Public health officials who have juggled bare-bones budgets for years are happy to have the additional money. Yet they worry it will soon dry up as the pandemic recedes, continuing a boom-bust funding cycle that has plagued the U.S. public health system for decades. If budgets are slashed again, they warn, that could leave the nation where it was before covid: unprepared for a health crisis.

“We need funds that we can depend on year after year,” said Dr. Mysheika Roberts, the health commissioner of Columbus, Ohio.

When Roberts started in Columbus in 2006, an emergency preparedness grant paid for more than 20 staffers. By the time the coronavirus pandemic hit, it paid for about 10. Relief money that came through last year helped the department staff up its covid response teams. While the funding has helped the city cope with the immediate crisis, Roberts wonders if history will repeat itself.

After the pandemic is over, public health officials across the U.S. fear, they’ll be back to scraping together money from a patchwork of sources to provide basic services to their communities — much like after 9/11, SARS and Ebola.

When the mosquito-borne Zika virus tore through South America in 2016, causing serious birth defects in newborn babies, members of Congress couldn’t agree how, and how much, to spend in the U.S. for prevention efforts, such as education and mosquito abatement. The Centers for Disease Control and Prevention took money from its Ebola efforts, and from state and local health department funding, to pay for the initial Zika response. Congress eventually allocated $1.1 billion for Zika, but by then mosquito season had passed in much of the U.S.

“Something happens, we throw a ton of money at it, and then in a year or two we go back to our shrunken budgets and we can’t do the minimum things we have to do day in and day out, let alone be prepared for the next emergency,” said Chrissie Juliano, executive director of the Big Cities Health Coalition, which represents leaders of more than two dozen public health departments.

Funding for Public Health Emergency Preparedness, which pays for emergency capabilities for state and local health departments, dropped by about half between the 2003 and 2021 fiscal years, accounting for inflation, according to , a public health research and advocacy organization.

Even the federal , established with the Affordable Care Act to provide $2 billion a year for public health, was raided for cash over the past decade. If the money hadn’t been touched, eventually local and state health departments would have gotten an additional $12.4 billion.

Several lawmakers, led by Democratic U.S. Sen. Patty Murray of Washington, are looking to end the boom-bust cycle with that would eventually provide $4.5 billion annually in core public health funding. Health departments carry out essential government functions — such as managing water safety, issuing death certificates, tracking sexually transmitted diseases and preparing for infectious outbreaks.

Spending for state public health departments dropped by 16% per capita from 2010 to 2019, and spending for local health departments fell by 18%, KHN and The Associated Press found in a July investigation. At least 38,000 public health jobs were lost at the state and local level between the 2008 recession and 2019. Today, many public health workers are hired on a temporary or part-time basis. Some are paid so poorly they qualify for public aid. Those factors reduce departments’ ability to retain people with expertise.

Compounding those losses, the pandemic has prompted an exodus of public health officials because of harassment, political pressure and exhaustion. A yearlong analysis by the AP and KHN found at least 248 leaders of state and local health departments resigned, retired or were fired between April 1, 2020, and March 31, 2021. Nearly 1 in 6 Americans lost a local public health leader during the pandemic. Experts say it is the largest exodus of public health leaders in American history.

Brian Castrucci, CEO of the de Beaumont Foundation, which advocates for public health, calls Congress’ giant influx of cash in response to the crisis “wallpaper and drapes” because it doesn’t restore public health’s crumbling foundation.

“I worry at the end of this we’re going to hire up a bunch of contact tracers — and then lay them off soon thereafter,” Castrucci said. “We are continuing to kind of go from disaster to disaster without ever talking about the actual infrastructure.”

Castrucci and others say dependable money is needed for high-skill professionals, such as epidemiologists — data-driven disease detectives — and for technology upgrades that would help track outbreaks and get information to the public.

In Ohio, the computer system used to report cases to the state predates the invention of the iPhone. State officials had said for years they wanted to upgrade it, but they lacked the money and political will. Many departments across the country have relied on to report covid cases.

During the pandemic, Ohio’s that nearly 96% of local health departments it surveyed had problems with the state’s disease reporting system. Roberts said workers interviewing patients had to navigate several pages of questions, a major burden when handling 500 cases daily.

The system was so outdated that some information could be entered only in a non-searchable comment box, and officials struggled to pull data from the system to report to the public — such as how many people who tested positive had attended a Black Lives Matter rally, which last summer was a key question for people trying to understand whether protests contributed to the virus’s spread.

Ohio is working on a new system, but Roberts worries that, without a dependable budget, the state won’t be able to keep that one up to date either. 

“You’re going to need to upgrade that,” Roberts said. “And you’re going to need dollars to support that.”

In Washington, the public health director for Seattle and King County, Patty Hayes, said she is asked all the time why there isn’t a single, central place to register for a vaccine appointment. The answer comes down to money: Years of underfunding left departments across the state with antiquated computer systems that were not up to the task when covid hit.

Hayes recalls a time when her department would conduct mass vaccination drills, but that system was dismantled when the money dried up after the specter of 9/11 faded.

Roughly six years ago, an analysis found that her department was about $25 million short of what it needed annually for core public health work. Hayes said the past year has shown that’s an underestimate. For example, climate change is prompting more public health concerns, such as the effect on residents when wildfire smoke engulfed much of the Pacific Northwest in September.

Public health officials in some areas may struggle to make the case for more stable funding because a large swath of the public has questioned — and often been openly hostile toward — the mask mandates and business restrictions that public health officials have imposed through the pandemic.

In Missouri, some county commissioners who were frustrated at public health restrictions withheld money from the departments.

In Knox County, Tennessee, Mayor Glenn Jacobs narrated posted in the fall that showed a photo of health officials after referencing “sinister forces.” Later, someone spray-painted “DEATH” on the department office building. The Board of Health was stripped of its powers in March and given an advisory role. A spokesperson for the mayor’s office declined to comment on the video.

“This is going to change the position of public health and what we can and cannot do across the country,” said Dr. Martha Buchanan, the head of the health department. “I know it’s going to change it here.”

A found at least 24 states were crafting legislation that would limit or remove public health powers.

Back in Seattle, locally based companies have pitched in money and staff members for vaccine sites. Microsoft is hosting one location, while Starbucks offered customer service expertise to help design the sites. Hayes is grateful, but she wonders why a critical government function didn’t have the resources it needed during a pandemic.

If public health had been getting dependable funding, her staff could have been working more effectively with the data and preparing for emerging threats in the state where the was confirmed.

“They’ll look back at this response to the pandemic in this country as a great example of a failure of a country to prioritize the health of its citizens, because it didn’t commit to public health,” she said. “That will be part of the story.”

KHN senior correspondent Anna Maria Barry-Jester and Montana correspondent Katheryn Houghton contributed to this report.

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Tisha Coleman has lived in close-knit Linn County, Kansas, for 42 years and never felt so alone.

As the public health administrator, she’s struggled every day of to keep her rural county along the Missouri border safe. In this community with no hospital, she’s failed to persuade her neighbors to wear masks and take precautions against COVID-19, even as cases rise. In return, she’s been harassed, sued, vilified — and called a Democrat, an insult in her circles.

Even her husband hasn’t listened to her, refusing to require customers to wear masks at the family’s hardware store in Mound City.

“People have shown their true colors,” Coleman said. “I’m sure that I’ve lost some friends over this situation.”

By November, the months of fighting over masks and quarantines were already wearing her down. Then she got COVID-19, likely from her husband, who she thinks picked it up at the hardware store. Her mother got it, too, and died on Sunday, 11 days after she was put on a ventilator.

Across the U.S., state and local public health officials such as Coleman have found themselves at the center of a political storm as they combat . Amid a fractured federal response, the usually invisible army of workers charged with preventing the spread of infectious diseases has . Their expertise on how to fight the coronavirus is often disregarded.

Some have become the target of far-right activists, conservative groups and anti-vaccination extremists, who have coalesced around common goals — fighting mask orders, quarantines and contact tracing with protests, threats and personal attacks.

The backlash has moved beyond the angry fringe. In the courts, public health powers are being undermined. Lawmakers in at least 24 states have crafted legislation to weaken public health powers, which could make it more difficult for communities to respond to other health emergencies in the future.

“What we’ve taken for granted for 100 years in public health is now very much in doubt,” said Lawrence Gostin, an expert in public health law at Georgetown University in Washington, D.C.

It is a further erosion of the nation’s already fragile public health infrastructure. At least 181 state and local public health leaders in 38 states have resigned, retired or been fired since April 1, according to an by The Associated Press and KHN. According to experts, this is the largest exodus of public health leaders in American history. An untold number of lower-level staffers has also left.

“I’ve never seen or studied a pandemic that has been as politicized, as vitriolic and as challenged as this one, and I’ve studied a lot of epidemics,” said Dr. Howard Markel, a medical historian at the University of Michigan. “All of that has been very demoralizing for the men and women who don’t make a great deal of money, don’t get a lot of fame, but work 24/7.”

One in 8 Americans — 40 million people — lives in a community that has lost its local public health department leader during the pandemic. Top public health officials in 20 states have left state-level departments, including in North Dakota, which has lost three state health officers since May, one after another.

Many of the state and local officials left due to political blowback or pandemic pressure. Some departed to take higher-profile positions or due to health concerns. Others were fired for poor performance. Dozens retired.

KHN and AP reached out to public health workers and experts in every state and the National Association of County and City Health Officials; examined public records and news reports; and interviewed hundreds to gather the list.

Collectively, the loss of expertise and experience has created a leadership vacuum in the profession, public health experts say. Many health departments are in flux as the nation rolls out and faces what are expected to be the worst months of the pandemic.

“We don’t have a long line of people outside of the door who want those jobs,” said Dr. Gianfranco Pezzino, health officer in Shawnee County, Kansas, who had decided to retire from his job at the end of the year, he said, because he’s burned out. “It’s a huge loss that will be felt probably for generations to come.”

But Pezzino could not even make it to Dec. 31. On Monday, after county commissioners , he . 

“You value the pressure from people with special economic interests more than science and good public health practice,” he to the commissioners. “In full conscience I cannot continue to serve as the health officer for a board that puts being able to patronize bars and sports venues in front of the health, lives and well-being of a majority of its constituents.”

Existing Problems

The departures accelerate problems that had already weakened the nation’s public health system. that per capita spending for state public health departments had dropped by 16%, and for local health departments by 18%, since 2010. At least 38,000 state and local public health jobs have disappeared since the 2008 recession.

Those diminishing resources were already prompting high turnover. Before the pandemic, nearly half of public health workers said in a survey they planned to retire or leave in the next five years. The top reason given was low pay.

Such reduced staffing in departments that have the power and responsibility to manage everything from water inspections to childhood immunizations left public health workforces ill-equipped when COVID-19 arrived. Then, when pandemic shutdowns cut tax revenues, some state and local governments cut their public health workforces further.

“Now we’re at this moment where we need this knowledge and leadership the most, everything has come together to cause that brain drain,” said Chrissie Juliano, executive director of the Big Cities Health Coalition, which represents leaders of more than two dozen public health departments.

Politics as Public Health Poison

Public health experts broadly agree that and save lives and livelihoods. Scientists say that and curtailing indoor activities can also help.

But with the pandemic coinciding with , simple acts such as wearing a mask morphed into , with right-wing conservatives saying such requirements stomped on individual freedom.

On the campaign trail, President Donald Trump ridiculed President-elect Joe Biden for wearing a mask and egged on by tweeting

Coleman, a Christian and a Republican, said that’s just what happened in Linn County. “A lot of people are shamed into not wearing a mask … because you’re considered a Democrat,” she said. “I’ve been called a ‘sheep.’”

The politicization has put some local governments at odds with their own health officials. In California, near Lake Tahoe, the Placer County Board of Supervisors voted to end a local health emergency and declared support for a widely discredited “herd immunity” strategy, which would let the virus spread. The idea is endorsed by many conservatives, including , as a way to keep the economy running, but it has been denounced by public health experts who say millions more people will unnecessarily suffer and die. The supervisors also endorsed a false conspiracy theory claiming many COVID-19 deaths are not actually from COVID-19.

The meeting occurred just days after county Public Health Officer Dr. Aimee Sisson explained to the board the rigorous standards used for counting COVID-19 deaths. Sisson quit the next day.

In Idaho, protests against public health measures are intensifying. Hundreds of protesters, some armed, and health board members’ homes in Boise on Dec. 8, screaming and blaring air horns. They included members of the anti-vaccination group Health Freedom Idaho.

Dr. Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine, has tracked the anti-vaccine movement and said it has linked up with political extremists on the right, and taken on a larger anti-science role, pushing back against other public health measures such as contact tracing and physical distancing.

Members of a group called the Freedom Angels in California, which sprung up in 2019 around a state law to tighten vaccine requirements, have been organizing protests at health departments, posing with guns and calling themselves a militia on the group’s Facebook page.

The latest Idaho protests came after a July skirmish in which Ammon Bundy who tried to stop him and his maskless supporters from entering a health meeting.

Bundy, whose family led armed standoffs against federal agents in 2014 and 2016, has become , most recently forming a multistate network called People’s Rights that has organized protests against public health measures.

“We don’t believe they have a right to tell us that we have to put a manmade filter over our face to go outside,” Bundy said. “It’s not about, you know, the mandates or the mask. It’s about them not having that right to do it.”

Kelly Aberasturi, vice chair for the Southwest District Health, which covers six counties, said the worker Bundy shoved was “just trying to do his job.”

Aberasturi, a self-described “extremist” right-wing Republican, said he, too, has been subjected to the backlash. Aberasturi doesn’t support mask mandates, but he did back the board’s recommendation that people in the community wear masks. He said people who believe even a recommendation goes too far have threatened to protest at his house.

The Mask Fight in Kansas

The public health workforce in Kansas has been hit hard — 17 of the state’s 100 health departments have lost their leaders since the end of March. 

Democratic Gov. Laura Kelly in July, but the state legislature allowed counties to opt out. A recent showed the 24 Kansas counties that had upheld the mandate saw a 6% decrease in COVID-19, while the 81 counties that opted out entirely saw a 100% increase.

Coleman, who pushed unsuccessfully for Linn County to uphold the rule, was sued for putting a community member into quarantine, a lawsuit she won. In late November, she spoke at a to discuss a new mask mandate — it was her first day back in the office after her own bout with COVID-19.

She pleaded for a plan to help stem the surge in cases. One resident referenced Thomas Jefferson, saying, “I prefer a dangerous freedom over a peaceful slavery.” Another falsely argued that masks caused elevated carbon dioxide. Few, besides Coleman, wore a mask at the meeting.

Commissioner Mike Page supported the mask order, noting that a close friend was fighting COVID-19 in the hospital and saying he was “ashamed” that members of the community had sued their public health workers while other communities supported theirs.

In the end, the commissioners encouraged community members to wear masks but opted out of a county-wide rule, writing they had determined that they are “not necessary to protect the public health and safety of the county.”

Coleman was disappointed but not surprised. “At least I know I’ve done everything I can to attempt to protect the people,” she said.

The next day, Coleman discussed Christmas decorations with her mother as she drove her to the hospital.

Stripping of Powers

The state bill that let Linn County opt out of the governor’s mask mandate is one of dozens of efforts to erode public health powers in state legislatures across the country.

For decades, government authorities have had the legal power to stop foodborne illnesses and infectious diseases by closing businesses and quarantining individuals, among other measures.

When people contract tuberculosis, for example, the local health department might isolate them, require them to wear a mask when they leave their homes, require family members to get tested, relocate them so they can isolate and make sure they take their medicine. Such measures are meant to protect everyone and avoid the shutdown of businesses and schools.

Now, opponents of those measures are turning to state legislatures and even the Supreme Court to strip public officials of those powers, defund local health departments or even dissolve them. The American Legislative Exchange Council, a corporate-backed group of conservative lawmakers, has published for .

Lawmakers in Missouri, Louisiana, Ohio, Virginia and at least 20 other states have crafted bills to limit public health powers. In some states, the efforts have failed; in others, legislative leaders have embraced them enthusiastically.

Tennessee’s Republican House leadership is backing a bill to constrain the state’s six local health departments, granting their powers to mayors instead. The bill stems from clashes between the mayor of Knox County and the local health board over mask mandates and business closures.

In Idaho, lawmakers to review the authority of local health districts in the next session. The move doesn’t sit right with Aberasturi, who said it’s hypocritical coming from state lawmakers who profess to believe in local control.

Meanwhile, governors in Wisconsin, Kansas and Michigan, among others, have been sued by their own legislators, state think tanks or others for using their executive powers to restrict business operations and require masks. In Ohio, a group of lawmakers is seeking to impeach Republican Gov. Mike DeWine over his pandemic rules.

The U.S. Supreme Court in 1905 found it was constitutional for officials to issue orders to protect the public health, in a case upholding a Cambridge, Massachusetts, requirement to get a smallpox vaccine. But a indicated the majority of justices are willing to put new constraints on those powers.

“It is time — past time — to make plain that, while the pandemic poses many grave challenges, there is no world in which the Constitution tolerates color-coded executive edicts that reopen liquor stores and bike shops but shutter churches, synagogues, and mosques,” Justice Neil Gorsuch wrote.

Gostin, the health law professor, said the decision could embolden state legislators and governors to weaken public health authority, creating “a snowballing effect on the erosion of public health powers and, ultimately, public’s trust in public health and science.”

Who’s Left?

Many health officials who have stayed in their jobs have faced not only political backlash but also threats of personal violence. Armed paramilitary groups have put public health in their sights.

In California, a man with ties to the right-wing, anti-government Boogaloo movement was accused of stalking and threatening Santa Clara’s health officer. The suspect was arrested and has pleaded not guilty. The Boogaloo movement is associated with multiple murders, including of a Bay Area sheriff deputy and federal security officer.

Linda Vail, health officer for Michigan’s Ingham County, has received emails and letters at her home saying she’d be “taken down like the governor,” which Vail took to be a reference to . Even as other health officials are leaving, Vail is choosing to stay despite the threats.

“I can completely understand why some people, they’re just done,” she said. “There are other places to go work.”

In mid-November, Danielle Swanson, public health administrator in Republic County, Kansas, said she was planning to resign as soon as she and enough of her COVID-19-positive staff emerged from isolation. Someone threatened to go to her department with a gun because of a quarantine, and she’s received hand-delivered hate mail and calls from screaming residents.

“It’s very stressful. It’s hard on me; it’s hard on my family that I do not see,” she said. “For the longest time, I held through it thinking there’s got to be an end in sight.”

Swanson said some of her employees have told her once she goes, they probably will not stay.

As public health officials depart across the country, the question of who takes their places has plagued Dr. Oxiris Barbot, who in August amid a clash with Democratic Mayor Bill de Blasio. During the height of the pandemic, the mayor empowered the city’s hospital system to lead the fight against COVID-19, passing over her highly regarded department.

“I’m concerned about the degree to which they will have the fortitude to tell elected officials what they need to hear instead of what they want to hear,” Barbot said.

In Kentucky, 189 employees, about 1 in 10, left local health departments from March through Nov. 21, according to Sara Jo Best, public health director of the Lincoln Trail District Health Department. That comes after a decade of decline: Staff numbers fell 49% from 2009 to 2019. She said workers are exhausted and can’t catch up on the overwhelming number of contact tracing investigations, much less run COVID-19 testing, combat flu season and prepare for COVID-19 vaccinations.

And the remaining workforce is aging. According to the de Beaumont Foundation, which advocates for local public health, 42% of governmental public health workers are over age 50.

Back in Linn County, cases are rising. As of Dec. 14, 1 out of every 24 residents has tested positive.

The day after her mother was put on a ventilator, Coleman fought to hold back tears as she described the 71-year-old former health care worker with a strong work ethic.

“Of course, I could give up and throw in the towel, but I’m not there yet,” she said, adding that she will “continue to fight to prevent this happening to someone else.”

Coleman, whose mother died Sunday, has noticed more people are wearing masks these days.

But at the family hardware store, they are still not required.

This story is a collaboration between The Associated Press and KHN.

Methodology

KHN and AP counted how many state and local public health leaders have left their jobs since April 1, or who plan to leave by Dec. 31.

The analysis includes the exits of top department officials regardless of the reason. Some departments have more than one top position and some had multiple top officials leave from the same position over the course of the pandemic.

To compile the list, reporters reached out to public health associations and experts in every state and interviewed hundreds of public health employees. They also received information from the National Association of County and City Health Officials, and combed news reports and public records, such as meeting minutes and news releases.

The population served by each local health department is calculated using the Census Bureau 2019 Population Estimates based on each department’s jurisdiction.

The count of legislation came from reviewing bills in every state, prefiled bills for 2021 sessions, where available, and news reports. The bills include limits on quarantines, contact tracing, vaccine requirements and emergency executive powers.

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By February, as the disease crept across the U.S., Keeley said she found her calling: a career in public health. “This is something that’s going to be necessary,” Keeley remembered thinking. “This is something I can do. This is something I’m interested in.”

In August, Keeley began studying at the University of Illinois at Urbana-Champaign to become an epidemiologist.

Public health programs in the United States have seen a surge in enrollment as the coronavirus has swept through the country, killing more than 246,000 people. As state and local public health departments struggle with unprecedented challenges — slashed budgets, surging demand, staff departures and even threats to workers’ safety — a new generation is entering the field.

Among the more than 100 schools and public health programs that use the common application — a single admissions application form that students can send to multiple schools — there was a 20% increase in applications to master’s in public health programs for the current academic year, to nearly 40,000, according to the Association of Schools and Programs of Public Health.

Some programs are seeing even bigger jumps. Applications to Brown University’s small master’s in public health program rose 75%, according to Annie Gjelsvik, a professor and director of the program.

Demand was so high as the pandemic hit full force in the spring that Brown extended its application deadline by over a month. Seventy students ultimately matriculated this fall, up from 41 last year.

“People interested in public health are interested in solving complex problems,” Gjelsvik said. “The COVID pandemic is a complex issue that’s in the forefront every day.”

It’s too early to say whether the jump in interest in public health programs is specific to that field or reflects a broader surge of interest in graduate programs in general, according to those who track graduate school admissions. Factors such as pandemic-related deferrals and disruptions in international student admissions make it difficult to compare programs across the board.

Magnolia E. Hernández, an assistant dean at Florida International University’s Robert Stempel College of Public Health and Social Work, said new student enrollments in its master’s in public health program grew 63% from last year. The school has especially seen an uptick in interest among Black students, from 21% of newly admitted students last fall to 26.8% this year.

Kelsie Campbell is one of them. She’s part Jamaican and part British. When she heard in both the British and American media that Black and ethnic minorities were being disproportionately hurt by the pandemic, she wanted to focus on why.

“Why is the Black community being impacted disproportionately by the pandemic? Why is that happening?” Campbell asked. “I want to be able to come to you and say ‘This is happening. These are the numbers and this is what we’re going to do.’”

The biochemistry major at Florida International said she plans to explore that when she begins her MPH program at Stempel College in the spring. She said she hopes to eventually put her public health degree to work helping her own community.

“There’s power in having people from your community in high places, somebody to fight for you, somebody to be your voice,” she said.

Public health students are already working on the front lines of the nation’s pandemic response in many locations. Students at Brown’s public health program, for example, are crunching infection data and tracing the spread of the disease for the Rhode Island Department of Health.

Some students who had planned to work in public health shifted their focus as they watched the devastation of COVID-19 in their communities. In college, Emilie Saksvig, 23, double-majored in civil engineering and public health. She was supposed to start working this year as a Peace Corps volunteer to help with water infrastructure in Kenya. She had dreamed of working overseas on global public health.

The pandemic forced her to cancel those plans, and she decided instead to pursue a master’s degree in public health at Emory University.

“The pandemic has made it so that it is apparent that the United States needs a lot of help, too,” she said. “It changed the direction of where I wanted to go.”

These students are entering a field that faced serious challenges even before the pandemic exposed the strains on the underfunded patchwork of state and local public health departments. An analysis by AP and KHN found that since 2010, per capita spending for state public health departments has dropped by 16%, and for local health departments by 18%. At least 38,000 state and local public health jobs have disappeared since the 2008 recession.

And the workforce is aging: Forty-two percent of governmental public health workers are over 50, according to the de Beaumont Foundation, and the field has high turnover. Before the pandemic, nearly half of public health workers said they planned to retire or leave their organizations for other reasons in the next five years. Poor pay topped the list of reasons. Some public health workers are paid so little that they qualify for public aid.

Brian Castrucci, CEO of the de Beaumont Foundation, which advocates for public health, said government public health jobs need to be a “destination job” for top graduates of public health schools.

“If we aren’t going after the best and the brightest, it means that the best and the brightest aren’t protecting our nation from those threats that can, clearly, not only devastate from a human perspective, but from an economic perspective,” Castrucci said.

The pandemic put that already-stressed public health workforce in the middle of what became a pitched political battle over how to contain the disease. As public health officials recommended closing businesses and requiring people to wear masks, many, including Dr. Anthony Fauci, the U.S. government’s top virus expert, faced threats and political reprisals, AP and KHN found. Many were pushed out of their jobs. An ongoing count by AP/KHN has found that more than 100 public health leaders in dozens of states have retired, quit or been fired since April.

Those threats have had the effect of crystallizing for students the importance of their work, said Patricia Pittman, a professor of health policy and management at George Washington University’s Milken Institute School of Public Health.

“Our students have been both indignant and also energized by what it means to become a public health professional,” Pittman said. “Indignant because many of the local and the national leaders who are trying to make recommendations around public health practices were being mistreated. And proud because they know that they are going to be part of that front-line public health workforce that has not always gotten the respect that it deserves.”

Saksvig compared public health workers to law enforcement in the way they both have responsibility for enforcing rules that can alter people’s lives.

“I feel like before the coronavirus, a lot of people didn’t really pay attention to public health,” she said. “Especially now when something like a pandemic is happening, public health people are just on the forefront of everything.”

KHN Midwest correspondent Lauren Weber and KHN senior correspondent Anna Maria Barry-Jester contributed to this report.

This story is a collaboration between The Associated Press and KHN.

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While Musicant diverted workers from violence prevention and other core programs to the COVID-19 response, state officials debated how to distribute $1.87 billion Minnesota received in federal aid.

As she waited for federal help, the got $6 million in federal money to continue operations, and a debt collection company outside Minneapolis received at least $5 million from the federal Paycheck Protection Program, according to federal data.

It was not until Aug. 5 — months after Congress approved aid for the pandemic — that Musicant’s department finally received $1.7 million, the equivalent of $4 per Minneapolis resident.

“It’s more a hope and a prayer that we’ll have enough money,” Musicant said.

Since the pandemic began, Congress has set aside trillions of dollars to ease the crisis. A joint KHN and Associated Press investigation finds that many communities with big outbreaks have spent little of that federal money on local public health departments for work such as testing and contact tracing. Others, like Minnesota, were slow to do so.

For example, the states, territories and 154 large cities and counties that received allotments from the $150 billion Coronavirus Relief Fund reported spending only 25% of it through June 30, according to reports that recipients submitted to the U.S. Treasury Department.

Many localities have deployed more money since that June 30 reporting deadline, and both Republican and Democratic governors say they need more to avoid layoffs and cuts to vital state services. Still, as cases in the U.S. top 5.2 million and deaths soar past 167,000, Republicans in Congress are pointing to the slow spending to argue against sending more money to state and local governments to help with their pandemic response.

“States and localities have only spent about a fourth of the money we already sent them in the springtime,” Senate Majority Leader Mitch McConnell said Tuesday. Congressional Democrats’ efforts to get more money for states, he said, “aren’t based on math. They aren’t based on the pandemic.”

Negotiations over a new pandemic relief bill broke down last week, in part because Democrats and Republicans could not agree on funding for state and local governments.

KHN and the AP requested detailed spending breakdowns from recipients of money from the Coronavirus Relief Fund — created in March as part of the $1.9 trillion CARES Act — and received responses from 23 states and 62 cities and counties. Those entities dedicated 23% of their spending from the fund through June to public health and 7% to public health and safety payroll.

An additional 22% was transferred to local governments, some of which will eventually pass it down to health departments. The rest went to other priorities, such as distance learning.

So little money has flowed to some local health departments for many reasons: Bureaucracy has bogged things down, politics have crept into the process, and understaffed departments have struggled to take time away from critical needs to navigate the red tape required to justify asking for extra dollars.

“It does not make sense to me how anyone thinks this is a way to do business,” said E. Oscar Alleyne, chief of programs and services at the National Association of County and City Health Officials. “We are never going to get ahead of the pandemic response if we are still handicapped.”

Last month, KHN and the AP detailed how state and local public health departments across the U.S. have been starved for decades. Over 38,000 public health worker jobs have been lost since 2008, and per capita spending on local health departments has been cut by 18% since 2010. That’s left them underfunded and without adequate resources to confront the coronavirus pandemic.

“Public health has been cut and cut and cut over the years, but we’re so valuable every time you turn on the television,” said Jan Morrow, the director and 41-year veteran of Ripley County health department in rural Missouri. “We are picking up all the pieces, but the money is not there. They’ve cut our budget until there’s nothing left.”

Politics and Red Tape

Why did the Minneapolis health department have to wait so long for CARES Act money?

Congress mandated that the Coronavirus Relief Fund be distributed to states and local governments based on population. Minneapolis, with 430,000 residents, missed the threshold of 500,000 people that would have allowed it to receive money directly.

The state of Minnesota, however, received $1.87 billion, a portion of which was meant to be sent to local communities. Lawmakers initially sent some state money to tide communities over until the federal money came through — the Minneapolis health department got about $430,000 in state money to help pay for things like testing.

But when it came time to decide how to use the CARES Act money, lawmakers in Minnesota’s Republican-controlled Senate and Democratic-controlled House were at loggerheads.

Myron Frans, commissioner of Minnesota Management and Budget, said that disagreement, on top of the economic crisis and pandemic, left the legislature in turmoil.

After the police killing of George Floyd in Minneapolis, the city erupted in protests over racial injustice, making a difficult situation even more challenging.

Democratic Gov. Tim Walz favored targeting some of the money to harder-hit communities, a move that might have helped Minneapolis, where cases have surged since mid-July. But lawmakers couldn’t agree. Negotiations dragged on, and a special session merely prolonged the standoff.

Finally, the governor divvied up the money using a population-based formula developed earlier by Republican and Democratic legislative leaders that did not take into account COVID-19 caseloads or racial disparities.

“We knew we needed to get it out the door,” Frans said.

The state then sent hundreds of millions of dollars to local communities. Still, even after the money got to Minneapolis a month ago, Musicant had to wait as city leaders made difficult choices about how to spend the money as the economy cratered and the list of needs grew.

“Even when it gets to the local government, you still have to figure out how to get it to local public health,” Musicant said.

Meanwhile, some in Minneapolis have noticed a lack of services. Dr. Jackie Kawiecki has been providing help to people at a volunteer medical station near the place where Floyd was killed ― an area that at times has drawn hundreds or thousands of people per day. She said the city did not do enough free, easy-to-access testing in its neighborhoods this summer.

“I still don’t think that the amount of testing offered is adequate, from a public health standpoint,” Kawiecki said.

A coalition of groups that includes the National Governors Association has blamed the spending delays on the federal government, saying the final guidance on how states could spend the money came late in June, shortly before the reporting period ended. The coalition said state and local governments had moved “expeditiously and responsibly” to use the money as they deal with skyrocketing costs for health care, emergency response and other vital programs.

New York’s Nassau County was among six counties, cities and states that had spent at least 75% of its funds by June 30.

While most of the money was not spent before then, the National Association of State Budget Officers says a July 23 survey of 45 states and territories found they had allocated, or set aside, an average of 74% of the money.

But if they have, that money has been slow to make it to many local health departments.

As of mid-July in Missouri, at least 50 local health departments had yet to receive any of the federal money they requested, according to a state survey. The money must first flow through local county commissioners, some of whom aren’t keen on sending money to public health agencies.

“You closed their businesses down in order to save their people’s lives and so that hurt the economy,” said Larry Jones, executive director of the Missouri Center for Public Health Excellence, an organization of public health leaders. “So they’re mad at you and don’t want to give you money.”

The winding path federal money takes as it makes its way to states and cities also could exacerbate the stark economic and health inequalities in the U.S. if equity isn’t considered in decision-making, said Wizdom Powell, director of the University of Connecticut Health Disparities Institute.

“Problems are so vast you could unintentionally further entrench inequities just by how you distribute funds,” Powell said.

‘Everything Fell Behind’

The amounts eventually distributed can induce head-scratching.

Some cities received large federal grants, including Louisville, Kentucky, whose health department was given $42 million by April, more than doubling its annual budget. Because of the way the money was distributed, Louisville’s health department alone received more money from the CARES Act than the entire government of the city of Minneapolis, which received $32 million in total.

Philadelphia’s health department was awarded $100 million from a separate fund from the Centers for Disease Control and Prevention.

Honolulu County, where COVID cases have remained relatively low, received $124,454 for every positive case it had reported as of Aug. 9, while El Paso County in Texas got just $1,685 per case. Multnomah County, Oregon — with nearly a quarter of its state’s COVID-19 cases — landed only 2%, or $28 million, of the state’s $1.6 billion allotment.

Rural Saline County in Missouri received the same funding as counties of similar size, even though the virus hit the area particularly hard. In April, outbreaks began tearing through a Cargill meatpacking plant and a local factory there. By late May, the health department confirmed 12 positive cases at a local jail.

Tara Brewer, Saline’s health department administrator, said phone lines were ringing off the hook, jamming the system. Eventually, several department employees handed out their personal cellphone numbers to take calls from residents looking to be tested or seeking care for coronavirus symptoms.

“Everything fell behind,” Brewer said.

The school vaccination clinic in April was canceled, and a staffer who works as a Spanish translator for the Women, Infants and Children nutritional program was enlisted to contact-trace for additional COVID-19 exposures. All food inspections stopped.

It was late July when $250,000 in federal CARES Act money finally reached the 11-person health department, Brewer said — four months after Congress approved the spending and three months after the county’s first outbreak.

That was far too late for Brewer to hire the army of contact tracers that might have helped slow the spread of the virus back in April. She said the money already has been spent on antibody testing and reimbursements for groceries and medical equipment the department had bought for quarantined residents.

Another problem: Some local health officials say that the laborious process required to qualify for some of the federal aid discourages overworked public health officials from even trying to secure more money and that funds can be uneven in arriving.

Lisa Macon Harrison, public health director for Granville Vance Public Health in rural Oxford, North Carolina, said it’s tough to watch major hospital systems — some of which are sitting on billions in reserves — receive direct deposits, while her department received only about $122,000 through three grants by the end of July. Her team filled out a 25-page application just to get one of them.

She is now waiting to receive an estimated $400,000 more. By contrast, the Duke University Hospital System, which includes a facility that serves Granville, already has received over $67.3 million from the federal Provider Relief Fund.

“I just don’t understand the extra layers of onus for the bureaucracy, especially if hundreds of millions of dollars are going to the hospitals and we have to be responsible to apply for 50 grants,” she said.

The money comes from dozens of funds, including several programs within the CARES Act. Nebraska alone received money from 76 federal COVID relief funding sources.

Robert Miller, director of health for the Eastern Highlands Health District in Connecticut, which covers 10 towns, received $29,596 of the $2.5 million the state distributed to local departments from the CDC fund and nothing from CARES. It was only enough to pay for some contact tracing and employee mileage.

Miller said that he could theoretically apply for a little more from the Federal Emergency Management Agency, but that the reporting requirements — which include collecting every receipt — are extremely cumbersome for an already overburdened department.

So he wonders: “Is the squeeze worth the juice?”

Back in Minneapolis, Musicant said the new money from CARES allowed the department to run a free COVID-19 testing site Saturday, at a church that serves the Hispanic community about a mile from the site of Floyd’s killing.

It will take more money to do everything the community needs, she says, but with Congress deadlocked, she’s not sure they’ll get it anytime soon.

AP writers Camille Fassett and Steve Karnowski contributed to this report.

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One of the latest departures came Sunday, when California’s public health director, Dr. Sonia Angell, was ousted following a technical glitch that caused a delay in reporting virus test results — information used to make decisions about reopening businesses and schools.

Last week, New York City’s health commissioner was replaced after months of friction with the police department and City Hall.

A review by KHN and The Associated Press finds at least 49 state and local public health leaders have resigned, retired or been fired since April across 23 states. The list has grown by more than 20 people since the AP and KHN started in June.

Dr. Tom Frieden, former director of the Centers for Disease Control and Prevention, called the numbers stunning. He said they reflect burnout, as well as attacks on public health experts and institutions from the highest levels of government, including from President Donald Trump, who has sidelined the CDC during the pandemic.

“The overall tone toward public health in the U.S. is so hostile that it has kind of emboldened people to make these attacks,” Frieden said.

The past few months have been “frustrating and tiring and disheartening” for public health officials, said former West Virginia public health commissioner Dr. Cathy Slemp, who was forced to resign by Republican Gov. Jim Justice in June.

“You care about community, and you’re committed to the work you do and societal role that you’re given. You feel a duty to serve, and yet it’s really hard in the current environment,” Slemp said in an interview Monday.

The departures come at a time when public health expertise is needed more than ever, said Lori Tremmel Freeman, CEO of the National Association of County and City Health Officials.

“We’re moving at breakneck speed here to stop a pandemic, and you can’t afford to hit the pause button and say, ‘We’re going to change the leadership around here and we’ll get back to you after we hire somebody,’” Freeman said.

As of Monday, confirmed infections in the United States stood at over 5 million, with deaths topping 163,000, the highest in the world, according to the count kept by Johns Hopkins University researchers. The confirmed number of coronavirus cases worldwide topped 20 million.

Many of the firings and resignations have to do with conflicts over mask orders or shutdowns to enforce social distancing, Freeman said. Despite the scientific evidence that such measures help prevent transmission of the coronavirus, many politicians and others have argued they are not needed, no matter what health experts tell them.

“It’s not a health divide; it’s a political divide,” Freeman said.

Some health officials said they were stepping down for family reasons, and some left for jobs at other agencies, such as the CDC. Some, , were ousted because of what higher-ups said was or a failure to do their job.

Others have complained that they were overworked, underpaid, unappreciated or thrust into a pressure-cooker environment.

“To me, a lot of the divisiveness and the stress and the resignations that are happening right and left are the consequence of the lack of a real national response plan,” said Dr. Matt Willis, health officer for Marin County in Northern California. “And we’re all left scrambling at the local and state level to extract resources and improvise solutions.”

Public health leaders from Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, down to officials in small communities have reported death threats and intimidation. Some have seen their home addresses published or been the subject of sexist attacks on social media. Fauci has said his have received threats.

In Ohio, the state’s health director, Dr. Amy Acton, resigned in June after months of pressure during which Republican lawmakers tried to strip her of her authority and armed protesters showed up at her house.

It was on Acton’s advice that GOP Gov. Mike DeWine became the first governor to shut down schools statewide. Acton also called off the state’s presidential primary in March just hours before polls were to open, angering those who saw it as an overreaction.

The executive director of Las Animas-Huerfano Counties District Health Department in Colorado, Kim Gonzales, found her car vandalized twice, and a group called Colorado Counties for Freedom ran a radio ad demanding that her authority be reduced. Gonzales has remained on the job.

In West Virginia, the governor forced Slemp’s resignation over what he said were discrepancies in the data. Slemp said the department’s work had been hurt by and slow computer networks. Tom Inglesby, director of the UPMC Center for Health Security at Johns Hopkins, said the issue amounted to a clerical error easily fixed.

Inglesby said it was deeply concerning that public health officials who told “uncomfortable truths” to political leaders had been removed.

“That’s terrible for the national response because what we need for getting through this, first of all, is the truth. We need data, and we need people to interpret the data and help political leaders make good judgments,” Inglesby said.

Since 2010, spending on state public health departments has dropped 16% per capita, and the amount devoted to local health departments has fallen 18%, according to a . At least 38,000 state and local public health jobs have disappeared since the 2008 recession, leaving a skeleton workforce for what was once viewed as one of the world’s top public health systems.

Another sudden departure came Monday along the Texas border. Dr. Jose Vazquez, the Starr County health authority, resigned after a proposal to increase his pay from $500 to $10,000 a month was rejected by county commissioners.

Starr County Judge Eloy Vera, a county commissioner who supported the raise, said Vazquez had been working 60 hours per week in the county, one of the poorest in the U.S. and recently one of those hit hardest by the virus.

“He felt it was an insult,” Vera said.

In Oklahoma, both the state health commissioner and state epidemiologist have been replaced since the outbreak began in March.

In rural Colorado, Emily Brown was fired in late May as director of the Rio Grande County Public Health Department after clashing with county commissioners over reopening recommendations. The person who replaced her resigned July 9.

The months of nonstop and often unappreciated work are prompting many public health workers to leave, said Theresa Anselmo of the Colorado Association of Local Public Health Officials.

“It will certainly slow down the pandemic response and become less coordinated,” she said. “Who’s going to want to take on this career if you’re confronted with the kinds of political issues that are coming up?”

Weber reported from St. Louis. Associated Press writers Paul Weber, Sean Murphy and Janie Har and California Healthline senior correspondent Anna Maria Barry-Jester contributed reporting.

This story is a collaboration between KHN and The Associated Press.

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Republican Gov. Jim Justice  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 .

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.

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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 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.

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 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.

Dr. Gianfranco Pezzino, health officer in Shawnee County, Kansas

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.”

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 . 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 43%, from a high of $59 in inflation-adjusted dollars per person in the late 1990s to $34 per person in 2019.

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 by the Association of State and Territorial Health Officials and the de Beaumont Foundation.

Even before the pandemic, 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.

Scott Becker, chief executive officer of the Association of Public Health Laboratories

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.”

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 [5] 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.

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 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.

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 at the time or why residents were willing to pay hundreds of 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 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 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.

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As the director of the Rio Grande County Public Health Department in rural Colorado, she was working 12- and 14-hour days, struggling to respond to the pandemic with only five full-time employees for more than 11,000 residents. Case counts were rising.

She was already at odds with county commissioners, who were pushing to loosen public health restrictions in late May, against her advice. She had previously clashed with them over data releases and had haggled over a variance regarding reopening businesses.

But she reasoned that standing up for public health principles was worth it, even if she risked losing the job that allowed her to live close to her hometown and help her parents with their farm.

Then came the Facebook post: a photo of her and other health officials with comments about their weight and references to “armed citizens” and “bodies swinging from trees.”

The commissioners had asked her to meet with them the next day. She intended to ask them for more support. Instead, she was fired.

“They finally were tired of me not going along the line they wanted me to go along,” she said.

In the battle against COVID-19, public health workers spread across states, cities and small towns make up an invisible army on the front lines.  But that army, which has suffered neglect for decades, is under assault when it’s needed most.

Officials who usually work behind the scenes managing everything from immunizations to water quality inspections have found themselves center stage. Elected officials and members of the public who are frustrated with the lockdowns and safety restrictions have at times turned public health workers into politicized punching bags, battering them with countless angry calls and even physical threats.

On Thursday, Ohio’s state health director, who had armed protesters come to her house, resigned. The health officer for Orange County, California, after weeks of criticism and personal threats from residents and other public officials over an order requiring face coverings in public.

As the pressure and scrutiny rise, many more health officials have chosen to leave or been pushed out of their jobs. A review by KHN and The Associated Press finds at least 27 state and local health leaders have resigned, retired or been fired since April across 13 states.

From North Carolina to California, they have left their posts due to a mix of backlash and stressful, nonstop working conditions, all while dealing with chronic staffing and funding shortages.

Some health officials have not been up to the job during the biggest health crisis in a century. Others previously had plans to leave or cited their own health issues.

But Lori Tremmel Freeman, CEO of the National Association of County and City Health Officials, said the majority of what she calls an “alarming” exodus resulted from increasing pressure as states reopen. Three of those 27 were members of her board and well known in the public health community — Rio Grande County’s Brown; Detroit’s senior public health adviser, Dr. Kanzoni Asabigi; and the head of North Carolina’s Gaston County Department of Health and Human Services, Chris Dobbins.

Asabigi’s sudden retirement, considering his stature in the public health community, shocked Freeman. She also was upset to hear about the departure of Dobbins, who was chosen as health director of the year for North Carolina . Asabigi and Dobbins did not reply to requests for comment.

“They just don’t leave like that,” Freeman said.

Public health officials are “really getting tired of the ongoing pressures and the blame game,” Freeman said. She warned that more departures could be expected in the coming days and weeks as political pressure trickles down from the federal to the state to the local level.

From the beginning of the coronavirus pandemic, federal public health officials have complained of being . The Centers for Disease Control and Prevention has been ; a government because he opposed a White House directive to allow widespread access to the malaria drug hydroxychloroquine as a COVID-19 treatment.

In Hawaii, U.S. Rep. Tulsi Gabbard called on the governor to fire his top public health officials, saying she believed they were too slow on testing, contact tracing and travel restrictions. In Wisconsin, several Republican lawmakers have repeatedly demanded that the state’s health services secretary resign, and the state’s conservative Supreme Court ruled 4-3 that she had exceeded her authority by extending a stay-at-home order.

With the increased public scrutiny, security details — like those seen on a federal level for Dr. Anthony Fauci, the top infectious disease expert — have been assigned to state health leaders, including Georgia’s after she was threatened. Ohio’s Dr. Amy Acton, who also had a security detail assigned after armed protesters showed up at her home, resigned Thursday.

In Orange County, in late May, nearly a hundred people attended a county supervisors meeting, waiting hours to speak against an order requiring face coverings. One person suggested that the order might make it necessary to invoke Second Amendment rights to bear arms, while another read aloud the home address of the order’s author — the county’s chief health officer, Dr. Nichole Quick — as well as the name of her boyfriend.

Quick, attending by phone, left the meeting. In a statement, the sheriff’s office later said Quick had expressed concern for her safety following “several threatening statements both in public comment and online.” She was given personal protection by the sheriff.

But Monday, after yet another public meeting that included criticism from members of the board of supervisors, Quick resigned. She could not be reached for comment. Earlier, the county’s deputy director of public health services, David Souleles, retired abruptly.

An official in another California county also has been given a security detail, said Kat DeBurgh, the executive director of the Health Officers Association of California, declining to name the county or official because the threats have not been made public.

Many local health leaders, accustomed to relative anonymity as they work to protect the public’s health, have been shocked by the growing threats, said Theresa Anselmo, the executive director of the Colorado Association of Local Public Health Officials.

After polling local health directors across the state at a meeting last month, Anselmo found about 80% said they or their personal property had been threatened since the pandemic began. About 80% also said they’d encountered threats to pull funding from their department or other forms of political pressure.

To Anselmo, the ugly politics and threats are a result of the politicization of the pandemic from the start. So far in Colorado, six top local health officials have retired, resigned or been fired. A handful of state and local health department staff members have left as well, she said.

“It’s just appalling that in this country that spends as much as we do on health care that we’re facing these really difficult ethical dilemmas: Do I stay in my job and risk threats, or do I leave because it’s not worth it?” Anselmo asked.

In California, senior health officials from seven counties, including Quick and Souleles, have resigned or retired since March 15. Dr. Charity Dean, the second in command at the state Department of Public Health, submitted her resignation June 4. Burnout seems to be contributing to many of those decisions, DeBurgh said.

In addition to the harm to current officers, DeBurgh is worried about the impact these events will have on recruiting people into public health leadership.

“It’s disheartening to see people who disagree with the order go from attacking the order to attacking the officer to questioning their motivation, expertise and patriotism,” said DeBurgh. “That’s not something that should ever happen.”

Some of the online abuse has been going on for years, said Bill Snook, a spokesperson for the health department in Kansas City, Missouri. He has seen instances in which people took a health inspector’s name and made a meme out of it, or said a health worker should be strung up or killed. He said opponents of vaccinations, known as anti-vaxxers, have called staffers “baby killers.”

The pandemic, though, has brought such behavior to another level.

In Ohio, the Delaware General Health District has had two lockdowns since the pandemic began — one after an angry individual came to the health department. Fortunately, the doors were locked, said Dustin Kent, program manager for the department’s residential services unit.

Angry calls over contact tracing continue to pour in, Kent said.

In Colorado, the Tri-County Health Department, which serves Adams, Arapahoe and Douglas counties near Denver, has also been getting hundreds of calls and emails from frustrated citizens, deputy director Jennifer Ludwig said.

Some have been angry their businesses could not open and blamed the health department for depriving them of their livelihood. Others were furious with neighbors who were not wearing masks outside. It’s a constant wave of “confusion and angst and anxiety and anger,” she said.

Then in April and May, rocks were thrown at one of their office’s windows — . The office was tagged with obscene graffiti. The department also received an email calling members of the department “tyrants,” adding “you’re about to start a hot-shooting … civil war.”  Health department workers decamped to another office.

Although the police determined there was no imminent threat, Ludwig stressed how proud she was of her staff, who weathered the pressure while working round-the-clock.

“It does wear on you, but at the same time we know what we need to do to keep moving to keep our community safe,” she said. “Despite the complaints, the grievances, the threats, the vandalism — the staff have really excelled and stood up.”

The threats didn’t end there, however: Someone asked on the health department’s Facebook page how many people would like to know the home addresses of the Tri-County Health Department leadership. “You want to make this a war??? No problem,” the poster wrote.

Back in Colorado’s Rio Grande County, some members of the community have rallied in support of Brown with and a of a local paper. Meanwhile, COVID-19 case counts have jumped from 14 to .

Brown is grappling with what she should do next: dive back into another strenuous public health job in a pandemic, or take a moment to recoup?

When she told her 6-year-old son she no longer had a job, he responded: “Good — now you can spend more time with us.”

This story is a collaboration between The Associated Press and Kaiser Health News.

AP writer Audrey McAvoy in Honolulu and KHN correspondent Angela Hart in Sacramento contributed to this report.

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Public health officials who have juggled bare-bones budgets for years are happy to have the additional money. Yet they worry it will soon dry up as the pandemic recedes, continuing a boom-bust funding cycle that has plagued the U.S. public health system for decades. If budgets are slashed again, they warn, that could leave the nation where it was before covid: unprepared for a health crisis.

“We need funds that we can depend on year after year,” said Dr. Mysheika Roberts, the health commissioner of Columbus, Ohio.

When Roberts started in Columbus in 2006, an emergency preparedness grant paid for more than 20 staffers. By the time the coronavirus pandemic hit, it paid for about 10. Relief money that came through last year helped the department staff up its covid response teams. While the funding has helped the city cope with the immediate crisis, Roberts wonders if history will repeat itself.

After the pandemic is over, public health officials across the U.S. fear, they’ll be back to scraping together money from a patchwork of sources to provide basic services to their communities — much like after 9/11, SARS and Ebola.

When the mosquito-borne Zika virus tore through South America in 2016, causing serious birth defects in newborn babies, members of Congress couldn’t agree how, and how much, to spend in the U.S. for prevention efforts, such as education and mosquito abatement. The Centers for Disease Control and Prevention took money from its Ebola efforts, and from state and local health department funding, to pay for the initial Zika response. Congress eventually allocated $1.1 billion for Zika, but by then mosquito season had passed in much of the U.S.

“Something happens, we throw a ton of money at it, and then in a year or two we go back to our shrunken budgets and we can’t do the minimum things we have to do day in and day out, let alone be prepared for the next emergency,” said Chrissie Juliano, executive director of the Big Cities Health Coalition, which represents leaders of more than two dozen public health departments.

Funding for Public Health Emergency Preparedness, which pays for emergency capabilities for state and local health departments, dropped by about half between the 2003 and 2021 fiscal years, accounting for inflation, according to , a public health research and advocacy organization.

Even the federal , established with the Affordable Care Act to provide $2 billion a year for public health, was raided for cash over the past decade. If the money hadn’t been touched, eventually local and state health departments would have gotten an additional $12.4 billion.

Several lawmakers, led by Democratic U.S. Sen. Patty Murray of Washington, are looking to end the boom-bust cycle with that would eventually provide $4.5 billion annually in core public health funding. Health departments carry out essential government functions — such as managing water safety, issuing death certificates, tracking sexually transmitted diseases and preparing for infectious outbreaks.

Spending for state public health departments dropped by 16% per capita from 2010 to 2019, and spending for local health departments fell by 18%, KHN and The Associated Press found in a July investigation. At least 38,000 public health jobs were lost at the state and local level between the 2008 recession and 2019. Today, many public health workers are hired on a temporary or part-time basis. Some are paid so poorly they qualify for public aid. Those factors reduce departments’ ability to retain people with expertise.

Compounding those losses, the pandemic has prompted an exodus of public health officials because of harassment, political pressure and exhaustion. A yearlong analysis by the AP and KHN found at least 248 leaders of state and local health departments resigned, retired or were fired between April 1, 2020, and March 31, 2021. Nearly 1 in 6 Americans lost a local public health leader during the pandemic. Experts say it is the largest exodus of public health leaders in American history.

Brian Castrucci, CEO of the de Beaumont Foundation, which advocates for public health, calls Congress’ giant influx of cash in response to the crisis “wallpaper and drapes” because it doesn’t restore public health’s crumbling foundation.

“I worry at the end of this we’re going to hire up a bunch of contact tracers — and then lay them off soon thereafter,” Castrucci said. “We are continuing to kind of go from disaster to disaster without ever talking about the actual infrastructure.”

Castrucci and others say dependable money is needed for high-skill professionals, such as epidemiologists — data-driven disease detectives — and for technology upgrades that would help track outbreaks and get information to the public.

In Ohio, the computer system used to report cases to the state predates the invention of the iPhone. State officials had said for years they wanted to upgrade it, but they lacked the money and political will. Many departments across the country have relied on to report covid cases.

During the pandemic, Ohio’s that nearly 96% of local health departments it surveyed had problems with the state’s disease reporting system. Roberts said workers interviewing patients had to navigate several pages of questions, a major burden when handling 500 cases daily.

The system was so outdated that some information could be entered only in a non-searchable comment box, and officials struggled to pull data from the system to report to the public — such as how many people who tested positive had attended a Black Lives Matter rally, which last summer was a key question for people trying to understand whether protests contributed to the virus’s spread.

Ohio is working on a new system, but Roberts worries that, without a dependable budget, the state won’t be able to keep that one up to date either. 

“You’re going to need to upgrade that,” Roberts said. “And you’re going to need dollars to support that.”

In Washington, the public health director for Seattle and King County, Patty Hayes, said she is asked all the time why there isn’t a single, central place to register for a vaccine appointment. The answer comes down to money: Years of underfunding left departments across the state with antiquated computer systems that were not up to the task when covid hit.

Hayes recalls a time when her department would conduct mass vaccination drills, but that system was dismantled when the money dried up after the specter of 9/11 faded.

Roughly six years ago, an analysis found that her department was about $25 million short of what it needed annually for core public health work. Hayes said the past year has shown that’s an underestimate. For example, climate change is prompting more public health concerns, such as the effect on residents when wildfire smoke engulfed much of the Pacific Northwest in September.

Public health officials in some areas may struggle to make the case for more stable funding because a large swath of the public has questioned — and often been openly hostile toward — the mask mandates and business restrictions that public health officials have imposed through the pandemic.

In Missouri, some county commissioners who were frustrated at public health restrictions withheld money from the departments.

In Knox County, Tennessee, Mayor Glenn Jacobs narrated posted in the fall that showed a photo of health officials after referencing “sinister forces.” Later, someone spray-painted “DEATH” on the department office building. The Board of Health was stripped of its powers in March and given an advisory role. A spokesperson for the mayor’s office declined to comment on the video.

“This is going to change the position of public health and what we can and cannot do across the country,” said Dr. Martha Buchanan, the head of the health department. “I know it’s going to change it here.”

A found at least 24 states were crafting legislation that would limit or remove public health powers.

Back in Seattle, locally based companies have pitched in money and staff members for vaccine sites. Microsoft is hosting one location, while Starbucks offered customer service expertise to help design the sites. Hayes is grateful, but she wonders why a critical government function didn’t have the resources it needed during a pandemic.

If public health had been getting dependable funding, her staff could have been working more effectively with the data and preparing for emerging threats in the state where the was confirmed.

“They’ll look back at this response to the pandemic in this country as a great example of a failure of a country to prioritize the health of its citizens, because it didn’t commit to public health,” she said. “That will be part of the story.”

KHN senior correspondent Anna Maria Barry-Jester and Montana correspondent Katheryn Houghton contributed to this report.

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Tisha Coleman has lived in close-knit Linn County, Kansas, for 42 years and never felt so alone.

As the public health administrator, she’s struggled every day of to keep her rural county along the Missouri border safe. In this community with no hospital, she’s failed to persuade her neighbors to wear masks and take precautions against COVID-19, even as cases rise. In return, she’s been harassed, sued, vilified — and called a Democrat, an insult in her circles.

Even her husband hasn’t listened to her, refusing to require customers to wear masks at the family’s hardware store in Mound City.

“People have shown their true colors,” Coleman said. “I’m sure that I’ve lost some friends over this situation.”

By November, the months of fighting over masks and quarantines were already wearing her down. Then she got COVID-19, likely from her husband, who she thinks picked it up at the hardware store. Her mother got it, too, and died on Sunday, 11 days after she was put on a ventilator.

Across the U.S., state and local public health officials such as Coleman have found themselves at the center of a political storm as they combat . Amid a fractured federal response, the usually invisible army of workers charged with preventing the spread of infectious diseases has . Their expertise on how to fight the coronavirus is often disregarded.

Some have become the target of far-right activists, conservative groups and anti-vaccination extremists, who have coalesced around common goals — fighting mask orders, quarantines and contact tracing with protests, threats and personal attacks.

The backlash has moved beyond the angry fringe. In the courts, public health powers are being undermined. Lawmakers in at least 24 states have crafted legislation to weaken public health powers, which could make it more difficult for communities to respond to other health emergencies in the future.

“What we’ve taken for granted for 100 years in public health is now very much in doubt,” said Lawrence Gostin, an expert in public health law at Georgetown University in Washington, D.C.

It is a further erosion of the nation’s already fragile public health infrastructure. At least 181 state and local public health leaders in 38 states have resigned, retired or been fired since April 1, according to an by The Associated Press and KHN. According to experts, this is the largest exodus of public health leaders in American history. An untold number of lower-level staffers has also left.

“I’ve never seen or studied a pandemic that has been as politicized, as vitriolic and as challenged as this one, and I’ve studied a lot of epidemics,” said Dr. Howard Markel, a medical historian at the University of Michigan. “All of that has been very demoralizing for the men and women who don’t make a great deal of money, don’t get a lot of fame, but work 24/7.”

One in 8 Americans — 40 million people — lives in a community that has lost its local public health department leader during the pandemic. Top public health officials in 20 states have left state-level departments, including in North Dakota, which has lost three state health officers since May, one after another.

Many of the state and local officials left due to political blowback or pandemic pressure. Some departed to take higher-profile positions or due to health concerns. Others were fired for poor performance. Dozens retired.

KHN and AP reached out to public health workers and experts in every state and the National Association of County and City Health Officials; examined public records and news reports; and interviewed hundreds to gather the list.

Collectively, the loss of expertise and experience has created a leadership vacuum in the profession, public health experts say. Many health departments are in flux as the nation rolls out and faces what are expected to be the worst months of the pandemic.

“We don’t have a long line of people outside of the door who want those jobs,” said Dr. Gianfranco Pezzino, health officer in Shawnee County, Kansas, who had decided to retire from his job at the end of the year, he said, because he’s burned out. “It’s a huge loss that will be felt probably for generations to come.”

But Pezzino could not even make it to Dec. 31. On Monday, after county commissioners , he . 

“You value the pressure from people with special economic interests more than science and good public health practice,” he to the commissioners. “In full conscience I cannot continue to serve as the health officer for a board that puts being able to patronize bars and sports venues in front of the health, lives and well-being of a majority of its constituents.”

Existing Problems

The departures accelerate problems that had already weakened the nation’s public health system. that per capita spending for state public health departments had dropped by 16%, and for local health departments by 18%, since 2010. At least 38,000 state and local public health jobs have disappeared since the 2008 recession.

Those diminishing resources were already prompting high turnover. Before the pandemic, nearly half of public health workers said in a survey they planned to retire or leave in the next five years. The top reason given was low pay.

Such reduced staffing in departments that have the power and responsibility to manage everything from water inspections to childhood immunizations left public health workforces ill-equipped when COVID-19 arrived. Then, when pandemic shutdowns cut tax revenues, some state and local governments cut their public health workforces further.

“Now we’re at this moment where we need this knowledge and leadership the most, everything has come together to cause that brain drain,” said Chrissie Juliano, executive director of the Big Cities Health Coalition, which represents leaders of more than two dozen public health departments.

Politics as Public Health Poison

Public health experts broadly agree that and save lives and livelihoods. Scientists say that and curtailing indoor activities can also help.

But with the pandemic coinciding with , simple acts such as wearing a mask morphed into , with right-wing conservatives saying such requirements stomped on individual freedom.

On the campaign trail, President Donald Trump ridiculed President-elect Joe Biden for wearing a mask and egged on by tweeting

Coleman, a Christian and a Republican, said that’s just what happened in Linn County. “A lot of people are shamed into not wearing a mask … because you’re considered a Democrat,” she said. “I’ve been called a ‘sheep.’”

The politicization has put some local governments at odds with their own health officials. In California, near Lake Tahoe, the Placer County Board of Supervisors voted to end a local health emergency and declared support for a widely discredited “herd immunity” strategy, which would let the virus spread. The idea is endorsed by many conservatives, including , as a way to keep the economy running, but it has been denounced by public health experts who say millions more people will unnecessarily suffer and die. The supervisors also endorsed a false conspiracy theory claiming many COVID-19 deaths are not actually from COVID-19.

The meeting occurred just days after county Public Health Officer Dr. Aimee Sisson explained to the board the rigorous standards used for counting COVID-19 deaths. Sisson quit the next day.

In Idaho, protests against public health measures are intensifying. Hundreds of protesters, some armed, and health board members’ homes in Boise on Dec. 8, screaming and blaring air horns. They included members of the anti-vaccination group Health Freedom Idaho.

Dr. Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine, has tracked the anti-vaccine movement and said it has linked up with political extremists on the right, and taken on a larger anti-science role, pushing back against other public health measures such as contact tracing and physical distancing.

Members of a group called the Freedom Angels in California, which sprung up in 2019 around a state law to tighten vaccine requirements, have been organizing protests at health departments, posing with guns and calling themselves a militia on the group’s Facebook page.

The latest Idaho protests came after a July skirmish in which Ammon Bundy who tried to stop him and his maskless supporters from entering a health meeting.

Bundy, whose family led armed standoffs against federal agents in 2014 and 2016, has become , most recently forming a multistate network called People’s Rights that has organized protests against public health measures.

“We don’t believe they have a right to tell us that we have to put a manmade filter over our face to go outside,” Bundy said. “It’s not about, you know, the mandates or the mask. It’s about them not having that right to do it.”

Kelly Aberasturi, vice chair for the Southwest District Health, which covers six counties, said the worker Bundy shoved was “just trying to do his job.”

Aberasturi, a self-described “extremist” right-wing Republican, said he, too, has been subjected to the backlash. Aberasturi doesn’t support mask mandates, but he did back the board’s recommendation that people in the community wear masks. He said people who believe even a recommendation goes too far have threatened to protest at his house.

The Mask Fight in Kansas

The public health workforce in Kansas has been hit hard — 17 of the state’s 100 health departments have lost their leaders since the end of March. 

Democratic Gov. Laura Kelly in July, but the state legislature allowed counties to opt out. A recent showed the 24 Kansas counties that had upheld the mandate saw a 6% decrease in COVID-19, while the 81 counties that opted out entirely saw a 100% increase.

Coleman, who pushed unsuccessfully for Linn County to uphold the rule, was sued for putting a community member into quarantine, a lawsuit she won. In late November, she spoke at a to discuss a new mask mandate — it was her first day back in the office after her own bout with COVID-19.

She pleaded for a plan to help stem the surge in cases. One resident referenced Thomas Jefferson, saying, “I prefer a dangerous freedom over a peaceful slavery.” Another falsely argued that masks caused elevated carbon dioxide. Few, besides Coleman, wore a mask at the meeting.

Commissioner Mike Page supported the mask order, noting that a close friend was fighting COVID-19 in the hospital and saying he was “ashamed” that members of the community had sued their public health workers while other communities supported theirs.

In the end, the commissioners encouraged community members to wear masks but opted out of a county-wide rule, writing they had determined that they are “not necessary to protect the public health and safety of the county.”

Coleman was disappointed but not surprised. “At least I know I’ve done everything I can to attempt to protect the people,” she said.

The next day, Coleman discussed Christmas decorations with her mother as she drove her to the hospital.

Stripping of Powers

The state bill that let Linn County opt out of the governor’s mask mandate is one of dozens of efforts to erode public health powers in state legislatures across the country.

For decades, government authorities have had the legal power to stop foodborne illnesses and infectious diseases by closing businesses and quarantining individuals, among other measures.

When people contract tuberculosis, for example, the local health department might isolate them, require them to wear a mask when they leave their homes, require family members to get tested, relocate them so they can isolate and make sure they take their medicine. Such measures are meant to protect everyone and avoid the shutdown of businesses and schools.

Now, opponents of those measures are turning to state legislatures and even the Supreme Court to strip public officials of those powers, defund local health departments or even dissolve them. The American Legislative Exchange Council, a corporate-backed group of conservative lawmakers, has published for .

Lawmakers in Missouri, Louisiana, Ohio, Virginia and at least 20 other states have crafted bills to limit public health powers. In some states, the efforts have failed; in others, legislative leaders have embraced them enthusiastically.

Tennessee’s Republican House leadership is backing a bill to constrain the state’s six local health departments, granting their powers to mayors instead. The bill stems from clashes between the mayor of Knox County and the local health board over mask mandates and business closures.

In Idaho, lawmakers to review the authority of local health districts in the next session. The move doesn’t sit right with Aberasturi, who said it’s hypocritical coming from state lawmakers who profess to believe in local control.

Meanwhile, governors in Wisconsin, Kansas and Michigan, among others, have been sued by their own legislators, state think tanks or others for using their executive powers to restrict business operations and require masks. In Ohio, a group of lawmakers is seeking to impeach Republican Gov. Mike DeWine over his pandemic rules.

The U.S. Supreme Court in 1905 found it was constitutional for officials to issue orders to protect the public health, in a case upholding a Cambridge, Massachusetts, requirement to get a smallpox vaccine. But a indicated the majority of justices are willing to put new constraints on those powers.

“It is time — past time — to make plain that, while the pandemic poses many grave challenges, there is no world in which the Constitution tolerates color-coded executive edicts that reopen liquor stores and bike shops but shutter churches, synagogues, and mosques,” Justice Neil Gorsuch wrote.

Gostin, the health law professor, said the decision could embolden state legislators and governors to weaken public health authority, creating “a snowballing effect on the erosion of public health powers and, ultimately, public’s trust in public health and science.”

Who’s Left?

Many health officials who have stayed in their jobs have faced not only political backlash but also threats of personal violence. Armed paramilitary groups have put public health in their sights.

In California, a man with ties to the right-wing, anti-government Boogaloo movement was accused of stalking and threatening Santa Clara’s health officer. The suspect was arrested and has pleaded not guilty. The Boogaloo movement is associated with multiple murders, including of a Bay Area sheriff deputy and federal security officer.

Linda Vail, health officer for Michigan’s Ingham County, has received emails and letters at her home saying she’d be “taken down like the governor,” which Vail took to be a reference to . Even as other health officials are leaving, Vail is choosing to stay despite the threats.

“I can completely understand why some people, they’re just done,” she said. “There are other places to go work.”

In mid-November, Danielle Swanson, public health administrator in Republic County, Kansas, said she was planning to resign as soon as she and enough of her COVID-19-positive staff emerged from isolation. Someone threatened to go to her department with a gun because of a quarantine, and she’s received hand-delivered hate mail and calls from screaming residents.

“It’s very stressful. It’s hard on me; it’s hard on my family that I do not see,” she said. “For the longest time, I held through it thinking there’s got to be an end in sight.”

Swanson said some of her employees have told her once she goes, they probably will not stay.

As public health officials depart across the country, the question of who takes their places has plagued Dr. Oxiris Barbot, who in August amid a clash with Democratic Mayor Bill de Blasio. During the height of the pandemic, the mayor empowered the city’s hospital system to lead the fight against COVID-19, passing over her highly regarded department.

“I’m concerned about the degree to which they will have the fortitude to tell elected officials what they need to hear instead of what they want to hear,” Barbot said.

In Kentucky, 189 employees, about 1 in 10, left local health departments from March through Nov. 21, according to Sara Jo Best, public health director of the Lincoln Trail District Health Department. That comes after a decade of decline: Staff numbers fell 49% from 2009 to 2019. She said workers are exhausted and can’t catch up on the overwhelming number of contact tracing investigations, much less run COVID-19 testing, combat flu season and prepare for COVID-19 vaccinations.

And the remaining workforce is aging. According to the de Beaumont Foundation, which advocates for local public health, 42% of governmental public health workers are over age 50.

Back in Linn County, cases are rising. As of Dec. 14, 1 out of every 24 residents has tested positive.

The day after her mother was put on a ventilator, Coleman fought to hold back tears as she described the 71-year-old former health care worker with a strong work ethic.

“Of course, I could give up and throw in the towel, but I’m not there yet,” she said, adding that she will “continue to fight to prevent this happening to someone else.”

Coleman, whose mother died Sunday, has noticed more people are wearing masks these days.

But at the family hardware store, they are still not required.

This story is a collaboration between The Associated Press and KHN.

Methodology

KHN and AP counted how many state and local public health leaders have left their jobs since April 1, or who plan to leave by Dec. 31.

The analysis includes the exits of top department officials regardless of the reason. Some departments have more than one top position and some had multiple top officials leave from the same position over the course of the pandemic.

To compile the list, reporters reached out to public health associations and experts in every state and interviewed hundreds of public health employees. They also received information from the National Association of County and City Health Officials, and combed news reports and public records, such as meeting minutes and news releases.

The population served by each local health department is calculated using the Census Bureau 2019 Population Estimates based on each department’s jurisdiction.

The count of legislation came from reviewing bills in every state, prefiled bills for 2021 sessions, where available, and news reports. The bills include limits on quarantines, contact tracing, vaccine requirements and emergency executive powers.

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By February, as the disease crept across the U.S., Keeley said she found her calling: a career in public health. “This is something that’s going to be necessary,” Keeley remembered thinking. “This is something I can do. This is something I’m interested in.”

In August, Keeley began studying at the University of Illinois at Urbana-Champaign to become an epidemiologist.

Public health programs in the United States have seen a surge in enrollment as the coronavirus has swept through the country, killing more than 246,000 people. As state and local public health departments struggle with unprecedented challenges — slashed budgets, surging demand, staff departures and even threats to workers’ safety — a new generation is entering the field.

Among the more than 100 schools and public health programs that use the common application — a single admissions application form that students can send to multiple schools — there was a 20% increase in applications to master’s in public health programs for the current academic year, to nearly 40,000, according to the Association of Schools and Programs of Public Health.

Some programs are seeing even bigger jumps. Applications to Brown University’s small master’s in public health program rose 75%, according to Annie Gjelsvik, a professor and director of the program.

Demand was so high as the pandemic hit full force in the spring that Brown extended its application deadline by over a month. Seventy students ultimately matriculated this fall, up from 41 last year.

“People interested in public health are interested in solving complex problems,” Gjelsvik said. “The COVID pandemic is a complex issue that’s in the forefront every day.”

It’s too early to say whether the jump in interest in public health programs is specific to that field or reflects a broader surge of interest in graduate programs in general, according to those who track graduate school admissions. Factors such as pandemic-related deferrals and disruptions in international student admissions make it difficult to compare programs across the board.

Magnolia E. Hernández, an assistant dean at Florida International University’s Robert Stempel College of Public Health and Social Work, said new student enrollments in its master’s in public health program grew 63% from last year. The school has especially seen an uptick in interest among Black students, from 21% of newly admitted students last fall to 26.8% this year.

Kelsie Campbell is one of them. She’s part Jamaican and part British. When she heard in both the British and American media that Black and ethnic minorities were being disproportionately hurt by the pandemic, she wanted to focus on why.

“Why is the Black community being impacted disproportionately by the pandemic? Why is that happening?” Campbell asked. “I want to be able to come to you and say ‘This is happening. These are the numbers and this is what we’re going to do.’”

The biochemistry major at Florida International said she plans to explore that when she begins her MPH program at Stempel College in the spring. She said she hopes to eventually put her public health degree to work helping her own community.

“There’s power in having people from your community in high places, somebody to fight for you, somebody to be your voice,” she said.

Public health students are already working on the front lines of the nation’s pandemic response in many locations. Students at Brown’s public health program, for example, are crunching infection data and tracing the spread of the disease for the Rhode Island Department of Health.

Some students who had planned to work in public health shifted their focus as they watched the devastation of COVID-19 in their communities. In college, Emilie Saksvig, 23, double-majored in civil engineering and public health. She was supposed to start working this year as a Peace Corps volunteer to help with water infrastructure in Kenya. She had dreamed of working overseas on global public health.

The pandemic forced her to cancel those plans, and she decided instead to pursue a master’s degree in public health at Emory University.

“The pandemic has made it so that it is apparent that the United States needs a lot of help, too,” she said. “It changed the direction of where I wanted to go.”

These students are entering a field that faced serious challenges even before the pandemic exposed the strains on the underfunded patchwork of state and local public health departments. An analysis by AP and KHN found that since 2010, per capita spending for state public health departments has dropped by 16%, and for local health departments by 18%. At least 38,000 state and local public health jobs have disappeared since the 2008 recession.

And the workforce is aging: Forty-two percent of governmental public health workers are over 50, according to the de Beaumont Foundation, and the field has high turnover. Before the pandemic, nearly half of public health workers said they planned to retire or leave their organizations for other reasons in the next five years. Poor pay topped the list of reasons. Some public health workers are paid so little that they qualify for public aid.

Brian Castrucci, CEO of the de Beaumont Foundation, which advocates for public health, said government public health jobs need to be a “destination job” for top graduates of public health schools.

“If we aren’t going after the best and the brightest, it means that the best and the brightest aren’t protecting our nation from those threats that can, clearly, not only devastate from a human perspective, but from an economic perspective,” Castrucci said.

The pandemic put that already-stressed public health workforce in the middle of what became a pitched political battle over how to contain the disease. As public health officials recommended closing businesses and requiring people to wear masks, many, including Dr. Anthony Fauci, the U.S. government’s top virus expert, faced threats and political reprisals, AP and KHN found. Many were pushed out of their jobs. An ongoing count by AP/KHN has found that more than 100 public health leaders in dozens of states have retired, quit or been fired since April.

Those threats have had the effect of crystallizing for students the importance of their work, said Patricia Pittman, a professor of health policy and management at George Washington University’s Milken Institute School of Public Health.

“Our students have been both indignant and also energized by what it means to become a public health professional,” Pittman said. “Indignant because many of the local and the national leaders who are trying to make recommendations around public health practices were being mistreated. And proud because they know that they are going to be part of that front-line public health workforce that has not always gotten the respect that it deserves.”

Saksvig compared public health workers to law enforcement in the way they both have responsibility for enforcing rules that can alter people’s lives.

“I feel like before the coronavirus, a lot of people didn’t really pay attention to public health,” she said. “Especially now when something like a pandemic is happening, public health people are just on the forefront of everything.”

KHN Midwest correspondent Lauren Weber and KHN senior correspondent Anna Maria Barry-Jester contributed to this report.

This story is a collaboration between The Associated Press and KHN.

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While Musicant diverted workers from violence prevention and other core programs to the COVID-19 response, state officials debated how to distribute $1.87 billion Minnesota received in federal aid.

As she waited for federal help, the got $6 million in federal money to continue operations, and a debt collection company outside Minneapolis received at least $5 million from the federal Paycheck Protection Program, according to federal data.

It was not until Aug. 5 — months after Congress approved aid for the pandemic — that Musicant’s department finally received $1.7 million, the equivalent of $4 per Minneapolis resident.

“It’s more a hope and a prayer that we’ll have enough money,” Musicant said.

Since the pandemic began, Congress has set aside trillions of dollars to ease the crisis. A joint KHN and Associated Press investigation finds that many communities with big outbreaks have spent little of that federal money on local public health departments for work such as testing and contact tracing. Others, like Minnesota, were slow to do so.

For example, the states, territories and 154 large cities and counties that received allotments from the $150 billion Coronavirus Relief Fund reported spending only 25% of it through June 30, according to reports that recipients submitted to the U.S. Treasury Department.

Many localities have deployed more money since that June 30 reporting deadline, and both Republican and Democratic governors say they need more to avoid layoffs and cuts to vital state services. Still, as cases in the U.S. top 5.2 million and deaths soar past 167,000, Republicans in Congress are pointing to the slow spending to argue against sending more money to state and local governments to help with their pandemic response.

“States and localities have only spent about a fourth of the money we already sent them in the springtime,” Senate Majority Leader Mitch McConnell said Tuesday. Congressional Democrats’ efforts to get more money for states, he said, “aren’t based on math. They aren’t based on the pandemic.”

Negotiations over a new pandemic relief bill broke down last week, in part because Democrats and Republicans could not agree on funding for state and local governments.

KHN and the AP requested detailed spending breakdowns from recipients of money from the Coronavirus Relief Fund — created in March as part of the $1.9 trillion CARES Act — and received responses from 23 states and 62 cities and counties. Those entities dedicated 23% of their spending from the fund through June to public health and 7% to public health and safety payroll.

An additional 22% was transferred to local governments, some of which will eventually pass it down to health departments. The rest went to other priorities, such as distance learning.

So little money has flowed to some local health departments for many reasons: Bureaucracy has bogged things down, politics have crept into the process, and understaffed departments have struggled to take time away from critical needs to navigate the red tape required to justify asking for extra dollars.

“It does not make sense to me how anyone thinks this is a way to do business,” said E. Oscar Alleyne, chief of programs and services at the National Association of County and City Health Officials. “We are never going to get ahead of the pandemic response if we are still handicapped.”

Last month, KHN and the AP detailed how state and local public health departments across the U.S. have been starved for decades. Over 38,000 public health worker jobs have been lost since 2008, and per capita spending on local health departments has been cut by 18% since 2010. That’s left them underfunded and without adequate resources to confront the coronavirus pandemic.

“Public health has been cut and cut and cut over the years, but we’re so valuable every time you turn on the television,” said Jan Morrow, the director and 41-year veteran of Ripley County health department in rural Missouri. “We are picking up all the pieces, but the money is not there. They’ve cut our budget until there’s nothing left.”

Politics and Red Tape

Why did the Minneapolis health department have to wait so long for CARES Act money?

Congress mandated that the Coronavirus Relief Fund be distributed to states and local governments based on population. Minneapolis, with 430,000 residents, missed the threshold of 500,000 people that would have allowed it to receive money directly.

The state of Minnesota, however, received $1.87 billion, a portion of which was meant to be sent to local communities. Lawmakers initially sent some state money to tide communities over until the federal money came through — the Minneapolis health department got about $430,000 in state money to help pay for things like testing.

But when it came time to decide how to use the CARES Act money, lawmakers in Minnesota’s Republican-controlled Senate and Democratic-controlled House were at loggerheads.

Myron Frans, commissioner of Minnesota Management and Budget, said that disagreement, on top of the economic crisis and pandemic, left the legislature in turmoil.

After the police killing of George Floyd in Minneapolis, the city erupted in protests over racial injustice, making a difficult situation even more challenging.

Democratic Gov. Tim Walz favored targeting some of the money to harder-hit communities, a move that might have helped Minneapolis, where cases have surged since mid-July. But lawmakers couldn’t agree. Negotiations dragged on, and a special session merely prolonged the standoff.

Finally, the governor divvied up the money using a population-based formula developed earlier by Republican and Democratic legislative leaders that did not take into account COVID-19 caseloads or racial disparities.

“We knew we needed to get it out the door,” Frans said.

The state then sent hundreds of millions of dollars to local communities. Still, even after the money got to Minneapolis a month ago, Musicant had to wait as city leaders made difficult choices about how to spend the money as the economy cratered and the list of needs grew.

“Even when it gets to the local government, you still have to figure out how to get it to local public health,” Musicant said.

Meanwhile, some in Minneapolis have noticed a lack of services. Dr. Jackie Kawiecki has been providing help to people at a volunteer medical station near the place where Floyd was killed ― an area that at times has drawn hundreds or thousands of people per day. She said the city did not do enough free, easy-to-access testing in its neighborhoods this summer.

“I still don’t think that the amount of testing offered is adequate, from a public health standpoint,” Kawiecki said.

A coalition of groups that includes the National Governors Association has blamed the spending delays on the federal government, saying the final guidance on how states could spend the money came late in June, shortly before the reporting period ended. The coalition said state and local governments had moved “expeditiously and responsibly” to use the money as they deal with skyrocketing costs for health care, emergency response and other vital programs.

New York’s Nassau County was among six counties, cities and states that had spent at least 75% of its funds by June 30.

While most of the money was not spent before then, the National Association of State Budget Officers says a July 23 survey of 45 states and territories found they had allocated, or set aside, an average of 74% of the money.

But if they have, that money has been slow to make it to many local health departments.

As of mid-July in Missouri, at least 50 local health departments had yet to receive any of the federal money they requested, according to a state survey. The money must first flow through local county commissioners, some of whom aren’t keen on sending money to public health agencies.

“You closed their businesses down in order to save their people’s lives and so that hurt the economy,” said Larry Jones, executive director of the Missouri Center for Public Health Excellence, an organization of public health leaders. “So they’re mad at you and don’t want to give you money.”

The winding path federal money takes as it makes its way to states and cities also could exacerbate the stark economic and health inequalities in the U.S. if equity isn’t considered in decision-making, said Wizdom Powell, director of the University of Connecticut Health Disparities Institute.

“Problems are so vast you could unintentionally further entrench inequities just by how you distribute funds,” Powell said.

‘Everything Fell Behind’

The amounts eventually distributed can induce head-scratching.

Some cities received large federal grants, including Louisville, Kentucky, whose health department was given $42 million by April, more than doubling its annual budget. Because of the way the money was distributed, Louisville’s health department alone received more money from the CARES Act than the entire government of the city of Minneapolis, which received $32 million in total.

Philadelphia’s health department was awarded $100 million from a separate fund from the Centers for Disease Control and Prevention.

Honolulu County, where COVID cases have remained relatively low, received $124,454 for every positive case it had reported as of Aug. 9, while El Paso County in Texas got just $1,685 per case. Multnomah County, Oregon — with nearly a quarter of its state’s COVID-19 cases — landed only 2%, or $28 million, of the state’s $1.6 billion allotment.

Rural Saline County in Missouri received the same funding as counties of similar size, even though the virus hit the area particularly hard. In April, outbreaks began tearing through a Cargill meatpacking plant and a local factory there. By late May, the health department confirmed 12 positive cases at a local jail.

Tara Brewer, Saline’s health department administrator, said phone lines were ringing off the hook, jamming the system. Eventually, several department employees handed out their personal cellphone numbers to take calls from residents looking to be tested or seeking care for coronavirus symptoms.

“Everything fell behind,” Brewer said.

The school vaccination clinic in April was canceled, and a staffer who works as a Spanish translator for the Women, Infants and Children nutritional program was enlisted to contact-trace for additional COVID-19 exposures. All food inspections stopped.

It was late July when $250,000 in federal CARES Act money finally reached the 11-person health department, Brewer said — four months after Congress approved the spending and three months after the county’s first outbreak.

That was far too late for Brewer to hire the army of contact tracers that might have helped slow the spread of the virus back in April. She said the money already has been spent on antibody testing and reimbursements for groceries and medical equipment the department had bought for quarantined residents.

Another problem: Some local health officials say that the laborious process required to qualify for some of the federal aid discourages overworked public health officials from even trying to secure more money and that funds can be uneven in arriving.

Lisa Macon Harrison, public health director for Granville Vance Public Health in rural Oxford, North Carolina, said it’s tough to watch major hospital systems — some of which are sitting on billions in reserves — receive direct deposits, while her department received only about $122,000 through three grants by the end of July. Her team filled out a 25-page application just to get one of them.

She is now waiting to receive an estimated $400,000 more. By contrast, the Duke University Hospital System, which includes a facility that serves Granville, already has received over $67.3 million from the federal Provider Relief Fund.

“I just don’t understand the extra layers of onus for the bureaucracy, especially if hundreds of millions of dollars are going to the hospitals and we have to be responsible to apply for 50 grants,” she said.

The money comes from dozens of funds, including several programs within the CARES Act. Nebraska alone received money from 76 federal COVID relief funding sources.

Robert Miller, director of health for the Eastern Highlands Health District in Connecticut, which covers 10 towns, received $29,596 of the $2.5 million the state distributed to local departments from the CDC fund and nothing from CARES. It was only enough to pay for some contact tracing and employee mileage.

Miller said that he could theoretically apply for a little more from the Federal Emergency Management Agency, but that the reporting requirements — which include collecting every receipt — are extremely cumbersome for an already overburdened department.

So he wonders: “Is the squeeze worth the juice?”

Back in Minneapolis, Musicant said the new money from CARES allowed the department to run a free COVID-19 testing site Saturday, at a church that serves the Hispanic community about a mile from the site of Floyd’s killing.

It will take more money to do everything the community needs, she says, but with Congress deadlocked, she’s not sure they’ll get it anytime soon.

AP writers Camille Fassett and Steve Karnowski contributed to this report.

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One of the latest departures came Sunday, when California’s public health director, Dr. Sonia Angell, was ousted following a technical glitch that caused a delay in reporting virus test results — information used to make decisions about reopening businesses and schools.

Last week, New York City’s health commissioner was replaced after months of friction with the police department and City Hall.

A review by KHN and The Associated Press finds at least 49 state and local public health leaders have resigned, retired or been fired since April across 23 states. The list has grown by more than 20 people since the AP and KHN started in June.

Dr. Tom Frieden, former director of the Centers for Disease Control and Prevention, called the numbers stunning. He said they reflect burnout, as well as attacks on public health experts and institutions from the highest levels of government, including from President Donald Trump, who has sidelined the CDC during the pandemic.

“The overall tone toward public health in the U.S. is so hostile that it has kind of emboldened people to make these attacks,” Frieden said.

The past few months have been “frustrating and tiring and disheartening” for public health officials, said former West Virginia public health commissioner Dr. Cathy Slemp, who was forced to resign by Republican Gov. Jim Justice in June.

“You care about community, and you’re committed to the work you do and societal role that you’re given. You feel a duty to serve, and yet it’s really hard in the current environment,” Slemp said in an interview Monday.

The departures come at a time when public health expertise is needed more than ever, said Lori Tremmel Freeman, CEO of the National Association of County and City Health Officials.

“We’re moving at breakneck speed here to stop a pandemic, and you can’t afford to hit the pause button and say, ‘We’re going to change the leadership around here and we’ll get back to you after we hire somebody,’” Freeman said.

As of Monday, confirmed infections in the United States stood at over 5 million, with deaths topping 163,000, the highest in the world, according to the count kept by Johns Hopkins University researchers. The confirmed number of coronavirus cases worldwide topped 20 million.

Many of the firings and resignations have to do with conflicts over mask orders or shutdowns to enforce social distancing, Freeman said. Despite the scientific evidence that such measures help prevent transmission of the coronavirus, many politicians and others have argued they are not needed, no matter what health experts tell them.

“It’s not a health divide; it’s a political divide,” Freeman said.

Some health officials said they were stepping down for family reasons, and some left for jobs at other agencies, such as the CDC. Some, , were ousted because of what higher-ups said was or a failure to do their job.

Others have complained that they were overworked, underpaid, unappreciated or thrust into a pressure-cooker environment.

“To me, a lot of the divisiveness and the stress and the resignations that are happening right and left are the consequence of the lack of a real national response plan,” said Dr. Matt Willis, health officer for Marin County in Northern California. “And we’re all left scrambling at the local and state level to extract resources and improvise solutions.”

Public health leaders from Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, down to officials in small communities have reported death threats and intimidation. Some have seen their home addresses published or been the subject of sexist attacks on social media. Fauci has said his have received threats.

In Ohio, the state’s health director, Dr. Amy Acton, resigned in June after months of pressure during which Republican lawmakers tried to strip her of her authority and armed protesters showed up at her house.

It was on Acton’s advice that GOP Gov. Mike DeWine became the first governor to shut down schools statewide. Acton also called off the state’s presidential primary in March just hours before polls were to open, angering those who saw it as an overreaction.

The executive director of Las Animas-Huerfano Counties District Health Department in Colorado, Kim Gonzales, found her car vandalized twice, and a group called Colorado Counties for Freedom ran a radio ad demanding that her authority be reduced. Gonzales has remained on the job.

In West Virginia, the governor forced Slemp’s resignation over what he said were discrepancies in the data. Slemp said the department’s work had been hurt by and slow computer networks. Tom Inglesby, director of the UPMC Center for Health Security at Johns Hopkins, said the issue amounted to a clerical error easily fixed.

Inglesby said it was deeply concerning that public health officials who told “uncomfortable truths” to political leaders had been removed.

“That’s terrible for the national response because what we need for getting through this, first of all, is the truth. We need data, and we need people to interpret the data and help political leaders make good judgments,” Inglesby said.

Since 2010, spending on state public health departments has dropped 16% per capita, and the amount devoted to local health departments has fallen 18%, according to a . At least 38,000 state and local public health jobs have disappeared since the 2008 recession, leaving a skeleton workforce for what was once viewed as one of the world’s top public health systems.

Another sudden departure came Monday along the Texas border. Dr. Jose Vazquez, the Starr County health authority, resigned after a proposal to increase his pay from $500 to $10,000 a month was rejected by county commissioners.

Starr County Judge Eloy Vera, a county commissioner who supported the raise, said Vazquez had been working 60 hours per week in the county, one of the poorest in the U.S. and recently one of those hit hardest by the virus.

“He felt it was an insult,” Vera said.

In Oklahoma, both the state health commissioner and state epidemiologist have been replaced since the outbreak began in March.

In rural Colorado, Emily Brown was fired in late May as director of the Rio Grande County Public Health Department after clashing with county commissioners over reopening recommendations. The person who replaced her resigned July 9.

The months of nonstop and often unappreciated work are prompting many public health workers to leave, said Theresa Anselmo of the Colorado Association of Local Public Health Officials.

“It will certainly slow down the pandemic response and become less coordinated,” she said. “Who’s going to want to take on this career if you’re confronted with the kinds of political issues that are coming up?”

Weber reported from St. Louis. Associated Press writers Paul Weber, Sean Murphy and Janie Har and California Healthline senior correspondent Anna Maria Barry-Jester contributed reporting.

This story is a collaboration between KHN and The Associated Press.

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Republican Gov. Jim Justice  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 .

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.

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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 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.

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 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.

Dr. Gianfranco Pezzino, health officer in Shawnee County, Kansas

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.”

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 . 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 43%, from a high of $59 in inflation-adjusted dollars per person in the late 1990s to $34 per person in 2019.

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 by the Association of State and Territorial Health Officials and the de Beaumont Foundation.

Even before the pandemic, 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.

Scott Becker, chief executive officer of the Association of Public Health Laboratories

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.”

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 [5] 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.

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 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.

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 at the time or why residents were willing to pay hundreds of 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 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 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.

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As the director of the Rio Grande County Public Health Department in rural Colorado, she was working 12- and 14-hour days, struggling to respond to the pandemic with only five full-time employees for more than 11,000 residents. Case counts were rising.

She was already at odds with county commissioners, who were pushing to loosen public health restrictions in late May, against her advice. She had previously clashed with them over data releases and had haggled over a variance regarding reopening businesses.

But she reasoned that standing up for public health principles was worth it, even if she risked losing the job that allowed her to live close to her hometown and help her parents with their farm.

Then came the Facebook post: a photo of her and other health officials with comments about their weight and references to “armed citizens” and “bodies swinging from trees.”

The commissioners had asked her to meet with them the next day. She intended to ask them for more support. Instead, she was fired.

“They finally were tired of me not going along the line they wanted me to go along,” she said.

In the battle against COVID-19, public health workers spread across states, cities and small towns make up an invisible army on the front lines.  But that army, which has suffered neglect for decades, is under assault when it’s needed most.

Officials who usually work behind the scenes managing everything from immunizations to water quality inspections have found themselves center stage. Elected officials and members of the public who are frustrated with the lockdowns and safety restrictions have at times turned public health workers into politicized punching bags, battering them with countless angry calls and even physical threats.

On Thursday, Ohio’s state health director, who had armed protesters come to her house, resigned. The health officer for Orange County, California, after weeks of criticism and personal threats from residents and other public officials over an order requiring face coverings in public.

As the pressure and scrutiny rise, many more health officials have chosen to leave or been pushed out of their jobs. A review by KHN and The Associated Press finds at least 27 state and local health leaders have resigned, retired or been fired since April across 13 states.

From North Carolina to California, they have left their posts due to a mix of backlash and stressful, nonstop working conditions, all while dealing with chronic staffing and funding shortages.

Some health officials have not been up to the job during the biggest health crisis in a century. Others previously had plans to leave or cited their own health issues.

But Lori Tremmel Freeman, CEO of the National Association of County and City Health Officials, said the majority of what she calls an “alarming” exodus resulted from increasing pressure as states reopen. Three of those 27 were members of her board and well known in the public health community — Rio Grande County’s Brown; Detroit’s senior public health adviser, Dr. Kanzoni Asabigi; and the head of North Carolina’s Gaston County Department of Health and Human Services, Chris Dobbins.

Asabigi’s sudden retirement, considering his stature in the public health community, shocked Freeman. She also was upset to hear about the departure of Dobbins, who was chosen as health director of the year for North Carolina . Asabigi and Dobbins did not reply to requests for comment.

“They just don’t leave like that,” Freeman said.

Public health officials are “really getting tired of the ongoing pressures and the blame game,” Freeman said. She warned that more departures could be expected in the coming days and weeks as political pressure trickles down from the federal to the state to the local level.

From the beginning of the coronavirus pandemic, federal public health officials have complained of being . The Centers for Disease Control and Prevention has been ; a government because he opposed a White House directive to allow widespread access to the malaria drug hydroxychloroquine as a COVID-19 treatment.

In Hawaii, U.S. Rep. Tulsi Gabbard called on the governor to fire his top public health officials, saying she believed they were too slow on testing, contact tracing and travel restrictions. In Wisconsin, several Republican lawmakers have repeatedly demanded that the state’s health services secretary resign, and the state’s conservative Supreme Court ruled 4-3 that she had exceeded her authority by extending a stay-at-home order.

With the increased public scrutiny, security details — like those seen on a federal level for Dr. Anthony Fauci, the top infectious disease expert — have been assigned to state health leaders, including Georgia’s after she was threatened. Ohio’s Dr. Amy Acton, who also had a security detail assigned after armed protesters showed up at her home, resigned Thursday.

In Orange County, in late May, nearly a hundred people attended a county supervisors meeting, waiting hours to speak against an order requiring face coverings. One person suggested that the order might make it necessary to invoke Second Amendment rights to bear arms, while another read aloud the home address of the order’s author — the county’s chief health officer, Dr. Nichole Quick — as well as the name of her boyfriend.

Quick, attending by phone, left the meeting. In a statement, the sheriff’s office later said Quick had expressed concern for her safety following “several threatening statements both in public comment and online.” She was given personal protection by the sheriff.

But Monday, after yet another public meeting that included criticism from members of the board of supervisors, Quick resigned. She could not be reached for comment. Earlier, the county’s deputy director of public health services, David Souleles, retired abruptly.

An official in another California county also has been given a security detail, said Kat DeBurgh, the executive director of the Health Officers Association of California, declining to name the county or official because the threats have not been made public.

Many local health leaders, accustomed to relative anonymity as they work to protect the public’s health, have been shocked by the growing threats, said Theresa Anselmo, the executive director of the Colorado Association of Local Public Health Officials.

After polling local health directors across the state at a meeting last month, Anselmo found about 80% said they or their personal property had been threatened since the pandemic began. About 80% also said they’d encountered threats to pull funding from their department or other forms of political pressure.

To Anselmo, the ugly politics and threats are a result of the politicization of the pandemic from the start. So far in Colorado, six top local health officials have retired, resigned or been fired. A handful of state and local health department staff members have left as well, she said.

“It’s just appalling that in this country that spends as much as we do on health care that we’re facing these really difficult ethical dilemmas: Do I stay in my job and risk threats, or do I leave because it’s not worth it?” Anselmo asked.

In California, senior health officials from seven counties, including Quick and Souleles, have resigned or retired since March 15. Dr. Charity Dean, the second in command at the state Department of Public Health, submitted her resignation June 4. Burnout seems to be contributing to many of those decisions, DeBurgh said.

In addition to the harm to current officers, DeBurgh is worried about the impact these events will have on recruiting people into public health leadership.

“It’s disheartening to see people who disagree with the order go from attacking the order to attacking the officer to questioning their motivation, expertise and patriotism,” said DeBurgh. “That’s not something that should ever happen.”

Some of the online abuse has been going on for years, said Bill Snook, a spokesperson for the health department in Kansas City, Missouri. He has seen instances in which people took a health inspector’s name and made a meme out of it, or said a health worker should be strung up or killed. He said opponents of vaccinations, known as anti-vaxxers, have called staffers “baby killers.”

The pandemic, though, has brought such behavior to another level.

In Ohio, the Delaware General Health District has had two lockdowns since the pandemic began — one after an angry individual came to the health department. Fortunately, the doors were locked, said Dustin Kent, program manager for the department’s residential services unit.

Angry calls over contact tracing continue to pour in, Kent said.

In Colorado, the Tri-County Health Department, which serves Adams, Arapahoe and Douglas counties near Denver, has also been getting hundreds of calls and emails from frustrated citizens, deputy director Jennifer Ludwig said.

Some have been angry their businesses could not open and blamed the health department for depriving them of their livelihood. Others were furious with neighbors who were not wearing masks outside. It’s a constant wave of “confusion and angst and anxiety and anger,” she said.

Then in April and May, rocks were thrown at one of their office’s windows — . The office was tagged with obscene graffiti. The department also received an email calling members of the department “tyrants,” adding “you’re about to start a hot-shooting … civil war.”  Health department workers decamped to another office.

Although the police determined there was no imminent threat, Ludwig stressed how proud she was of her staff, who weathered the pressure while working round-the-clock.

“It does wear on you, but at the same time we know what we need to do to keep moving to keep our community safe,” she said. “Despite the complaints, the grievances, the threats, the vandalism — the staff have really excelled and stood up.”

The threats didn’t end there, however: Someone asked on the health department’s Facebook page how many people would like to know the home addresses of the Tri-County Health Department leadership. “You want to make this a war??? No problem,” the poster wrote.

Back in Colorado’s Rio Grande County, some members of the community have rallied in support of Brown with and a of a local paper. Meanwhile, COVID-19 case counts have jumped from 14 to .

Brown is grappling with what she should do next: dive back into another strenuous public health job in a pandemic, or take a moment to recoup?

When she told her 6-year-old son she no longer had a job, he responded: “Good — now you can spend more time with us.”

This story is a collaboration between The Associated Press and Kaiser Health News.

AP writer Audrey McAvoy in Honolulu and KHN correspondent Angela Hart in Sacramento contributed to this report.

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