CHARLESTON, W.Va. — The former West Virginia public health leader forced out by the governor says decades-old computer systems and cuts to staff over a period of years had made a challenging job even harder during a once-in-a-century pandemic.
Republican Gov. Jim Justice demanded Dr. Cathy Slemp’s resignation on June 24. He complained about discrepancies in the number of active cases and accused Slemp of not doing her job. He has refused to elaborate.
In her first comments about what happened, Slemp declined in a series of interviews to directly discuss the governor’s decision, saying she wanted to focus on improving the public health system. She defended how the data was handled and she detailed how money dwindled over the years. That meant fewer staff members, and they were hobbled by outdated technology that slowed their everyday work and their focus on the coronavirus.
Among the challenges: a computer network so slow that employees would sometimes lose their work when it timed out; the public’s demand for real-time data; and a struggle to feed information into systems designed when faxes were considered high-speed communication.
“We are driving a great-aunt’s Pinto when what you need is to be driving a Ferrari,” Slemp said.
A joint investigation published this month by KHN and The Associated Press detailed how state and local public health departments across the country have been starved for decades, leaving them underfunded and without adequate resources to confront the pandemic.
In West Virginia, spending on public health fell by 27% from 2010 to 2018, according to an AP/KHN analysis of data provided by the Association of State and Territorial Health Officials. Full-time jobs in the state public health department dropped from 875 in 2007 to 620 in 2019, according to the group.
Slemp said the staffing numbers were even worse than that when the pandemic hit because between 20% and 25% of all health department jobs were vacant. In epidemiology, the vacancy rate was 30%.
Those kinds of cuts “absolutely” had an effect on the department’s operations, she said.
At the beginning of the pandemic, Slemp said, workers received stacks of faxed lab reports that had to be entered manually, even though they had spent two decades trying to persuade some hospital and commercial labs to send their results electronically. After her department required it, she said, 37 labs started filing electronically within a week.
“There was a political will and a societal will to say, ‘We need to fix this,’” Slemp said.
Public health staffers had to come up with time-consuming workarounds, such as entering information about disease outbreaks onto paper forms because their computer systems weren’t designed for such work. That was the source of Justice’s complaints, which centered on exactly how many active cases of COVID-19 were in a prison, she said.
In Randolph County, where the prison is, a top local health official said confusion about the number of cases at the facility emerged because the state’s cumbersome electronic reporting system required thorough information on an infected person’s contacts before a case could be deemed cleared.
In an email, Bonnie Woodrum of the Randolph-Elkins Health Department said that it “hurt a little to be singled out as reporting inaccurate numbers” but that “it’s just a case of a small health department attempting to use an electronic reporting system that has never been easy to use.”
The problem had no impact on the ability to track new diseases in the state, Slemp said. Indeed, she said, the disputed data from the prison outbreak was being tracked, but it wasn’t getting entered as quickly as the more critical data for new cases, which they prioritized.
“Because that’s where the public health action is most critical,” Slemp said.
Slemp’s forced resignation drew criticism from leading national figures in public health, including Tom Inglesby of the Johns Hopkins Bloomberg School of Public Health. Inglesby, who serves with Slemp on the board of scientific counselors at the federal Centers for Disease Control and Prevention, praised Slemp’s management of the coronavirus in West Virginia.
He said the issue appeared to be a clerical error that was easily fixed.
“It’s a little like shooting the messenger,” Inglesby said.
Slemp said the governor never discussed his complaints with her before he demanded her resignation.
It’s challenging to be a public health leader “in a world that wants immediate information and definitive answers, when reality is, there are nuances,” she said. “Sometimes political expediency can conflict with public health practice.”
Smith reported from Providence, Rhode Island. KHN data reporter Hannah Recht contributed to this report
This story is a collaboration between The Associated Press and KHN.
El sistema de salud pública de los Estados Unidos ha subsistido en la precariedad durante décadas y carece de los recursos necesarios para enfrentar la peor crisis de salud en un siglo.
Mientras enfrentan juntos una pandemia que ha enfermado al menos a 2.3 millones de personas en el país, y matado a más de 120,000, y que ha costado millones de empleos y $3 mil millones en dinero de rescate federal, a los trabajadores de salud de los gobiernos estatales y locales a veces se les paga tan poco que califican para ayuda pública. Rastrean al coronavirus en registros compartidos por fax. Trabajando los siete días de la semana por meses, temiendo que se congelen sus salarios, que los despidan, e incluso la reacción negativa del público.
Desde 2010, el gasto para los departamentos de salud pública estatales ha disminuido un 16% per cápita, y el gasto para los departamentos de salud locales ha bajado un 18%, según un análisis de KHN y Associated Press. Al menos 38,000 empleos de salud pública locales y estatales han desaparecido desde la recesión de 2008, dejando en algunos lugares una fuerza laboral esquelética.
KHN y AP entrevistaron a más de 150 trabajadores de salud pública, legisladores y expertos, analizaron registros de gastos de cientos de departamentos de salud estatales y locales, e indagaron en las legislaturas estatales. La investigación reveló que, a todo nivel, el sistema está amenazado por la falta de financiación y medios.
A lo largo del tiempo, los departamentos de salud estatales y locales han recibido tan poco apoyo que se encontraron sin dirección, ignorados e incluso vilipendiados.
En medio de la recesión económica causada por la pandemia, los estados, las ciudades y los condados han comenzado a cesantear y despedir al personal, aun cuando los estados están reabriendo y comienzan a aumentar los casos de COVID.
“No le decimos al departamento de bomberos, ‘lo siento. No hubo incendios el año pasado, por lo que vamos a quitarle el 30% de su presupuesto’. Eso sería una locura, ¿verdad?”, dijo el doctor Gianfranco Pezzino, oficial de salud en el condado de Shawnee, en Kansas. “Pero lo hacemos con la salud pública, día tras día”.
El Departamento de Salud del condado de Toledo-Lucas, en Ohio, gastó solo $40 por persona en 2017. Cuando atacó el coronavirus, tenía tan poco personal que las tareas de Jennifer Gottschalk, supervisora de salud ambiental, incluían supervisar las inspecciones de campamentos y piscinas, y el control de roedores, además de la preparación para brotes.
Cuando Gottschalk, de 42 años, y cinco colegas se enfermaron con COVID-19, se encontró respondiendo llamadas de trabajo desde su cama del hospital. “Tienes que hacer lo que tienes que hacer para que el trabajo se haga”, expresó.
Casi dos tercios de los estadounidenses viven en condados que gastan más del doble en vigilancia policial que en la atención médica no hospitalaria, que incluye la salud pública.
La subvaloración de la salud pública contrasta con su papel multidimensional. A diferencia del sistema de atención médica que está dirigido a las personas, el de salud pública se centra en la salud de las comunidades en general. Las agencias están legalmente obligadas a proporcionar una amplia gama de servicios esenciales.
Jennifer Gottschalk, supervisora de salud del medio ambiente del Departamento de Salud del condado de Toledo-Lucas, en su oficina en Toledo, Ohio. “La semana pasada los gritos de los residentes por dos horas seguidas sobre regulaciones que no puedo controlar me dejaron completamente agotada”, dijo a mediados de junio.(AP Photo/Paul Sancya)
“A la salud pública le encanta decir: cuando hacemos nuestro trabajo, no pasa nada. Pero nadie nos da una medalla por eso”, dijo Scott Becker, director ejecutivo de la Asociación de Laboratorios de Salud Pública. “Les hacemos pruebas al 97% de los bebés de los Estados Unidos para detectar trastornos metabólicos, y otros problemas. Testeamos el agua. ¿Te gusta nadar en el lago y no te gusta que tenga excremento? Piensa en nosotros”.
El público no ve los desastres que se evitan. Y es fácil no prestar atención a lo que no vemos.
Una historia de privaciones
Las promesas ocasionales del gobierno federal de apoyar los esfuerzos locales de salud pública han sido efímeras.
Por ejemplo, la Ley de Cuidado de Salud a Bajo Precio (ACA) estableció el Fondo de Prevención y Salud Pública, que se suponía alcanzaría los $2 mil millones anuales para 2015. Pero la administración Obama y el Congreso lo postergaron por otras prioridades, y ahora la administración Trump está presionando para derogar ACA, lo cual lo eliminaría.
Si no se hubiera tocado, los departamentos de salud estatales y locales hubieran recibido eventualmente un monto adicional de $12.4 mil millones, lo que los hubiera fortalecido frente a la actual pandemia.
Los líderes locales y estatales tampoco lograron priorizar la salud pública. En Carolina del Norte, por ejemplo, la fuerza laboral de salud pública del condado de Wake se redujo de 882 personas en 2007 a 614 una década después, incluso cuando la población creció un 30%.
Años de recortes financieros dejaron frágil a esta fuerza laboral predominantemente femenina. En 2017, más de una quinta parte de los trabajadores de salud pública en los departamentos locales o regionales fuera de las grandes ciudades ganaron $35,000 o menos al año, según una investigación realizada por la Asociación de Oficiales de Salud Territoriales y Estatales y la Fundación Beaumont.
María Fernanda rastrea contactos de personas con COVID en el Departamento de Salud del condado de Miami-Dade, en su oficina de El Doral, en Florida, en mayo. En los estados, los departamentos de salud locales, encargados de realizar este trabajo de detectives tienen una fuerza laboral mucho menor de la que se requiere para esta tarea.(AP Photo/Lynne Sladky)
Hace dos años, Julia Crittendon, ahora de 46 años, aceptó un trabajo en el departamento de salud estatal de Kentucky. Pasaba sus días reuniendo información sobre las parejas sexuales de las personas para combatir la propagación del VIH y la sífilis. Ganaba tan poco que calificó para Medicaid, el programa de salud federal gerenciado por los estados para los estadounidenses de bajos recursos. Al no ver oportunidades de crecimiento, renunció.
Desde que comenzó la pandemia, líderes de salud pública estatales y locales han renunciado en masa. Desde abril, al menos 32 presentaron su renuncia, se retiraron o fueron despedidos en 16 estados, según una revisión de KHN/AP.
De mal en peor
Scott Lockard, director de salud pública para el Departamento de Salud del distrito Kentucky River, en Appalachia, está luchando contra el virus con un servicio celular 3G, registros en papel y un tercio de los empleados comparado con los que tenía el departamento hace 20 años.
En la zona rural de Missouri, Melanie Hutton, administradora del Centro de Salud Pública del condado de Cooper, dijo que su estado le dio $18,000 al servicio de ambulancias local para combatir COVID y proporcionó máscaras a los departamentos de bomberos y policía.
“Para nosotros, ni una moneda de cinco centavos, ni una máscara”, contó. “Obtuvimos [cinco] galones de desinfectante de manos casero hecho por prisioneros”.
La Asociación de Oficiales de Salud Territoriales y Estatales dijo que, desde que comenzó la pandemia, el gobierno federal ha asignado más de $13 mil millones para actividades de los departamentos de salud estatales y locales, incluyendo rastreo de contactos, control de infecciones y actualizaciones tecnológicas.
En el condado de Fairfax, en Virginia, las pruebas para COVID-19 han estado disponibles sin costo y sin una orden del doctor. El día de la foto, el 23 de mayo, de 10 am a 6 pm, oficiales planeaban hacerle la prueba a unas 1,000 personas, mientras cientos hacían fila en autos y a pie, en este sitio de pruebas al paso en Annandale.(AP Photo/Jacquelyn Martin)
Pero al menos 14 estados ya han recortado los presupuestos o los empleos del departamento de salud, o estuvieron considerando activamente estos recortes en junio, según una revisión de KHN/AP.
Las reducciones amenazan con limitar programas cruciales como clínicas de inmunización, control de mosquitos, diabetes y programas de nutrición para adultos mayores. Estos recortes pueden hacer que las comunidades ya vulnerables lo sean aún más, dijo E. Oscar Alleyne, jefe de programas y servicios de la Asociación Nacional de Oficiales de Salud del Condado y la Ciudad.
Las personas que han pasado sus vidas trabajando en la salud pública temen estar viendo un patrón que les resulta familiar: los funcionarios descuidan esta infraestructura y luego, cuando surge una crisis, responden con una rápida inyección de efectivo.
Si bien ese dinero temporal es necesario para combatir la pandemia, expertos en salud pública dicen que no solucionará la base erosionada, que es la encargada de proteger la salud de la nación mientras miles continúan muriendo.
Contribuyeron con este informe: los escritores de Associated Press Mike Stobbe en Nueva York; Mike Householder en Toledo, Ohio; Lindsay Whitehurst en Salt Lake City, Utah; Brian Witte en Annapolis, Maryland; Jim Anderson en Denver; Sam Metz en Carson City, Nevada; Summer Ballentine en Jefferson City, Missouri; Alan Suderman en Richmond, Virginia; Sean Murphy en Oklahoma City, Oklahoma; Mike Catalini en Trenton, New Jersey; David Eggert en Lansing, Michigan; Andrew DeMillo en Little Rock, Arkansas; Jeff Amy en Atlanta; Melinda Deslatte en Baton Rouge, Louisiana; Morgan Lee en Santa Fe, New Mexico; Mark Scolforo en Harrisburg, Pennsylvania; y el escritor de Economía de AP Christopher Rugaber, en Washington, D.C.
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 2.6 million in the U.S., killed more than 126,000 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 that 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 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 members of already limited staffs, 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 thing 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, Kansas. “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 stopped only 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 said 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. Nearly two-thirds of Americans live in counties that spend more than twice as much on policing as they spend on non-hospital health care, which includes public health.
Jennifer Gottschalk, environmental health supervisor of the Toledo-Lucas County Health Department, works in her office in Toledo, Ohio. “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.(AP Photo/Paul Sancya)
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 to KHN and AP 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.
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? But we do that with public health, day in and day out.
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.”
A stack of paperwork detailing positive COVID-19 test results sits in a box at the Toledo-Lucas County Health Department offices. 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 an analysis of government spending on public health by KHN and The Associated Press.(AP Photo/Paul Sancya)
In Scott County, Indiana, when preparedness coordinator Patti Hall began working at the health department 34 years ago, it ran a children’s clinic and a home health agency with several nurses and aides. But over time, the children’s clinic lost funding and closed. Medicare changes paved the way for private services to replace the home health agency. Department staff dwindled in the 1990s and early 2000s. The county was severely outgunned when rampant opioid use and needle sharing sparked an outbreak of HIV in 2015.
Besides just five full-time and one part-time county public health positions, there was only one doctor in the outbreak’s epicenter of Austin. Indiana’s then-Gov. Mike Pence, now leading the nation’s coronavirus response as vice president, waited 29 days after the outbreak was announced to sign an executive order allowing syringe exchanges. At the time, a state official said that only five people from agencies across Indiana were available to help with HIV testing in the county.
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.
Former Iowa Sen. Tom Harkin, a Democrat who championed the fund, said he was furious when the Obama White House took billions from it, breaking what he said was an agreement.
“I haven’t spoken to Barack Obama since,” Harkin said.
If the fund had remained untouched, an additional $12.4 billion would eventually have flowed to local and state health departments.
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 research by the Association of State and Territorial Health Officials and the de Beaumont Foundation.
Maria Fernanda works on COVID contact tracing at the Florida Department of Health in Miami-Dade County in Doral, Florida, in May. In state after state, local health departments charged with doing the detective work of running down the contacts of coronavirus patients are falling well short of the number of people needed to do the job.(AP Photo/Lynne Sladky)
Even before the pandemic, nearly half of public health workers planned to retire or leave their organizations for other reasons in the next five years. Poor pay topped the list of reasons.
Armed with a freshly minted bachelor’s degree, Julia Crittendon took a job two years ago as a disease intervention specialist with Kentucky’s state health department. She spent her days gathering detailed information about people’s sexual partners to fight the spread of HIV and syphilis. She tracked down phone numbers and drove hours to pick up reluctant clients.
The mother of three loved the work but made so little money that she qualified for Medicaid, the federal-state insurance program for America’s poorest. Seeing no opportunity to advance, she left.
“We’re like the redheaded stepchildren, the forgotten ones,” said Crittendon, 46.
Public health loves to say: When we do our job, nothing happens. But that’s not really a great badge. 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.
Such low pay is endemic, with some employees qualifying for the nutrition program for new moms and babies that they administer. People with the training for many public health jobs, which can include a bachelor’s or master’s degree, can make much more money in the private health care sector, robbing the public departments of promising recruits.
Dr. Tom Frieden, a former CDC director, said the agency “intentionally underpaid people” in a training program that sent early-career professionals to state and local public health departments to build the workforce.
“If we paid them at the very lowest level at the federal scale,” he said in an interview, “they would have to take a 10-20% pay cut to continue on at the local health department.”
As low pay sapped the workforce, budget cuts sapped services.
In Alaska, the Division of Public Health’s spending dropped 9% from 2014 to 2018 and staffing fell by 82 positions in a decade to 426. Tim Struna, chief of public health nursing in Alaska, said declines in oil prices in the mid-2010s led the state to make cuts to public health nursing services. They eliminated well-child exams for children over 6, scaled back searches for the partners of people with certain sexually transmitted infections and limited reproductive health services to people 29 and younger.
Living through an endless stream of such cuts and their aftermath, those workers on the ground grew increasingly worried about mustering the “surge capacity” to expand beyond their daily responsibilities to handle inevitable emergencies.
When the fiercest of enemies showed up in the U.S. this year, the depleted public health army struggled to hold it back.
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.”
In Virginia’s Fairfax County, COVID-19 testing was available at no cost and without a doctor’s order. Officials had planned on testing about 1,000 people from 10 a.m. to 6 p.m. on May 23, as hundreds lined up in cars and on foot at this site in Annandale.(AP Photo/Jacquelyn Martin)
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 Hall, the preparedness coordinator.
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, Illinois, citing a TV show.
Pezzino, whose department in Kansas serves Topeka and Shawnee County, said he had been trying to hire an epidemiologist, who would study, track and analyze data on health issues, since he came to the department 14 years ago. Finally, less than three years ago, they hired one. She just left, and he thinks it will be nearly impossible to find another.
While epidemiologists are nearly universal in departments serving large populations, hardly any departments serving smaller populations have one. Only 28% of local health departments have an epidemiologist or statistician.
Strapped departments are now forced to spend money on contact tracers, masks and gloves to keep their workers safe and to do basic outreach.
Melanie Hutton, administrator for the Cooper County Public Health Center in rural Missouri, pointed out the local ambulance department got $18,000, and the fire and police departments got masks to fight COVID-19.
“For us, not a nickel, not a face mask,” she said. “We got  gallons of homemade hand sanitizer made by the prisoners.”
Public health workers are leaving in droves. At least 34 state and local public health leaders have announced their resignations, 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.
Jennifer Gottschalk underwent a test for COVID-19 in a Toledo, Ohio, hospital on March 24. As the environmental health supervisor for the Toledo-Lucas County Health Department, she fielded calls about COVID-19 cases from a hospital bed while fighting the disease herself. She then worked throughout her home isolation, stopping only when her coughing was too severe to talk.(Jennifer Gottschalk via AP)
Gottschalk walks down a hallway of the department’s offices in Toledo, Ohio, on June 24. When the coronavirus pandemic struck earlier in the year, 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.(AP Photo/Paul Sancya)
Many are putting their health at risk. In Prince George’s County, Maryland, public health worker Chantee Mack died after, family and co-workers believe, she and several colleagues contracted the disease in the office.
A Difficult Road Ahead
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 the 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.
Roland Mack holds a poster with pictures and messages made by family members in memory of his sister, Chantee Mack, in District Heights, Maryland, on June 19. The Prince George’s County, Maryland, public health worker died of COVID-19 after, family and co-workers believe, she and several colleagues contracted the disease in their office.(AP Photo/Federica Narancio)
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, Tennessee, furloughed 26 out of 260 workers for eight weeks.
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.
Cincinnati temporarily furloughed approximately 170 health department employees.
Robert Brown, chair of Cincinnati’s Primary Care Board, questions why police officers and firefighters didn’t face similar furloughs at the time or why residents were willing to pay hundreds of millions in taxes over decades for the Bengals’ football stadium.
“How about investing in something that’s going to save some lives?” he asked.
In 2018, Boston spent five times as much on its police department as its public health department. The city recently pledged to transfer $3 million from its approximately $60 million police overtime budget to its public health commission.
Looking ahead, more cuts are coming. Possible budget shortfalls in Brazos County, Texas, may force the health department to limit its mosquito-surveillance program and eliminate up to one-fifth of its staff and one-quarter of immunization clinics.
Months into the pandemic response, health departments are still trying to ramp up to fight COVID-19. Cases are surging in states including Texas, Arizona and Florida.
Meanwhile, childhood vaccinations began plunging in the second half of March, according to a CDC study analyzing supply orders. Officials worry whether they will be able to get kids back up to date in the coming months. In Detroit, the childhood vaccination rate dipped below 40%, as clinics shuttered and people stayed home, creating the potential for a different outbreak.
Cutting or eliminating non-COVID activities is dangerous, said E. Oscar Alleyne, chief of programs and services at the National Association of County and City Health Officials. Cuts to programs such as diabetes control and senior nutrition make already vulnerable communities even more vulnerable, which makes them more likely to suffer serious complications from COVID. Everything is connected, he said.
It could be a year before there’s a widely available vaccine. Meanwhile, other illnesses, including mental health problems, are smoldering.
The people who spend their lives working in public health say the temporary coronavirus funds won’t fix the eroded foundation entrusted with protecting the nation’s health as thousands continue to die.
Contributing to this report were: Associated Press writers Mike Stobbe in New York; Mike Householder in Toledo, Ohio; Lindsay Whitehurst in Salt Lake City, Utah; Brian Witte in Annapolis, Maryland; Jim Anderson in Denver; Sam Metz in Carson City, Nevada; Summer Ballentine in Jefferson City, Missouri; Alan Suderman in Richmond, Virginia; Sean Murphy in Oklahoma City, Oklahoma; Mike Catalini in Trenton, New Jersey; David Eggert in Lansing, Michigan; Andrew DeMillo in Little Rock, Arkansas; Jeff Amy in Atlanta; Melinda Deslatte in Baton Rouge, Louisiana; Morgan Lee in Santa Fe, New Mexico; Mark Scolforo in Harrisburg, Pennsylvania; and AP economics writer Christopher Rugaber, in Washington, D.C.
To assess the state of the public health system in the United States, KHN and The Associated Press analyzed data on government spending and staffing at national, state and local levels.
What reporters found was a mix of survey and budget data, each measuring a slightly different concept of “public health.”
Some datasets track only state public health systems, not agencies that operate at a county, city or regional level. Other data, including some from the U.S. Census Bureau, covers spending on all non-hospital health care. Public health efforts are mixed in with the costs of providing local medical transportation, running community clinics and offering mental health services.
The lack of comprehensive data specifically about public health makes assessing community programs, agencies and staffing levels difficult, experts say. Public health information is scattered and can’t be easily compared, unlike data about hospitals and medical treatment, according to Betty Bekemeier, a public health systems researcher and professor at the University of Washington. She is seeking to fix this as the leader of a multistate effort to standardize local health department spending data.
“We will not be able to improve our systems if we don’t have a better idea of how it works,” she said.
KHN and AP calculated 2016-18 average annual state spending directly on public health initiatives using the State Health Expenditure Dataset. To create the dataset, a team of researchers encoded data from the Census Bureau’s “Annual Survey of State Government Finances,” isolating public health costs to get the clearest sense of what governments spend only on public health efforts.
The data includes spending by all state agencies and their transfers to local governments. To account for inflation for this and all spending data, KHN and the AP adjusted amounts to 2019 dollars using a price deflator from the Bureau of Economic Analysis targeted toward government expenses.
When creating national percentage change estimates, reporters excluded a handful of states missing comparable spending or staffing data.
The analysis included census finance data from state and local governments to compare spending on non-hospital health with other priorities such as policing and highway construction and maintenance.
At the local level, the National Association of County and City Health Officials’ “National Profile Study” surveys local health departments every three years and weights answers to account for nonresponse.
Beyond that, some states collect local health department spending and staffing data. Reporters used detailed data on local health departments in Florida, Minnesota, Missouri, North Carolina, Ohio and Washington — along with census population estimates — to examine per capita trends over time.
Finally, AP statehouse reporters posed an identical set of questions to states to get a sense of recent and upcoming budget and staffing changes to state public health departments. The AP gathered responses from 43 states.
Local and state public health departments across the country work to ensure that people in their communities have healthy water to drink, their restaurants don’t serve contaminated food and outbreaks of infectious diseases don’t spread. Those departments now find themselves at the forefront of fighting the coronavirus pandemic.
But years of budget and staffing cuts have left them unprepared to face the worst health crisis in a century.
KHN and The Associated Press sought to understand the scale of the cuts and how the decades-long starvation of public health departments by federal, state and local governments has affected the system meant to protect the nation’s health.
Here are six key takeaways from the KHN-AP investigation:
Since 2010, spending for state public health departments has dropped by 16% per capita, and for local health departments by 18%. Local public health spending varies widely by county or town, even within the same state.
At least 38,000 state and local public health jobs have disappeared since the 2008 recession, leaving a skeletal workforce in what was once viewed as one of the world’s top public health systems.
Nearly two-thirds of Americans live in counties that spend more than twice as much on policing as they spend on non-hospital health care, which includes public health.
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.
Some public health workers earn so little that they qualify for government assistance. During the pandemic, many have found themselves disrespected, ignored or even vilified. At least 31 state and local public health leaders have announced their resignations, retired or been fired in 15 states since April.
States, cities and counties whose tax revenues have declined during the current recession have begun laying off and furloughing public health staffers. At least 15 states have cut health department budgets or positions, or were actively considering such cuts in June, even as coronavirus cases surged in several states.
COVID-19 cases were climbing at Michigan’s McLaren Flint hospital. So Roger Liddell, 64, who procured supplies for the hospital, asked for an N95 respirator for his own protection, since his work brought him into the same room as COVID-positive patients.
But the hospital denied his request, said Kelly Indish, president of the American Federation of State, County and Municipal Employees Local 875.
On March 30, Liddell posted on Facebook that he had worked the previous week in both the critical care unit and the ICU and had contracted the virus. “Pray for me God is still in control,” he wrote. He died April 10.
Roger Liddell(Courtesy of Bill Sohmer)
The hospital’s problems with personal protective equipment (PPE) were well documented. In mid-March, the state office of the Occupational Safety and Health Administration (OSHA) received five complaints, which described employees receiving “zero PPE.” The cases were closed April 21, after the hospital presented paperwork saying problems had been resolved. There was no onsite inspection, and the hospital’s written response was deemed sufficient to close the complaints, a local OSHA spokesperson confirmed.
The grief and fear gripping workers and their families reflect a far larger pattern. Since March, more than 4,100 COVID-related complaints regarding health care facilities have poured into the nation’s network of federal and state OSHA offices, which are tasked with protecting workers from harm on the job.
A KHN investigation found that at least 35 health care workers died after OSHA received safety complaints about their workplaces. Yet by June 21, the agency had quietly closed almost all of those complaints, and none of them led to a citation or a fine.
The complaint logs, which have been made public, show thousands of desperate pleas from workers seeking better protective gear for their hospitals, medical offices and nursing homes.
The quick closure of complaints underscores the Trump administration’s hands-off approach to oversight, said former OSHA official Deborah Berkowitz. Instead of cracking down, the agency simply sent letters reminding employers to follow Centers for Disease Control and Prevention guidelines, said Berkowitz, now a director at the National Employment Law Project.
“This is a travesty,” she said.
A third of the health care-related COVID-19 complaints, about 1,300, remain open and about 275 fatality investigations are ongoing.
During a June 9 legislative hearing, Labor Secretary Eugene Scalia said OSHA had issued one coronavirus-related citation for violating federal standards. A Georgia nursing home was fined $3,900 for failing to report worker hospitalizations on time, OSHA’s records show.
“We have a number of cases we are investigating,” Scalia said at the Senate Finance Committee hearing. “If we find violations, we will certainly not hesitate to bring a case.”
Texts between Barbara Birchenough and her daughter, (in blue) Kristin Carbone.(Courtesy of Kristin Carbone)
A March 16 complaint regarding Clara Maass Medical Center in Belleville, New Jersey, illustrates the life-or-death stakes for workers on the front lines. The complaint says workers were “not allowed to wear” masks in the hallway outside COVID-19 patients’ rooms even though studies have since shown the highly contagious virus can spread throughout a health care facility. It also said workers “were not allowed adequate access” to PPE.
Nine days later, veteran Clara Maass registered nurse Barbara Birchenough texted her daughter: “The ICU nurses were making gowns out of garbage bags. … Dad is going to pick up large garbage bags for me just in case.”
Kristin Carbone, the eldest of four, said her mother was not working in a COVID area but was upset that patients with suspicious symptoms were under her care.
In a text later that day, Birchenough admitted: “I have a cough and a headache … we were exposed to six patients who we are now testing for COVID 19. They all of a sudden got coughs and fevers.”
“Please pray for all health care workers,” the text went on. “We are running out of supplies.”
By April 15, Birchenough, 65, had died of the virus. “They were not protecting their employees in my opinion,” Carbone said. “It’s beyond sad, but then I go to a different place where I’m infuriated.”
OSHA records show six investigations into a fatality or cluster of worker hospitalizations at the hospital. A Labor Department spokesperson said the initial complaints about Clara Maass remain open and did not explain why they continue to appear on a “closed” case list.
Nestor Bautista, 62, who worked closely with Birchenough, died of COVID-19 the same day as she did, according to Nestor’s sister, Cecilia Bautista. She said her brother, a nursing aide at Clara Maass for 24 years, was a quiet and devoted employee: “He was just work, work, work,” she said.
Barbara Birchenough(Courtesy of Kristin Carbone)
Nestor Bautista(Courtesy of Cecilia Bautista)
Responding to allegations in the OSHA complaint, Clara Maass Medical Center spokesperson Stacie Newton said the virus has “presented unprecedented challenges.”
“Although the source of the exposure has not been determined, several staff members” contracted the virus and “a few” have died, Newton said in an email. “Our staff has been in regular contact with OSHA, providing notifications and cooperating fully with all inquiries.”
Other complaints have been filed with OSHA offices across the U.S.
Twenty-one closed complaints alleged that workers faced threats of retaliation for actions such as speaking up about the lack of PPE. At a Delaware hospital, workers said they were not allowed to wear N95 masks, which protected them better than surgical masks, “for fear of termination or retaliation.” At an Atlanta hospital, workers said they were not provided proper PPE and were also threatened to be fired if they “raise[d] concerns about PPE when working with patients with Covid-19.”
Of the 4,100-plus complaints that flooded OSHA offices, over two-thirds are now marked as “closed” in an OSHA database. Among them was a complaint that staffers handling dead bodies in a small room off the lobby of a Manhattan nursing home weren’t given appropriate protective gear.
More than 100 of those cases were resolved within 10 days. One of those complaints said home health nurses in the Bronx were sent to treat COVID-19 patients without full protective gear. At a Massachusetts nursing home that housed COVID patients, staff members were asked to wash and reuse masks and disposable gloves, another complaint said. A complaint about an Ohio nursing home said workers were not required to wear protective equipment when caring for COVID patients. That complaint was closed three days after OSHA received it.
It remains unclear how OSHA resolved hundreds of the complaints. A Department of Labor spokesperson said in an email that some are closed based on an exchange of information between the employer and OSHA, and advised reporters to file Freedom of Information Act requests for details on others.
“The Department is committed to protecting America’s workers during the pandemic,” the Labor Department said in a statement. “OSHA has standards in place to protect employees, and employers who fail to take appropriate steps to protect their employees may be violating them.”
The agency advised its inspectors on May 19 to place reports of fatalities and imminent danger as a top priority, with a special focus on health care settings. Since late March, OSHA has opened more than 250 investigations into fatalities at health care facilities, government records show. Most of those cases are ongoing.
According to the mid-March complaints against McLaren Flint, workers did not receive needed N95 masks and “are not allowed to bring them from home.” They also said patients with COVID-19 were kept throughout the hospital.
Patrick Cain and his wife, Kate(Courtesy of Kelly Indish)
Filing complaints, though, did little for Liddell, or for his colleague, Patrick Cain, 52. After the complaints were filed, Cain, a registered nurse, was treating people still awaiting the results of COVID-19 diagnostic tests — potentially positive patients ― without an N95 respirator. He was also working outside a room where potential COVID-19 patients were undergoing treatments that research supported by the University of Nebraska has since shown can spread the virus widely in the air.
Cain felt vulnerable working outside of rooms where COVID patients were undergoing infection-spreading treatments, he wrote in a text to Indish on March 26.
Texts between union president Kelly Indish and Patrick Cain (right)(Courtesy of Kelly Indish)
“McLaren screwed us,” he wrote.
He fell ill in mid-March and died April 4.
McLaren has since revised its face-covering policy to provide N95s or controlled air-purifying respirators (CAPRs) to workers on the COVID floor, union members said.
A spokesperson for the McLaren Health Care system said the OSHA complaints are “unsubstantiated” and that its protocols have consistently followed government guidelines. “We have always provided appropriate PPE and staff training that adheres to the evolving federal, state, and local PPE guidelines,” Brian Brown said in an email.
Separate from the closed complaints, OSHA investigations into Liddell and Cain’s deaths are ongoing, according to a spokesperson for the state’s Department of Labor and Economic Opportunity.
Nurses at Kaiser Permanente Fresno Medical Center also said the complaints they aired before a nurse’s death have not been resolved. (KHN is not affiliated with Kaiser Permanente.)
On March 18, nurses filed an initial complaint. They told OSHA they were given surgical masks, instead of N95s. Less than a week later, other complaints said staffers were forced to reuse those surgical masks and evaluate patients for COVID without wearing an N95 respirator.
Several nurses who cared for one patient who wasn’t initially suspected of having COVID-19 in mid-March wore no protective gear, according to Amy Arlund, a Kaiser Fresno nurse and board member of the National Nurses Organizing Committee board of directors. Sandra Oldfield, a 53-year-old RN, was among them.
Arlund said Oldfield had filed an internal complaint with management about inadequate PPE around that time. Arlund said the patient’s illness was difficult to pin down, so dozens of workers were exposed to him and 10 came down with COVID-19, including Oldfield.
Sandra Oldfield(Courtesy of Lori Rodriguez)
Lori Rodriguez, Oldfield’s sister, said Sandra was upset that the patient she cared for who ended up testing positive for COVID-19 hadn’t been screened earlier.
“I don’t want to see anyone else lose their life like my sister did,” she said. “It’s just not right.”
Wade Nogy, senior vice president and area manager of Kaiser Permanente Fresno, confirmed that Oldfield had exposure to a patient before COVID-19 was suspected. He said Kaiser Permanente “has years of experience managing highly infectious diseases, and we are safely treating patients who have been infected with this virus.”
Kaiser Permanente spokesperson Marc Brown said KP “responded to these complaints with information, documents and interviews that demonstrated we are in compliance with OSHA regulations to protect our employees.” He said the health system provides nurses and other staff “with the appropriate protective equipment.”
California OSHA officials said the initial complaints were accurate and the hospital was not in compliance with a state law requiring workers treating COVID patients to have respirators. However, the officials said the requirement had been waived due to global shortages.
Kaiser Fresno is now in compliance, Cal/OSHA said in a statement, but the agency has ongoing investigations at the facility.
Arlund said tension around protective gear remains high at the hospital. On each shift, she said, nurses must justify their need for a respirator, face shield or hair cap. She expressed surprise that the OSHA complaints were considered “closed.”
“I’m very concerned to hear they are closing cases when I know they haven’t reached out to front-line nurses,” Arlund said. “We do not consider any of them closed.”