in more full-time nurses to address mental health, in addition to the existing vacancies they are trying to fill. But she said she doesn’t think going back to the old days of operating clinics is the role of the health department. 

“You know, the work we are doing tends to be more population level help. And often we are going out to people as opposed to staffing at a clinic and waiting for people to come to us,” she said.

Nationwide nursing shortage at critical levels

Besides, hiring more full-time nurses could be tough for the city. Not only has the pandemic intensified the demand for nurses and clinical support staff, the industry has been experiencing shortages across the country.

Joel Shalowitz, an adjunct professor of preventive medicine at Northwestern University, said that’s because there are less people going into nursing school, fewer instructors to teach them, and a significant portion of the existing pool of nurses is nearing retirement age. When you couple that with the aging population, and the added medical needs associated with elder care, the shortage could turn critical, he said.

“Ideally you would love to have full-time people, right? Okay, so then the question is, where are you going to find full-time people?” Shalowitz said “There’s a shortage. What are you going to do about the shortage?”

Shalowitz said there are ways the city could address this. City colleges could provide more incentives to get people interested in the profession, or the city could subsidize housing to help recruit more nurses.

Chicago’s contract with Sunbelt ends next summer with the option for two consecutive one-year extensions. A spokesperson said it’s an option the health department will likely take.

Meanwhile, Arwady is encouraging anyone who served as a temp nurse for the city to apply for one of the full-time nurse positions in her department.

Claudia Morell is a metro reporter for WBEZ. Follow @claudiamorell.