The U.S. public health system has been starved for decades and lacks the resources to confront the worst health crisis in a century.
Marshaled against a virus that has sickened at least 2.74 million in the U.S., killed more than 130,000 people and cost tens of millions of jobs and $3 trillion in federal rescue money, state and local government health workers on the ground are sometimes paid so little, they qualify for public aid.
They track the coronavirus on paper records shared via fax. Working seven-day weeks for months on end, they fear pay freezes, public backlash and even losing their jobs.
Since 2010, spending for state public health departments has dropped by 16% per capita and spending for local health departments has fallen by 18%, according to a Kaiser Health News (KHN) and Associated Press analysis of government spending on public health. At least 38,000 state and local public health jobs have disappeared since the 2008 recession, leaving a skeletal workforce for what was once viewed as one of the world’s top public health systems.
KHN and AP interviewed more than 150 public health workers, policymakers and experts, analyzed spending records from hundreds of state and local health departments, and surveyed statehouses. On every level, the investigation found, the system is underfunded and under threat, unable to protect the nation’s health.
Dr. Robert Redfield, the director of the Centers for Disease Control and Prevention, said in an interview in April that his “biggest regret” was “that our nation failed over decades to effectively invest in public health.”
So when this outbreak arrived — and when, according to public health experts, the federal government bungled its response — hollowed-out state and local health departments were ill-equipped to step into the breach.
Over time, their work had received so little support that they found themselves without direction, disrespected, ignored, even vilified. The desperate struggle against COVID-19 became increasingly politicized and grew more difficult.
States, cities and counties in dire straits have begun laying off and furloughing their limited staff, and even more devastation looms, as states reopen and cases surge. Historically, even when money pours in following crises such as Zika and H1N1, it disappears after the emergency subsides. Officials fear the same is happening now.
“We don’t say to the fire department, ‘Oh, I’m sorry. There were no fires last year, so we’re going to take 30% of your budget away.’ That would be crazy, right?” said Dr. Gianfranco Pezzino, the health officer in Shawnee County, Kan. “But we do that with public health, day in and day out.”
Ohio’s Toledo-Lucas County Health Department spent $17 million, or $40 per person, in 2017.
Jennifer Gottschalk, 42, works for the county as an environmental health supervisor. When the coronavirus struck, the county’s department was so short-staffed that her duties included overseeing campground and pool inspections, rodent control and sewage programs while also supervising outbreak preparedness for a community of more than 425,000 people.
When Gottschalk and five colleagues fell ill with COVID-19, she found herself fielding calls about a COVID-19 case from her hospital bed, then working through her home isolation. She only stopped when her coughing was too severe to talk on calls.
“You have to do what you have to do to get the job done,” Gottschalk said.
Now, after months of working with hardly a day off, she says the job is wearing on her. So many lab reports on coronavirus cases came in, the office fax machine broke. She faces a backlash from the community over coronavirus restrictions, and there are countless angry phone calls.
Things could get worse; possible county budget cuts loom.
But Toledo-Lucas is no outlier. Public health ranks low on the nation’s financial priority list.
More than three-quarters of Americans live in states that spend less than $100 per person annually on public health. Spending ranges from $32 in Louisiana to $263 in Delaware, according to data provided by the State Health Expenditure Dataset project.
That money represents less than 1.5% of most states’ total spending, with half of it passed down to local health departments.
The share of spending devoted to public health belies its multidimensional role. Agencies are legally bound to provide a broad range of services, from vaccinations and restaurant inspections to protection against infectious disease. Distinct from the medical care system geared toward individuals, the public health system focuses on the health of communities at large.
“Public health loves to say: When we do our job, nothing happens. But that’s not really a great badge,” said Scott Becker, chief executive officer of the Association of Public Health Laboratories. “We test 97% of America’s babies for metabolic or other disorders. We do the water testing. You like to swim in the lake and you don’t like poop in there? Think of us.”
But the public doesn’t see the disasters they thwart. And it’s easy to neglect the invisible.
A history of deprivation
The local health department was a well-known place in the 1950s and 1960s, when Harris Pastides, president emeritus of the University of South Carolina, was growing up in New York City.
“My mom took me for my vaccines. We would get our injections there for free. We would get our polio sugar cubes there for free,” said Pastides, an epidemiologist. “In those days, the health departments had a highly visible role in disease prevention.”
The United States’ decentralized public health system, which matches federal funding and expertise with local funding, knowledge and delivery, was long the envy of the world, said Saad Omer, director of the Yale Institute for Global Health.
“A lot of what we’re seeing right now could be traced back to the chronic funding shortages,” Omer said. “The way we starve our public health system, the way we have tried to do public health outcomes on the cheap in this country.”
The HIV outbreak exploded into the worst ever to hit rural America, infecting more than 230 people.
At times, the federal government has promised to support local public health efforts, to help prevent similar calamities. But those promises were ephemeral.
Two large sources of money established after Sept. 11, 2001 — the Public Health Emergency Preparedness program and the Hospital Preparedness Program — were gradually chipped away.
The Affordable Care Act established the Prevention and Public Health Fund, which was supposed to reach $2 billion annually by 2015. The Obama administration and Congress raided it to pay for other priorities, including a payroll tax cut. The Trump administration is pushing to repeal the ACA, which would eliminate the fund, said Carolyn Mullen, senior vice president of government affairs and public relations at the Association of State and Territorial Health Officials.
But local and state leaders also did not prioritize public health over the years.
In Florida, for example, 2% of state spending goes to public health. Spending by local health departments in the state fell 39%, from a high of $57 in inflation-adjusted dollars per person in the late 1990s to $35 per person last year.
In North Carolina, Wake County’s public health workforce dropped from 882 in 2007 to 614 a decade later, even as the population grew by 30%.
In Detroit, the health department had 700 employees in 2009, then was effectively disbanded during the city’s bankruptcy proceedings. It’s been built back up, but today still has only 200 workers for 670,000 residents.
Many departments rely heavily on disease-specific grant funding, creating unstable and temporary positions. The CDC’s core budget, some of which goes to state and local health departments, has essentially remained flat for a decade. Federal money currently accounts for 27% of local public health spending.
Years of such financial pressure increasingly pushed workers in this predominantly female workforce toward retirement or the private sector and kept potential new hires away.
More than a fifth of public health workers in local or regional departments outside big cities earned $35,000 or less a year in 2017, as did 9% in big city departments, according to researchby the Association of State and Territorial Health Officials and the de Beaumont Foundation.
A decimated surge capacity
As the public health director for the Kentucky River District Health Department in rural Appalachia, Scott Lockard is battling the pandemic with 3G cell service, paper records and one-third of the employees the department had 20 years ago.
He redeployed his nurse administrator to work round-the-clock on contact tracing, alongside the department’s school nurse and the tuberculosis and breastfeeding coordinator. His home health nurse, who typically visits older patients, now works on preparedness plans. But residents aren’t making it easy on them.
“They’re not wearing masks, and they’re throwing social distancing to the wind,” Lockard said in mid-June, as cases surged. “We’re paying for it.”
Even with more staff since the HIV outbreak, Indiana’s Scott County Health Department employees worked evenings, weekends and holidays to deal with the pandemic, including outbreaks at a food packing company and a label manufacturer. Indiana spends $37 a person on public health.
“When you get home, the phone never stops, the emails and texts never stop,” said Scott County’s preparedness coordinator Patti Hall.
All the while, she and her colleagues worry about keeping HIV under control and preventing drug overdoses from rising. Other health problems don’t just disappear because there is a pandemic.
“We’ve been used to being able to `MacGyver’ everything on a normal day, and this is not a normal day,” said Amanda Mehl, the public health administrator for Boone County, Ill., citing a TV show.
Public health workers are leaving in droves. At least 34 state and local public health leaders have announced their resignation, retired or been fired in 17 states since April, a KHN/AP review found. Others face threats and armed demonstrators.
Ohio’s Gottschalk said the backlash has been overwhelming.
“Being yelled at by residents for almost two hours straight last week on regulations I cannot control left me feeling completely burned out,” she said in mid-June.
A difficult road ahead
Vice President Mike Pence, in an op-ed in The Wall Street Journal on June 16, said the public health system was “far stronger” than it was when coronavirus hit.
It’s true that the federal government this year has allocated billions for public health in response to the pandemic, according to the Association of State and Territorial Health Officials. That includes more than $13 billion to state and local health departments, for activities including contact tracing, infection control and technology upgrades.
A KHN/AP review found that some state and local governments are also pledging more money for public health. Alabama’s budget for next year, for example, includes $35 million more for public health than it did this year.
But overall, spending is about to be slashed again as the boom-bust cycle continues.
In most states, the new budget year begins July 1, and furloughs, layoffs and pay freezes have already begun in some places. Tax revenues evaporated during lockdowns, all but ensuring there will be more. At least 14 states have already cut health department budgets or positions or were actively considering such cuts in June, according to a KHN/AP review.
Since the pandemic began, Michigan temporarily cut most of its state health workers’ hours by one-fifth. Pennsylvania required more than 65 of its 1,200 public health workers to go on temporary leave, and others lost their jobs. Knox County, Tenn., furloughed 26 out of 260 workers for eight weeks.
Dr. Tom Frieden, formerly of the CDC, said it’s “stunning” that the U.S. is furloughing public health workers amid a pandemic. The country should demand the resources for public health, he said, just the way it does for the military.
“This is about protecting Americans,” Frieden said..
This story is a collaboration between The Associated Press and KHN (Kaiser Health News), which is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation) that is not affiliated with Kaiser Permanente.