Their work includes major agency priorities such as HIV testing and monitoring, as well as work at the nation’s leading sexually transmitted infections lab. And while employees are back, many projects have been canceled or stalled, as funding disappears or is delayed.

“For a while, work was staring at a blank screen,” an HIV scientist said. “I had a couple of projects before this. I’m trying to get them restarted.”

“We don’t know what’s happening or what to do,” said an HIV prevention researcher who was fired then rehired.

These employees voiced deep concern over the future of the agency and its work on HIV and other threats. The unprecedented downsizing could lead to loss of life and higher spending on medical care, they say. Their uncertain employment status has sunk morale. Many worry about the future of public health.

On Aug. 8, a gunman identified by Georgia authorities as Patrick Joseph White fired shots at CDC buildings in Atlanta. A first responder on the scene, DeKalb County police officer David Rose, was killed. White, who was found dead, was possibly motivated by his views on vaccines, according to news reports.

The attack added another level of anxiety for agency workers.

“We feel threatened from inside, and, obviously, now from outside,” a lab scientist said Aug. 10. “The trauma runs so differently in all of us. And is this the last straw for some of us? The overall morale — would you go back in the building and you could be shot at?”

Healthbeat interviewed 11 CDC workers, who offered a rare glimpse into conditions at the agency. All but one had been fired then offered their jobs back. Most have worked on HIV-related projects for at least several years. All spoke on the condition of anonymity, citing a fear of retaliation.

They fear their employment, in the HIV scientist’s terms, “is on shaky ground.”

“I’m concerned there is chaos and that we lost ground on HIV prevention” from reductions in data collection and layoffs of local public health workers, an HIV epidemiologist said. “I feel like a pawn on a chessboard.”

HHS spokesperson Emily Hilliard responded to a query with this statement:

“Under Secretary Kennedy’s leadership, the nation’s critical public health functions remain intact and effective. The Trump administration is committed to protecting essential services — whether it’s supporting coal miners and firefighters through NIOSH, safeguarding public health through lead prevention, or researching and tracking the most prevalent communicable diseases. HHS is streamlining operations without compromising mission-critical work. Enhancing the health and well-being of all Americans remains our top priority.”

The workers received some positive news July 31, when a Senate committee voted to keep CDC funding at more than $9 billion, near its current level. “It is very encouraging, but that’s only one step in the appropriations process,” the HIV researcher said.

Still, under the Trump administration’s budget request, the CDC’s programs on HIV face uncertainty. John Brooks, who retired as chief medical officer of the CDC’s Division of HIV Prevention last year, expressed concern over the Ending the HIV Epidemic initiative. Launched in President Donald Trump’s first term, it “breathed new life into HIV prevention,” Brooks said.

The successes of the Ending the HIV Epidemic initiative are jeopardized by the administration plan to scale back HIV prevention efforts, Brooks said. That would include the potential elimination of the CDC Division of HIV Prevention, which provides funds to state health departments and other groups for testing and prevention, conducts HIV monitoring and surveillance, researches HIV prevention and care, and assists medical professionals with training and education.

“There is no way to achieve the goals of EHE without maintaining the national prevention infrastructure it depends on,” Brooks said. “There is every reason to worry that in fact new HIV infections will rise again.”

Under Secretary Robert F. Kennedy Jr., the Department of Health and Human Services carried out widespread layoffs at the CDC and other health agencies beginning in early April. Lawsuits over those mass firings are playing out in federal courts.

The administration’s budget blueprint would move CDC HIV work — with many fewer employees, according to people Healthbeat interviewed — to the Administration for a Healthy America, a new HHS division Kennedy has championed.

The Medical Monitoring Project, which tracks outcomes, quality, and gaps in HIV treatment, is set to be a casualty under the Trump restructuring plan, an HIV prevention physician said.

HHS officials have not communicated with the rank and file about the restructuring, several CDC workers said.

“It’s been crickets,” the HIV scientist said.

The White House’s proposed CDC budget for the next fiscal year contains a cut of more than 50%, plummeting from $9.2 billion in fiscal year 2025 to about $4.2 billion, according to administration documents and public health advocacy groups, with some agency functions transferred to the proposed AHA. The Senate committee, by an overwhelming vote, injected billions back into the agency budget and declined to fund the AHA.

U.S. Sen. Jon Ossoff, a Georgia Democrat, thanked the committee for “rejecting the unacceptable effort to defund most of the CDC.”

“The budget request from the White House included a 56% cut to the world’s preeminent epidemiological agency,” Ossoff said. He also criticized a “systematic destruction of morale at the CDC, the disbandment of entire agencies focused on maternal health and neonatal health and disease prevention at the CDC.”

If the White House prevails and the prevention program is eliminated, “we would see most states have no funding for HIV prevention,” said Emily Schreiber, senior director of policy and legislative affairs for the National Alliance of State and Territorial AIDS Directors. “That means most states would not be able to conduct any HIV testing, any referral to care, and/or referral to preventive services like PrEP,” or pre-exposure prophylaxis, a drug that .

“It means that states would not be able to help people get access to medications,” she said, “and that means that we would see new cases and an increased spread of HIV across the United States.”

“We would definitely see layoffs at the CDC, and I think we’d probably see them at state health departments and community-based organizations as well,” she added.

The Los Angeles County Department of Public Health has recently laid off or reassigned dozens of HIV workers due to funding problems, according to a statement emailed to Healthbeat.

“I fear all HIV prevention work will go away permanently,” the HIV prevention researcher said. “I don’t think this administration wants HIV prevention work to be done by the federal government.”

Georgia leads U.S. states in the rate of new HIV infections, according to the latest data from . CDC workers also said they’re concerned that vulnerable communities of color and LGBTQ+ communities would be deeply harmed by funding cuts.

In Georgia and other states, information provided by the Medical Monitoring Project about access to care will disappear, the HIV physician said. Information on prevention and treatment will dwindle for people who are disadvantaged, he said, including those with substance abuse problems or mental illness, transgender people, and those living in poverty.

“There is a lot of anger and sadness among people over the termination of the project,” the physician said. “A lot of the enthusiasm is gone.”

An effective home testing program for HIV plans to shutter this fall, said Patrick Sullivan, the project’s lead scientist and a professor at Emory University’s Rollins School of Public Health. In its notice canceling funding for the project, the CDC said it no longer had the staff to oversee it. Based at Emory, the project delivered more than 900,000 free home testing kits to people across the country through an easy-to-use website and integration with dating apps.

More than 100 HIV workers were among the more than 450 CDC staffers brought back, said employees interviewed by Healthbeat. Some cited , support in Congress, and advocacy by patient groups and pharmaceutical companies for their reinstatement. “Members of Congress are going to bat for HIV,” the epidemiologist said.

Several are closely watching a lawsuit brought by 20 Democratic attorneys general, seeking to halt an agency restructuring plan Kennedy . They are also paying attention to a lawsuit filed in California that challenges the firings.

A few people whose jobs were restored have retired or moved on to other work. “Some people aren’t trusting we will remain, so they’re leaving,” the HIV prevention researcher said.

At the CDC’s sexually transmitted infections lab in Atlanta, work has also slowed due to a shrinking staff and new spending constraints on supplies, the lab scientist said.

Restored lab workers are focusing on high-priority areas such as syphilis and gonorrhea while other diseases have been back-burnered, the scientist said, adding “a lot of what we were doing was staying ahead of the next pathogen, and we feel like our time and effort to do that now is limited.”

“We’re all public health because we know what the mission is,” the scientist said. “We just want to get our job done and protect the American public.”

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But the area housing the regional office of the Department of Health and Human Services was eerily quiet.

In March, HHS announced it would close as part of a broad restructuring to consolidate the department’s work and reduce the number of staff by 20,000, to 62,000. The HHS Region 2 office in New York City, which has served New Jersey, New York, Puerto Rico, and the U.S. Virgin Islands, was among those getting the ax.

Public health experts and advocates say that , like the one in New York City, form the connective tissue between the federal government and many locally based services. Whether ensuring local social service programs like Head Start get their federal grants, investigating Medicare claims complaints, or facilitating hospital and health system provider enrollment in Medicare and Medicaid programs, regional offices provide a key federal access point for people and organizations. Consolidating regional offices could have serious consequences for the nation’s public health system, they warn.

“All public health is local,” said Georges Benjamin, executive director of the American Public Health Association. “When you have relative proximity to the folks you’re liaising to, they have a sense of the needs of those communities, and they have a sense of the political issues that are going on in these communities.”

The other offices slated to close are in Boston, Chicago, San Francisco, and Seattle. Together, the five serve 22 states and a handful of U.S. territories. Services for the shuttered regional offices will be divvied up among the remaining regional offices in Atlanta, Dallas, Denver, Kansas City, and Philadelphia.

The elimination of regional HHS offices has already had an outsize impact on Head Start, a long-standing federal program that provides free child care and supportive services to children from many of the nation’s poorest families. It is among the examples cited against the federal government challenging the HHS restructuring brought by New York, 18 other states, and the District of Columbia, which notes that, as a result, “many programs are at imminent risk of being forced to pause or cease operations.”

The HHS site included a regional Head Start office that was closed and laid off staff last month. The Trump administration had sought for Head Start, according to a draft budget document that outlines dramatic cuts at HHS, which Congress would need to approve. indicate the administration may be stepping back from this plan; however, other childhood and early-development programs could still be on the chopping block.

Bonnie Eggenburg, president of the New Jersey Head Start Association, said her organization has long relied on the HHS regional office to be “our boots on the ground for the federal government.” During challenging times, such as the covid-19 pandemic or Hurricanes Sandy and Maria, the regional office helped Head Start programs design services to meet the needs of children and families. “They work with us to make sure we have all the support we can get,” she said.

In recent weeks, payroll and other operational payments have been delayed, and employees have been asked to justify why they need the money as part of a new “” initiative instituted by the Elon Musk-led Department of Government Efficiency, created by President Donald Trump through an executive order.

“Right now, most programs don’t have anyone to talk to and are unsure as to whether or not that notice of award is coming through as expected,” Eggenburg said.

HHS regional office employees who worked on Head Start helped providers fix technical issues, address budget questions, and discuss local issues, like the city’s growing population of migrant children, said Susan Stamler, executive director of . Based in New York City, the organization represents dozens of neighborhood settlement houses — community groups that provide services to local families such as language classes, housing assistance, and early-childhood support, including some Head Start programs.

“Today, the real problem is people weren’t given a human contact,” she said of the regional office closure. “They were given a website.”

To Stamler, closing the regional Head Start hub without a clear transition plan “demonstrates a lack of respect for the people who are running these programs and services,” while leaving families uncertain about their child care and other services.

“It’s astonishing to think that the federal government might be reexamining this investment that pays off so deeply with families and in their communities,” she said.

Without regional offices, HHS will be less informed about which health initiatives are needed locally, said Zach Hennessey, chief strategy officer of Public Health Solutions, a nonprofit provider of health services in New York City.

“Where it really matters is within HHS itself,” he said. “Those are the folks that are now blind — but their decisions will ultimately affect us.”

Dara Kass, an emergency physician who was the HHS Region 2 director under the Biden administration, described the job as being an ambassador.

“The office is really about ensuring that the community members and constituents had access to everything that was available to them from HHS,” Kass said.

, division offices for the Administration for Community Living, the FDA’s Office of Inspections and Investigations, and the Substance Abuse and Mental Health Services Administration have already closed or are slated to close, along with several other division offices.

HHS did not provide an on-the-record response to a request for comment but has maintained that shuttering regional offices will not hurt services.

Under the reorganization, many HHS agencies are either being eliminated or folded into other agencies, including the recently created Administration for a Healthy America, under HHS Secretary Robert F. Kennedy Jr.

“We aren’t just reducing bureaucratic sprawl. We are realigning the organization with its core mission and our new priorities in reversing the chronic disease epidemic,” Kennedy said announcing the reorganization.

Regional office staffers were laid off at the beginning of April. Now there appears to be a skeleton crew shutting down the offices. On a recent day, an Administration for Children and Families worker who answered a visitor’s buzz at the entrance estimated that only about 15 people remained. When asked what’s next, the employee shrugged.

The Trump administration’s downsizing effort will also eliminate six of 10 regional outposts of the HHS Office of the General Counsel, a squad of lawyers supporting the Centers for Medicare & Medicaid Services and other agencies in beneficiary coverage disputes and issues related to provider enrollment and participation in federal programs.

Unlike private health insurance companies, Medicare is a federal health program governed by statutes and regulations, said Andrew Tsui, a partner at Arnall Golden Gregory about the regional office closings.

“When you have the largest federal health insurance program on the planet, to the extent there could be ambiguity or appeals or grievances,” Tsui said, “resolving them necessarily requires the expertise of federal lawyers, trained in federal law.”

Overall, the loss of the regional HHS offices is just one more blow to public health efforts at the state and local levels.

State health officials are confronting the “total disorganization of the federal transition” and cuts to key federal partners like the Centers for Disease Control and Prevention, CMS, and the FDA, said James McDonald, the New York state health commissioner.

“What I’m seeing is, right now, it’s not clear who our people ought to contact, what information we’re supposed to get,” he said. “We’re just not seeing the same partnership that we so relied on in the past.”

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Years ago, Wilkins was dating a man newly diagnosed with HIV and went to get tested, she said, but was not offered PrEP.

Since then, Wilkins said, doctors either have told her she doesn’t need the drug or were reluctant to prescribe it. Her insurance through work would not cover a long-acting injectable form that tends to have better results than the original pill form. Getting to appointments across Atlanta for the pills was a challenge. She is now enrolled in a drug trial for a promising PrEP injection but worries about future access and cost.

Preexposure prophylaxis, known as PrEP, reduces the risk of new HIV infections through sex by 99% and among injectable drug users , according to the Centers for Disease Control and Prevention.

Among states, Georgia has the of new HIV infections, but residents — especially women and Black patients like Wilkins — are often not getting PrEP, data shows.

A rule enacted by the Biden administration that took effect for many Affordable Care Act plans on Jan. 1 should make it easier for people like Wilkins to get long-acting PrEP injectable drugs.

A new Trump administration adds an X factor to this and other federal health programs. On Jan. 27, the White House announced a federal funding freeze, which sent shudders through health agencies and nonprofits. By Jan. 29, it had reversed the order.

Federal initiatives like the and HIV prevention funding seemed to be affected — and “blocking access to PrEP would have deadly consequences,” said Wayne Turner, a senior attorney at the National Health Law Program.

Georgia has big in PrEP uptake, said Patrick Sullivan, who is an epidemiology professor at Emory University and leads AIDSVu and PrEPVu, which track HIV data and access to the drug — work that is backed by Gilead Sciences, a PrEP drug manufacturer.

Public health experts use what’s called a “PrEP-to-need ratio” to measure how many people at risk of HIV are getting the drug. A higher number is better. In Georgia for 2023, the statewide ratio was 6, while it was nearly 167 in Vermont, .

While the ratio for white people in Georgia was roughly 22, it was about 3 for Black people and just over 3 for Hispanic people. And while it was 7 for men, it was just over 2 for women.

“Black people generally are underserved by PrEP, and women are underserved by PrEP relative to men,” Sullivan said.

Increasing PrEP uptake would help the state cut its new HIV diagnoses, said Dylan Baker, associate medical director at Grady Health’s HIV Prevention Program.

Georgia’s rate of new HIV diagnoses was 27 per 100,000 in 2022, according to the most recent available data. That’s second only to Washington, D.C., and more than double the national rate of 13 per 100,000. That amounts to about 2,500 new cases diagnosed in Georgia in a year.

Globally about 3.5 million people used PrEP in 2023, up from 200,000 in 2017 but short of the United Nations’ 2025 target of 21.2 million people, by the United Nations Program on HIV/AIDS.

PrEP users in Atlanta report many challenges in getting the drug, including cost, medical providers who don’t prescribe it, stigma, a lack of inclusive marketing, and transportation. Wilkins said she has run up against all of those.

“Here I am telling you that I’m here to get tested because I have come into contact with someone who was living with HIV, and we had a sexual relationship, and you’re not even mentioning PrEP to me,” Wilkins said. “That was a disservice.”

Insurers Now Required To Cover PrEP

Cost has long been a barrier. The Biden administration last fall requiring most insurers to cover the full cost of all forms of PrEP, without prior authorization, along with certain lab work and other services. This includes pills as well as Apretude, an injection given every two months.

That means insured PrEP users should not face , said Carl Schmid, executive director of the , which lobbied for the rule.

It applies to those on the federal marketplace plans and most large private health plans. A similar rule exists for Medicare and Medicare Advantage plans.

Schmid said he does not think the Trump administration will repeal the rule, but he is concerned the U.S. Supreme Court could end coverage for preventive services, including PrEP, when it issues a decision in , anticipated this summer.

The rule will not help the uninsured. In Georgia, which did not expand Medicaid under the ACA, about are uninsured.

“The cost is also a struggle, especially given different people are part of the gig economy, a lot of folks don’t always have access to health insurance,” said Maximillian Boykin, an Atlanta PrEP user.

Expanding Medicaid would help. States that have done so, Sullivan said, “have higher levels of PrEP uptake.”

Winning the PrEP Lottery

Since getting on PrEP in 2019, Wilkins has encountered two doctors who did not want to prescribe it.

One female OB-GYN told her “‘Girl, at our age, we should know better.’” Wilkins said , telling her that such comments are stigmatizing.

When Wilkins moved, she looked for a nearby primary care provider so she would not have to pay for transportation to get PrEP.

But the doctor she found, Wilkins said, told her to find an infectious disease specialist for PrEP.

“‘You’re not treating an infectious disease,’ I say. ‘This is preventive care,’” Wilkins recalled.

Wilkins’ fortunes turned when she was selected to join a study for a twice-yearly injectable form of PrEP.

Lenacapavir, already approved for HIV treatment, showed promising results for HIV prevention in . Wilkins is part of a trial in Atlanta including about 250 cisgender women nationally who have sex with men.

It’s much better than a daily pill or even a shot once every two months, Wilkins said.

She hopes to stay on the drug, but the U.S. list price for lenacapavir as an HIV treatment averages about $40,000 a year.

Gilead last year announced it signed royalty-free licensing agreements with six manufacturers to make generic lenacapavir for 120 primarily low- and lower-middle-income countries.

It’s not clear where it falls with the Biden rule. “We believe it should be covered,” Schmid said, “but want the federal government to state that clearly.”

For many patients, challenges remain. Most people are willing to travel about 30 minutes for routine health care, Sullivan said, but in cities like Atlanta, those relying on public transportation may face longer commutes to PrEP providers. Some who need PrEP have unstable housing without firm mailing addresses.

Privacy is another concern. “Everybody should be able to find a place that's comfortable,” Sullivan said. “More of that can go on in primary health care.”

Others agree that public health messaging around PrEP services should target more diverse audiences. Dázon Dixon Diallo is the founder of , an HIV, sexual, and reproductive health organization focused on Black women in the Southeast.

“You’re not going to get to us by giving us a 3-second cameo in a commercial about PrEP,” she said. “There’s no story in there for me, right?”

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But the scale of the farmers’ efforts to treat the sick cows stunned him. They showed videos of systems they built to hydrate hundreds of cattle at once. In 14-hour shifts, dairy workers pumped gallons of electrolyte-rich fluids into ailing cows through metal tubes inserted into the esophagus.

“It was like watching a field hospital on an active battlefront treating hundreds of wounded soldiers,” he said.

Nearly a year into the first outbreak of the bird flu among cattle, the virus shows no sign of slowing. The U.S. government failed to eliminate the virus on dairy farms when it was confined to a handful of states, by quickly identifying infected cows and taking measures to keep their infections from spreading. Now at least 875 herds across 16 states have tested positive.

Experts say they have lost faith in the government’s ability to contain the outbreak.

“We are in a terrible situation and going into a worse situation,” said Angela Rasmussen, a virologist at the University of Saskatchewan in Canada. “I don’t know if the bird flu will become a pandemic, but if it does, we are screwed.”

To understand how the bird flu got out of hand, Â鶹ŮÓÅ Health News interviewed nearly 70 government officials, farmers and farmworkers, and researchers with expertise in virology, pandemics, veterinary medicine, and more.

Together with emails obtained from local health departments through public records requests, this investigation revealed key problems, including deference to the farm industry, eroded public health budgets, neglect for the safety of agriculture workers, and the sluggish pace of federal interventions.

Case in point: The U.S. Department of Agriculture this month announced a to test milk nationwide. Researchers welcomed the news but said it should have happened months ago — before the virus was so entrenched.

“It’s disheartening to see so many of the same failures that emerged during the covid-19 crisis reemerge,” said Tom Bollyky, director of the Global Health Program at the Council on Foreign Relations.

Far more bird flu damage is inevitable, but the extent of it will be left to the Trump administration and Mother Nature. Already, the USDA has funneled more than $1.7 billion into tamping down the bird flu on poultry farms since 2022, which includes reimbursing farmers who’ve had to cull their flocks, and more than $430 million into combating the bird flu on dairy farms. In coming years, the bird flu may cost billions of dollars more in expenses and losses. Dairy industry experts say the virus kills roughly 2% to 5% of infected dairy cows and reduces a herd’s milk production by about 20%.

Worse, the outbreak poses the threat of a pandemic. More than 60 people in the U.S. have been infected, mainly by cows or poultry, but cases could skyrocket if the virus evolves to spread efficiently from person to person. And the of a person critically ill in Louisiana with the bird flu shows that the virus can be dangerous.

Just a could allow the bird flu to spread between people. Because viruses mutate within human and animal bodies, each infection is like a pull of a slot machine lever.

“Even if there’s only a 5% chance of a bird flu pandemic happening, we’re talking about a pandemic that probably looks like 2020 or worse,” said Tom Peacock, a bird flu researcher at the Pirbright Institute in the United Kingdom, referring to covid. “The U.S. knows the risk but hasn’t done anything to slow this down,” he added.

Beyond the bird flu, the federal government’s handling of the outbreak reveals cracks in the U.S. health security system that would allow other risky new pathogens to take root. “This virus may not be the one that takes off,” said Maria Van Kerkhove, director of the emerging diseases group at the World Health Organization. “But this is a real fire exercise right now, and it demonstrates what needs to be improved.”

A Slow Start

It may have been a grackle, a goose, or some other wild bird that infected a cow in northern Texas. In February, the state’s dairy farmers took note when cows stopped making milk. They worked alongside veterinarians to figure out why. In less than two months, veterinary researchers identified the highly pathogenic H5N1 bird flu virus as the culprit.

Long listed among pathogens with pandemic potential, the bird flu’s unprecedented spread among cows marked a worrying shift. It had evolved to thrive in animals that are more like people biologically than birds.

After the USDA announced the dairy outbreak on March 25, control shifted from farmers, veterinarians, and local officials to state and federal agencies. Collaboration disintegrated almost immediately.

Farmers worried the government might block their milk sales or even demand sick cows be killed, as poultry are, said Kay Russo, a livestock veterinarian in Fort Collins, Colorado.

Instead, Russo and other veterinarians said, they were dismayed by inaction. The USDA didn’t respond to their urgent requests to support studies on dairy farms — and for money and confidentiality policies to protect farmers from financial loss if they agreed to test animals.

The USDA announced that it would conduct studies itself. But researchers grew anxious as weeks passed without results. “Probably the biggest mistake from the USDA was not involving the boots-on-the-ground veterinarians,” Russo said.

Will Clement, a USDA senior adviser for communications, said in an email: “Since first learning of H5N1 in dairy cattle in late March 2024, USDA has worked swiftly and diligently to assess the prevalence of the virus in U.S. dairy herds.” The agency provided research funds to state and national animal health labs beginning in April, he added.

The USDA didn’t require lactating cows to be tested before interstate travel until April 29. By then, the outbreak had spread to eight other states. Farmers often move cattle across great distances, for calving in one place, raising in warm, dry climates, and milking in cooler ones. Analyses of the implied that it spread between cows rather than repeatedly jumping from birds into herds.

Milking equipment was a likely source of infection, and there were hints of other possibilities, such as through the air as cows coughed or in droplets on objects, like work boots. But not enough data had been collected to know how exactly it was happening. Many farmers declined to test their herds, despite an announcement of funds to compensate them for lost milk production in May.

“There is a fear within the dairy farmer community that if they become officially listed as an affected farm, they may lose their milk market,” said Jamie Jonker, chief science officer at the National Milk Producers Federation, an organization that represents dairy farmers. To his knowledge, he added, this hasn’t happened.

Speculation filled knowledge gaps. Zach Riley, head of the Colorado Livestock Association, said he suspected that wild birds may be spreading the virus to herds across the country, despite scientific data suggesting otherwise. Riley said farmers were considering whether to install “floppy inflatable men you see outside of car dealerships” to ward off the birds.

Advisories from agriculture departments to farmers were somewhat speculative, too. Officials recommended biosecurity measures such as disinfecting equipment and limiting visitors. As the virus kept spreading throughout the summer, USDA senior official Eric Deeble said at a press briefing, “The response is adequate.”

The USDA, the Centers for Disease Control and Prevention, and the Food and Drug Administration presented a united front at these briefings, calling it a “One Health” approach. In reality, agriculture agencies took the lead.

This was explicit in an email from a local health department in Colorado to the county’s commissioners. “The State is treating this primarily as an agriculture issue (rightly so) and the public health part is secondary,” wrote Jason Chessher, public health director in Weld County, Colorado. The state’s leading agriculture county, Weld’s livestock and poultry industry produces about $1.9 billion in sales each year.

Patchy Surveillance

In July, the bird flu spread from dairies in Colorado to poultry farms. To contain it, two poultry operations employed about — Spanish-speaking immigrants as young as 15 — to cull flocks. Inside hot barns, they caught infected birds, gassed them with carbon dioxide, and disposed of the carcasses. Many did the hazardous job without goggles, face masks, and gloves.

By the time Colorado’s health department asked if workers felt sick, five women and four men had been infected. They all had red, swollen eyes — conjunctivitis — and several had such symptoms as fevers, body aches, and nausea.

State health departments posted online notices offering farms protective gear, but dairy workers in several states told Â鶹ŮÓÅ Health News that they had none. They also hadn’t heard about the bird flu, never mind tests for it.

Studies in Colorado, Michigan, and Texas would later show that bird flu cases had gone under the radar. In , eight dairy workers who hadn’t been tested — 7% of those studied — had antibodies against the virus, a sign that they had been infected.

Missed cases made it impossible to determine how the virus jumped into people and whether it was growing more infectious or dangerous. “I have been distressed and depressed by the lack of epidemiologic data and the lack of surveillance,” said Nicole Lurie, an executive director at the international organization the Coalition for Epidemic Preparedness Innovations, who served as assistant secretary for preparedness and response in the Obama administration.

Citing “insufficient data,” the British government raised of the risk posed by the U.S. dairy outbreak in July from three to four on a six-tier scale.

Virologists around the world said they were flabbergasted by how poorly the United States was tracking the situation. “You are surrounded by highly pathogenic viruses in the wild and in farm animals,” said Marion Koopmans, head of virology at Erasmus Medical Center in the Netherlands. “If three months from now we are at the start of the pandemic, it is nobody’s surprise.”

Although the bird flu is not yet spreading swiftly between people, a shift in that direction could cause immense suffering. The CDC has repeatedly described the cases among farmworkers this year as mild — they weren’t hospitalized. But that doesn’t mean symptoms are a breeze, or that the virus can’t cause worse.

“It does not look pleasant,” wrote Sean Roberts, an emergency services specialist at the Tulare County, California, health department in an email to colleagues in May. He described photographs of an infected dairy worker in another state: “Apparently, the conjunctivitis that this is causing is not a mild one, but rather ruptured blood vessels and bleeding conjunctiva.”

Over the past 30 years, half of around 900 people diagnosed with bird flu around the world have died. Even if the case fatality rate is much lower for this strain of the bird flu, covid showed how devastating a 1% death rate can be when a virus spreads easily.

Like other cases around the world, the person now hospitalized with the bird flu in Louisiana appears to have gotten the virus directly from birds. After the case was announced, the CDC saying, “A sporadic case of severe H5N1 bird flu illness in a person is not unexpected.”

‘The Cows Are More Valuable Than Us’

Local health officials were trying hard to track infections, according to hundreds of emails from county health departments in five states. But their efforts were stymied. Even if farmers reported infected herds to the USDA and agriculture agencies told health departments where the infected cows were, health officials had to rely on farm owners for access.

“The agriculture community has dictated the rules of engagement from the start,” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “That was a big mistake.”

Some farmers told health officials not to visit and declined to monitor their employees for signs of sickness. Sending workers to clinics for testing could leave them shorthanded when cattle needed care. “Producer refuses to send workers to Sunrise [clinic] to get tested since they’re too busy. He has pinkeye, too,” said an email from the Weld, Colorado, health department.

“We know of 386 persons exposed — but we know this is far from the total,” said an email from a public health specialist to officials at Tulare’s health department recounting a call with state health officials. “Employers do not want to run this through worker’s compensation. Workers are hesitant to get tested due to cost,” she wrote.

Jennifer Morse, medical director of the Mid-Michigan District Health Department, said local health officials have been hesitant to apply pressure after the backlash many faced at the peak of covid. Describing the 19 rural counties she serves as “very minimal-government-minded,” she said, “if you try to work against them, it will not go well.”

Rural health departments are also stretched thin. Organizations that specialize in outreach to farmworkers offered to assist health officials early in the outbreak, but months passed without contracts or funding. During the first years of covid, lagging government to farmworkers and other historically marginalized groups led to a of the disease among people of color.

Kevin Griffis, director of communications at the CDC, said the agency worked with the National Center for Farmworker Health throughout the summer “to reach every farmworker impacted by H5N1.” But Bethany Boggess Alcauter, the center’s director of public health programs, said it didn’t receive a CDC grant for bird flu outreach until October, to the tune of $4 million. Before then, she said, the group had very limited funds for the task. “We are certainly not reaching ‘every farmworker,’” she added.

Farmworker advocates also pressed the CDC for money to offset workers’ financial concerns about testing, including paying for medical care, sick leave, and the risk of being fired. This amounted to an offer of $75 each. “Outreach is clearly not a huge priority,” Boggess said. “I hear over and over from workers, ‘The cows are more valuable than us.’”

The USDA has so far put more than $2.1 billion into reimbursing poultry and dairy farmers for losses due to the bird flu and other measures to control the spread on farms. Federal agencies have also put $292 million into developing and stockpiling bird flu vaccines for animals and people. In a controversial decision, the CDC has advised against offering the ones on hand to farmworkers.

“If you want to keep this from becoming a human pandemic, you focus on protecting farmworkers, since that’s the most likely way that this will enter the human population,” said Peg Seminario, an occupational health researcher in Bethesda, Maryland. “The fact that this isn’t happening drives me crazy.”

Nirav Shah, principal deputy director of the CDC, said the agency aims to keep workers safe. “Widespread awareness does take time,” he said. “And that’s the work we’re committed to doing.”

As President-elect Donald Trump comes into office in January, farmworkers may be even less protected. Trump’s pledge of mass deportations will have repercussions whether they happen or not, said Tania Pacheco-Werner, director of the Central Valley Health Policy Institute in California.

Many dairy and poultry workers are living in the U.S. without authorization or on temporary visas linked to their employers. Such precarity made people less willing to see doctors about covid symptoms or complain about unsafe working conditions in 2020. Pacheco-Werner said, “Mass deportation is an astronomical challenge for public health.”

Not ‘Immaculate Conception’

A switch flipped in September among experts who study pandemics as national security threats. A patient in Missouri had the bird flu, and no one knew why. “Evidence points to this being a one-off case,” Shah said at a briefing with journalists. About a month later, the agency revealed it was not.

Antibody tests found that a person who lived with the patient had been infected, too. The CDC didn’t know how the two had gotten the virus, and the possibility of human transmission couldn’t be ruled out.

Nonetheless, at an October briefing, Shah said the public risk remained low and the USDA’s Deeble said he was optimistic that the dairy outbreak could be eliminated.

Experts were perturbed by such confident statements in the face of uncertainty, especially as California’s outbreak spiked and was mysteriously infected by the same strain of virus found on dairy farms.

“This wasn’t just immaculate conception,” said Stephen Morrison, director of the Global Health Policy Center at the Center for Strategic and International Studies. “It came from somewhere and we don’t know where, but that hasn’t triggered any kind of reset in approach — just the same kind of complacency and low energy.”

Sam Scarpino, a disease surveillance specialist in the Boston area, wondered how many other mysterious infections had gone undetected. Surveillance outside of farms was even patchier than on them, and bird flu tests have been hard to get.

Although pandemic experts had identified the CDC’s singular hold on testing for new viruses as a key explanation for why America was hit so hard by covid in 2020, the system remained the same. Bird flu tests could be run only by the CDC and public health labs until this month, even though commercial and academic diagnostic laboratories had inquired about running tests since April. The CDC and FDA should have tried to help them along months ago, said Ali Khan, a former top CDC official who now leads the University of Nebraska Medical Center College of Public Health.

As winter sets in, the bird flu becomes harder to spot because patient symptoms may be mistaken for the seasonal flu. Flu season also raises a risk that the two flu viruses could swap genes if they infect a person simultaneously. That could form a hybrid bird flu that spreads swiftly through coughs and sneezes.

A sluggish response to emerging outbreaks may simply be a new, unfortunate norm for America, said Bollyky, at the Council on Foreign Relations. If so, the nation has gotten lucky that the bird flu still can’t spread easily between people. Controlling the virus will be much harder and costlier than it would have been when the outbreak was small. But it’s possible.

Agriculture officials could start testing every silo of bulk milk, in every state, monthly, said Poulsen, the livestock veterinarian. “Not one and done,” he added. If they detect the virus, they’d need to determine the affected farm in time to stop sick cows from spreading infections to the rest of the herd — or at least to other farms. Cows can spread the bird flu before they’re sick, he said, so speed is crucial.

Curtailing the virus on farms is the best way to prevent human infections, said Jennifer Nuzzo, director of the Pandemic Center at Brown University, but human surveillance must be stepped up, too. Every clinic serving communities where farmworkers live should have easy access to bird flu tests — and be encouraged to use them. Funds for farmworker outreach must be boosted. And, she added, the CDC should change its position and offer farmworkers bird flu vaccines to protect them and ward off the chance of a hybrid bird flu that spreads quickly.

The rising number of cases not linked to farms signals a need for more testing in general. When patients are positive on a general flu test — a common diagnostic that indicates human, swine, or bird flu — clinics should probe more deeply, Nuzzo said.

The alternative is a wait-and-see approach in which the nation responds only after enormous damage to lives or businesses. This tack tends to rely on mass vaccination. But an effort analogous to Trump’s Operation Warp Speed is not assured, and neither is rollout like that for the first covid shots, given a rise in vaccine skepticism among Republican lawmakers.

Change may instead need to start from the bottom up — on dairy farms, still the most common source of human infections, said Poulsen. He noticed a shift in attitudes among farmers at the Dairy Expo: “They’re starting to say, ‘How do I save my dairy for the next generation?’ They recognize how severe this is, and that it’s not just going away.”

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Pero la magnitud de los esfuerzos de los ganaderos por tratar a las vacas enfermas lo dejó atónito. Le mostraron videos de los sistemas que habían construido para hidratar a cientos de reses a la vez. En turnos de 14 horas, los trabajadores bombeaban galones de líquidos ricos en electrolitos a las vacas enfermas a través de tubos metálicos insertados en el esófago.

“Era como ver el hospital de campaña en un frente de batalla tratando a cientos de soldados heridos”, afirmó.

Casi un año después del primer brote de gripe aviar en el ganado, el virus no muestra señales de detenerse. El gobierno estadounidense no consiguió eliminar el virus de los tambos cuando estaba confinado a un puñado de estados. No se identificó con rapidez a las vacas infectadas ni se tomaron medidas para evitar que el virus se propagara. Ahora, al menos 860 rebaños de 16 estados han dado positivo.

Expertos afirman haber perdido la fe en la capacidad del gobierno para contener el brote.

“Vivimos una situación terrible y vamos hacia una situación todavía peor”, dijo Angela Rasmussen, viróloga de la Universidad de Saskatchewan, en Canadá. “No sé si la gripe aviar se convertirá en pandemia, pero si ocurre, será un desastre”.

Para entender cómo la gripe aviar se les fue de las manos, Â鶹ŮÓÅ Health News entrevistó a unos 70 funcionarios del gobierno, agricultores y trabajadores agrícolas, y a investigadores expertos en virología, pandemias, medicina veterinaria y más.

En base a los correos electrónicos obtenidos de los departamentos de salud locales a través de solicitudes de acceso a documentos públicos, esta investigación reveló problemas clave, incluyendo la complacencia con la industria agrícola, presupuestos de salud pública reducidos, el descuido de la seguridad de los trabajadores agrícolas, y el ritmo lento de las intervenciones federales.

Un ejemplo: el Departamento de Agricultura (USDA) promulgó en diciembre una para analizar la leche en todo el país. Los investigadores recibieron con satisfacción la noticia, pero afirmaron que debería haberse hecho meses atrás, antes de que el virus estuviera tan arraigado.

“Es descorazonador ver cómo vuelven a aparecer muchas de las fallas que surgieron durante la crisis de covid-19”, afirmó Tom Bollyky, director del Programa de Salud Global en el Council on Foreign Relations.

Es inevitable que se produzcan muchos más daños por la gripe aviar, pero su alcance quedará en manos de la administración Trump y de la madre naturaleza.

El USDA ya ha destinado más de $1.700 millones a combatir la gripe aviar en las granjas avícolas desde 2022, lo que incluye el reembolso a los granjeros que han tenido que sacrificar sus rebaños, y más de $430 millones a combatir la gripe aviar en las granjas lecheras.

En los próximos años, la gripe aviar puede costar miles de millones de dólares más en gastos y pérdidas. Expertos de la industria láctea afirman que el virus mata aproximadamente entre el 2% y el 5% de las vacas lecheras infectadas y reduce la producción de leche de un rebaño en torno al 20%.

Peor lo que es peor aún, el brote conlleva la amenaza de una pandemia. Más de 60 personas se han infectado en Estados Unidos, principalmente por vacas o aves de corral, pero los casos podrían dispararse si el virus evoluciona para propagarse eficazmente de persona a persona.

Y la de una persona gravemente enferma de gripe aviar en Louisiana demuestra que el virus puede ser peligroso.

Unas podrían permitir que la gripe aviar se propagara entre las personas. Dado que los virus mutan dentro de los organismos humanos y animales, cada infección es como tirar de la palanca de una máquina tragamonedas.

“Aunque sólo haya un 5% de probabilidades de que se produzca una pandemia de gripe aviar, estamos hablando de una pandemia que probablemente se parezca a la de 2020 o a algo peor”, señaló Tom Peacock, investigador de la gripe aviar en el Instituto Pirbright del Reino Unido, refiriéndose a covid. “Estados Unidos conoce el riesgo, pero no ha hecho nada para frenarlo”, añadió.

Más allá de la gripe aviar, la gestión del brote por parte del gobierno federal revela grietas en el sistema de seguridad de la salud estadounidense que permitiría el arraigo de otros patógenos nuevos de riesgo. “Puede que no sea este virus”, dijo María Van Kerkhove, directora del grupo de enfermedades emergentes de la Organización Mundial de la Salud (OMS). “Pero ahora mismo esto es un simulacro de incendio real, y nos demuestra lo que hay que mejorar”.

Un comienzo lento

Pudo haber sido un tordo, un ganso o alguna otra ave silvestre la que infectó a una vaca en el norte de Texas. En febrero, los ganaderos del estado lo notaron cuando las vacas dejaron de producir leche. Colaboraron con los veterinarios para averiguar las causas. En menos de dos meses, los investigadores identificaron al virus H5N1 altamente patógeno de la gripe aviar como el culpable.

Incluido desde hacía tiempo entre los patógenos con potencial pandémico, la propagación sin precedentes de la gripe aviar entre las vacas marcó un giro preocupante. Había evolucionado para desarrollarse en animales biológicamente más parecidos a las personas que a las aves.

Después que el USDA anunciara el brote len tambos el 25 de marzo, el control pasó de los granjeros, veterinarios y funcionarios locales a las agencias estatales y federales. La colaboración se desintegró casi de inmediato.

A los granjeros les preocupaba que el gobierno pudiera bloquear la venta de leche o incluso exigir la matanza de las vacas enfermas, como se hace con las aves de corral, explicó Kay Russo, veterinaria de ganado de Fort Collins, Colorado.

Sin embargo, Russo y otros veterinarios se mostraron consternados por la inacción. El USDA no respondió a sus peticiones urgentes de apoyo a los estudios en granjas lecheras, ni al pedido de dinero y políticas de confidencialidad para proteger a los ganaderos de pérdidas económicas si accedían a realizar pruebas en animales.

El USDA anunció que realizaría los estudios. Pero los investigadores se inquietaron a medida que pasaban las semanas sin resultados. “Probablemente, el mayor error del USDA fue no involucrar a los veterinarios que están en las granjas”, afirmó Russo.

Will Clement, asesor principal de comunicaciones del USDA, respondió en un correo electrónico: “Desde que se supo por primera vez de la presencia del virus H5N1 en el ganado lechero a finales de marzo de 2024, el USDA ha trabajado con rapidez y diligencia para evaluar la prevalencia del virus en los tambos estadounidenses”. La agencia proporcionó fondos de investigación a los laboratorios estatales y nacionales de salud animal a partir de abril, añadió.

El USDA no exigió que las vacas lactantes se sometieran a pruebas antes de los viajes interestatales hasta el 29 de abril. Para entonces, el brote se había extendido a otros ocho estados. Los ganaderos suelen trasladar el ganado a grandes distancias, para parir en un lugar, criar en climas cálidos y secos, y ordeñar en otros más fríos. El análisis de del virus sugería que se propagaba entre las vacas en lugar de saltar constantemente de las aves a los rebaños.

El equipo para ordeñar era una fuente probable de infección, y había indicios de otras posibilidades, como a través del aire al toser las vacas o en gotas sobre objetos, como botas de trabajo. Pero no se habían recogido suficientes datos para saber cómo se producía exactamente. Muchos ganaderos se negaron a realizar pruebas en sus rebaños, a pesar de que en mayo se anunciaron fondos para compensarles por la pérdida de producción de leche.

“En la comunidad de ganaderos lecheros existe el temor de que, si se les incluye oficialmente en la lista de tambos afectados, puedan perder su mercado”, explicó Jamie Jonker, director científico de la Federación Nacional de Productores de Leche, organización que representa a este grupo. Que él sepa, agregó, esto no ha ocurrido.

La especulación sustituyó a los hechos. Zach Riley, director de la Asociación de Ganaderos de Colorado, dijo que sospechaba que las aves silvestres podrían estar propagando el virus a los rebaños de todo el país, a pesar de que los datos científicos sugieren lo contrario. Riley anunció que los ganaderos se estaban planteando la posibilidad de instalar “figuras inflables gigantes como las que se ven fuera de los concesionarios de automóviles” para ahuyentar a las aves.

Las recomendaciones de los departamentos de agricultura a los ganaderos fueron también algo especulativas. Los funcionarios recomendaron medidas de bioseguridad como desinfectar el equipo y limitar las visitas. Mientras el virus seguía propagándose a lo largo del verano, el alto funcionario del USDA, Eric Deeble, declaró en una rueda de prensa: “La respuesta es la adecuada”.

El USDA, los Centros para el Control y la Prevención de Enfermedades (CDC) y la Administración de Alimentos y Medicamentos (FDA) presentaron un frente unido en estas sesiones informativas, denominándolas “Una sola salud”. En realidad, las agencias de agricultura tomaron la iniciativa.

Así se desprende de un correo electrónico enviado por un departamento de salud local de Colorado a los comisionados del condado. “El Estado está tratando esto como una cuestión de agricultura (con razón) y la parte de salud pública es secundaria”, escribió Jason Chessher, director de salud pública del condado de Weld, Colorado. Como principal condado agrícola del estado, la industria ganadera y avícola de Weld produce alrededor de $1.900 millones en ventas cada año.

Vigilancia inconsistente

En julio, la gripe aviar se propagó de las centrales lecheras de Colorado a las granjas avícolas. Para contenerla, dos instalaciones avícolas emplearon a unos —inmigrantes hispanohablantes, de 15 años los más jóvenes— para sacrificar a los animales. En el interior de graneros donde se alcanzaban altas temperaturas, atrapaban a las aves infectadas, las gaseaban con dióxido de carbono y se deshacían de los animales muertos. Muchos realizaron este peligroso trabajo sin gafas, máscaras ni guantes.

Cuando el departamento de salud de Colorado se interesó por la salud de los trabajadores, cinco mujeres y cuatro hombres ya se habían infectado. Todos tenían los ojos rojos e hinchados —conjuntivitis— y varios presentaban síntomas como fiebre, dolores corporales y náuseas.

Los departamentos estatales de salud publicaron en Internet avisos en los que ofrecían a las granjas equipos de protección, pero los trabajadores del sector lácteo de varios estados dijeron a Â鶹ŮÓÅ Health News que no tenían ninguno. Tampoco habían oído hablar de la gripe aviar, ni mucho menos de pruebas para detectarla.

Estudios realizados en Colorado, Michigan y Texas demostrarían más tarde que los casos de gripe aviar habían pasado desapercibidos. En , ocho trabajadores lácteos que no se habían sometido a las pruebas —el 7% de los estudiados— tenían anticuerpos contra el virus, señal de que habían estado infectados.

Los casos no detectados impidieron determinar cómo saltó el virus a las personas y si se estaba volviendo más infeccioso o peligroso. “Me he sentido angustiada y deprimida por la falta de datos epidemiológicos y la falta de vigilancia”, afirmó Nicole Lurie, directora ejecutiva de la organización internacional Coalition for Epidemic Preparedness Innovations, que fue subsecretaria de Preparación y Respuesta en la administración Obama.

Citando “datos insuficientes”, en julio, el gobierno británico elevó de tres a cuatro, en una escala de seis niveles, del riesgo planteado por el brote lácteo de Estados Unidos.

Virólogos de todo el mundo se mostraron asombrados por el deficiente seguimiento de la situación por parte de Estados Unidos. “Estamos rodeados de virus altamente patógenos en la naturaleza y en animales de granja”, dijo Marion Koopmans, jefe de virología del Centro Médico Erasmus de Holanda. “Si dentro de tres meses estamos en el inicio de la pandemia, no será una sorpresa para nadie”.

Aunque la gripe aviar aún no se propaga con rapidez entre las personas, un cambio en esa dirección podría causar enorme sufrimiento. Los CDC han descrito repetidamente los casos entre los trabajadores agrícolas de este año como leves: no fueron hospitalizados. Pero eso no significa que los síntomas sean benignos, o que el virus no pueda causar algo peor.

“No es agradable”, escribió Sean Roberts, especialista en servicios de emergencia del departamento de salud del condado de Tulare, California, en un correo electrónico enviado a sus colegas en mayo. Describía fotografías de un trabajador de lácteo infectado en otro estado: “Al parecer, la conjuntivitis que esto está provocando no es leve, es la rotura de vasos sanguíneos y hemorragia de la conjuntiva”.

En los últimos 30 años, la mitad de las cerca de 900 personas diagnosticadas con gripe aviar en todo el mundo han muerto. Aunque la tasa de mortalidad es mucho más baja para esta cepa de la gripe aviar, covid demostró lo devastador que puede ser un 1% de mortalidad cuando un virus se propaga con facilidad.

Al igual que otros casos en todo el mundo, la persona hospitalizada con gripe aviar en Louisiana parece haber contraído el virus directamente de las aves. Tras anunciarse el caso, los CDC en el que afirmaban: “Un caso esporádico de enfermedad grave por gripe aviar H5N1 en una persona no es algo inesperado”.

“Las vacas son más valiosas que nosotros”

Funcionarios de salud locales se esforzaban por rastrear las infecciones, según se desprende de cientos de correos electrónicos de los departamentos de salud de los condados en cinco estados. Pero sus esfuerzos se vieron obstaculizados.

Aunque los ganaderos informaban de los rebaños infectados al USDA y las agencias agrícolas comunicaban a los departamentos de salud dónde estaban las vacas infectadas, los oficiales de salud dependían de los propietarios de las granjas para acceder a los animales.

“La comunidad agrícola ha dictado las reglas del juego desde el principio”, afirmó Michael Osterholm, director del Centro de Investigación y Política de Enfermedades Infecciosas de la Universidad de Minnesota. “Ha sido un gran error”.

Algunos granjeros le pidieron a los funcionarios de salud que no fueran a sus instalaciones, y se negaron a vigilar a sus empleados en busca de signos de la enfermedad. Enviar a los trabajadores a las clínicas para que les hicieran pruebas podría dejarles sin personal cuando el ganado necesitara atención. “El productor se niega a enviar a los trabajadores a la [clínica] Sunrise para que se hagan las pruebas porque están demasiado ocupados. También tiene conjuntivitis”, decía un correo electrónico del departamento de salud de Weld, Colorado.

“Sabemos de 386 personas expuestas; pero también sabemos que este número está lejos del total”, contó en un correo electrónico una especialista en salud pública a los funcionarios del departamento de salud de Tulare, relatando una llamada con funcionarios de salud del estado. “Los empresarios no quieren pasar esto por el sistema de compensación de los trabajadores. Los trabajadores dudan en hacerse la prueba debido al costo”, escribió.

Jennifer Morse, directora médica del Departamento de Salud del Distrito de Mid-Michigan, afirmó que los funcionarios locales han dudado a la hora de ejercer presión tras la reacción violenta a la que muchos se enfrentaron en el momento álgido de covid. Morse describió a los 19 condados rurales en los que presta servicio como “de mentalidad de gobierno mínimo”, y dijo que “si intentas trabajar contra ellos, no saldrá bien”.

Los departamentos de salud rurales también están al límite de su capacidad. Al inicio del brote, as organizaciones especializadas en la atención a los trabajadores agrícolas se ofrecieron a ayudar a las autoridades, pero pasaron meses sin contratos ni financiación. Durante los primeros años de covid, la del gobierno para llegar a los trabajadores del campo, y a otros grupos históricamente marginados, provocó un de la enfermedad entre la población de color.

Kevin Griffis, director de comunicaciones de los CDC, declaró que la agencia trabajó con el Centro Nacional para la Salud de los Trabajadores Agrícolas durante todo el verano “para llegar a todos los trabajadores afectados por el H5N1”. Pero Bethany Boggess Alcauter, directora de programas de salud pública del centro, aseguró que no recibió ninguna subvención de los CDC para informar sobre la gripe aviar hasta octubre: fueron, $4 millones. Antes de eso, dijo, el grupo disponía de fondos muy limitados para la tarea. “Es evidente que no estamos llegando a ‘todos los trabajadores agrícolas’”, agregó.

Los activistas también presionaron a los CDC para que aportaran dinero para calmar las preocupaciones económicas de los trabajadores en relación con las pruebas, incluido el pago de la atención médica, las bajas por enfermedad y el riesgo de despido. Esto supuso una oferta de $75 para cada uno. “Está claro que la divulgación no es una gran prioridad”, afirmó Boggess. “Esto es lo que les escucho decir a los trabajadores: ‘Las vacas son más valiosas que nosotros’”.

Hasta el momento, el USDA ha destinado más de $2,100 millones para reembolsar a los avicultores y productores lácteos las pérdidas ocasionadas por la gripe aviar y otras medidas para controlar la propagación en las granjas. Las agencias federales también han invertido $292 millones en el desarrollo y almacenamiento de vacunas contra la gripe aviar para animales y personas. En una controvertida decisión, los CDC han desaconsejado ofrecer las vacunas disponibles a los trabajadores agrícolas.

“Si se quiere evitar que se convierta en una pandemia humana, hay que centrarse en la protección de los trabajadores agrícolas, ya que es la forma más probable de que esto entre en la población”, dijo Peg Seminario, una investigadora de salud ocupacional en Bethesda, Maryland. “El hecho de que esto no ocurra me vuelve loca”.

Nirav Shah, subdirector principal de los CDC, dijo que el objetivo de la agencia es proteger a los trabajadores. “La concienciación generalizada lleva tiempo”, señaló. “Y ese es el trabajo que estamos comprometidos a hacer”.

Con la llegada al poder del presidente electo Donald Trump, los trabajadores agrícolas pueden estar aún menos protegidos. La promesa de Trump de deportaciones masivas tendrá repercusiones tanto si se producen como si no, dijo Tania Pacheco-Werner, directora del Central Valley Health Policy Institute de California.

Muchos trabajadores de la industria láctea y avícola viven en Estados Unidos sin autorización o con visados temporales vinculados a sus empleadores. Esta precariedad hizo que en 2020 estuvieran menos dispuestos a acudir al médico por síntomas de covid o para quejarse de condiciones de trabajo inseguras. Pacheco-Werner dijo: “La deportación masiva es un desafío astronómico para la salud pública”.

No a la “Inmaculada Concepción”

Todo cambió en septiembre entre los expertos que estudian las pandemias como amenazas a la seguridad nacional. Un paciente de Missouri tenía gripe aviar y nadie sabía por qué. “Las pruebas apuntan a que se trata de un caso aislado”, declaró Shah en una reunión informativa con periodistas. Aproximadamente un mes después, la agencia reveló que no lo era.

Las pruebas de anticuerpos revelaron que una persona que vivía con el paciente también se había infectado. Los CDC no sabían cómo habían contraído el virus, y no se podía descartar la posibilidad de transmisión humana.

No obstante, en una reunión informativa celebrada en octubre, Shah afirmó que el riesgo para la población seguía siendo bajo y Deeble, del USDA, se mostró optimista ante la posibilidad de eliminar el brote lácteo.

A los expertos les inquietó la seguridad que transmitían estas declaraciones ante la incertidumbre reinante, sobre todo cuando el brote de California se disparó y resultó misteriosamente infectado por la misma cepa del virus hallada en las granjas lecheras.

“Esto no fue una inmaculada concepción”, dijo Stephen Morrison, director del Centro de Políticas de Salud Global en el Centro de Estudios Estratégicos e Internacionales. “Vino de alguna parte y no sabemos de dónde; pero eso no ha provocado ningún tipo de reajuste en el enfoque, sólo el mismo tipo de complacencia y baja energía”.

Sam Scarpino, especialista en vigilancia de enfermedades en la zona de Boston, se preguntaba cuántas otras infecciones misteriosas habían pasado desapercibidas. La vigilancia fuera de las granjas era aún más inconsistente, y las pruebas de la gripe aviar han sido difíciles de conseguir.

A pesar de que los expertos en pandemias habían señalado el freno de los CDC a las pruebas de detección de nuevos virus, como una explicación clave de por qué Estados Unidos se vio tan afectado por covid en 2020, el sistema seguía siendo el mismo. Las pruebas de la gripe aviar sólo podían ser realizadas por los CDC y los laboratorios de salud pública hasta este mes, a pesar de que los laboratorios de diagnóstico comerciales y académicos habían preguntado sobre la realización de pruebas desde abril. Los CDC y la FDA deberían haber intentado ayudarles hace meses, afirmó Ali Khan, ex alto funcionario de los CDC que ahora dirige la Facultad de Salud Pública del Centro Médico de la Universidad de Nebraska.

Con la llegada del invierno, la gripe aviar es más difícil de detectar porque los síntomas de los pacientes pueden confundirse con los de la gripe estacional. La temporada de gripe también plantea el riesgo de que los dos virus de la gripe intercambien genes si infectan a una persona al mismo tiempo. Esto podría dar lugar a una gripe aviar híbrida que se propagaría rápidamente a través de la tos y los estornudos.

Según Bollyky, del Council on Foreign Relations, la lentitud en la respuesta a los brotes emergentes puede ser simplemente una nueva y desafortunada norma para Estados Unidos. Si es así, el país ha tenido suerte de que la gripe aviar aún no pueda propagarse fácilmente entre las personas. Controlar el virus será mucho más difícil y costoso de lo que habría sido cuando el brote era pequeño. Pero es posible.

Las autoridades agrícolas podrían empezar a analizar mensualmente todos los silos de leche a granel de todos los estados, según Poulsen, veterinario de ganadería. “No sólo una vez”, añadió. Si detectan el virus, tendrían que identificar la granja afectada a tiempo para impedir que las vacas enfermas propaguen la infección al resto del rebaño, o al menos a otras granjas. Las vacas pueden propagar la gripe aviar antes de enfermar, dijo, por lo que la rapidez es crucial.

Según Jennifer Nuzzo, directora del Centro de Pandemias de la Universidad de Brown, la mejor forma de prevenir las infecciones humanas es reducir el virus en las granjas, pero también hay que intensificar la vigilancia humana. Todas las clínicas que atienden a las comunidades donde viven los trabajadores agrícolas deben tener fácil acceso a las pruebas de la gripe aviar, y se les debe animar a que las utilicen. Deben incrementarse los fondos destinados a la información entre los trabajadores agrícolas. Y, añadió, los CDC deberían cambiar su postura y ofrecer a los trabajadores del campo vacunas contra la gripe aviar para protegerlos y evitar la posibilidad de una gripe aviar híbrida que se propague rápidamente.

El creciente número de casos no relacionados con las granjas indica la necesidad de realizar más pruebas en general. Cuando los pacientes dan positivo en una prueba de la gripe —un diagnóstico común que indica gripe humana, porcina o aviar—, las clínicas deben indagar más a fondo, señaló Nuzzo.

La alternativa es un planteamiento de espera en el que el país responda sólo después de que se hayan producido enormes daños en vidas humanas o empresas. Este enfoque suele basarse en la vacunación masiva. Pero un esfuerzo parecido a la Operación Warp Speed de Trump no está asegurado, y tampoco lo está un despliegue como el de las primeras inyecciones de covid, dado el aumento del escepticismo sobre las vacunas entre los legisladores republicanos.

Según Poulsen, es posible que el cambio tenga que empezar desde abajo: en las granjas lecheras, que siguen siendo la fuente más común de infecciones humanas. En la Dairy Expo observó un cambio de actitud entre los ganaderos. “Empiezan a preguntarse: ¿Cómo puedo salvar mi ganado para la próxima generación? Reconocen lo grave que es esto, y que no va a desaparecer así como así”.

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Trump announced Thursday he’ll nominate Robert F. Kennedy Jr. to be secretary of the Health and Human Services Department, after saying during his campaign he’d let the anti-vaccine activist “go wild” on medicines, food, and health.

Should Kennedy win Senate confirmation, his critics say a radical antiestablishment medical movement with roots in past centuries would take power, threatening the achievements of a science-based public health order painstakingly built since World War II.

Trump said in a post on the social platform X that “Americans have been crushed by the industrial food complex and drug companies who have engaged in deception, misinformation, and disinformation when it comes to Public Health,” echoing Kennedy’s complaints about the medical establishment. The former Democratic presidential candidate will “end the Chronic Disease epidemic” and “Make American Great and Healthy Again!” Trump wrote.

Vaccine makers’ stocks dipped Thursday afternoon amid news reports ahead of Trump’s RFK announcement.

If Kennedy makes good on his vision for transforming public health, childhood vaccine mandates could wither. New vaccines might never win approval, even as the FDA allows dangerous or inefficient therapies onto the market. Agency websites could trumpet unproven or debunked health ideas. And if Trump’s plan to weaken civil service rights goes through, anyone who questions these decisions could be summarily fired.

“Never has anybody like RFK Jr. gotten anywhere close to the position he may be in to actually shape policy,” said Lewis Grossman, a law professor at American University and the author of “Choose Your Medicine,” a history of U.S. public health.

Kennedy and an adviser Calley Means, a health care entrepreneur, say dramatic changes are needed because of the high levels of chronic disease in the United States. Government agencies have corruptly tolerated or promoted unhealthy diets and dangerous drugs and vaccines, they say.

Means and Kennedy did not respond to requests for comment. Four conservative members of the first Trump health bureaucracy spoke on condition of anonymity. They eagerly welcomed the former president’s return but voiced few opinions about specific policies. Days after last week’s election, RFK Jr. announced that the Trump administration would immediately fire and replace 600 National Institutes of Health officials. He set up a website seeking crowdsourced nominees for federal appointments, with a host of vaccination foes and chiropractors among the early favorites.

At meetings last week at Mar-a-Lago involving Elon Musk, Tucker Carlson, Donald Trump Jr., Kennedy, and Means, according to Politico, some candidates for leading health posts included Jay Bhattacharya, a Stanford University scientist who opposed covid lockdowns; Florida Surgeon General Joseph Ladapo, who opposes mRNA covid vaccines and rejected well-established disease control practices during a measles outbreak; Johns Hopkins University surgeon Marty Makary; and Means’ sister, Stanford-trained surgeon and health guru Casey Means.

All are mavericks of a sort, though their ideas are not uniform. Yet the notion that they could elbow aside a century of science-based health policy is profoundly troubling to many health professionals. They see Kennedy’s presence at the heart of the Trump transition as a triumph of the “medical freedom” movement, which arose in opposition to the Progressive Era idea that experts should guide health care policy and practices.

It could represent a turning away from the expectation that mainstream doctors be respected for their specialized knowledge, said Howard Markel, an emeritus professor of pediatrics and history at the University of Michigan, who began his clinical career treating AIDS patients and ended it after suffering a yearlong bout of long covid.

“We’ve gone back to the idea of ‘every man his own doctor,’” he said, referring to a phrase that gained currency in the 19th century. It was a bad idea then and it’s even worse now, he said.

“What does that do to the morale of scientists?” Markel asked. The public health agencies, largely a post-WWII legacy, are “remarkable institutions, but you can screw up these systems, not just by defunding them but by deflating the true patriots who work in them.”

FDA Commissioner Robert Califf told a conference on Nov. 12 that he worried about mass firings at the FDA. “I’m biased, but I feel like the FDA is sort of at peak performance right now,” he said. At a conference the next day, CDC Director Mandy Cohen reminded listeners of the horrors of vaccine-preventable diseases like measles and polio. “I don’t want to have to see us go backward in order to remind ourselves that vaccines work,” she said.

Stocks of some the biggest vaccine developers fell after news outlets led by Politico reported that the RFK pick was expected. Moderna, the developer of one of the most popular covid-19 vaccines, closed down 5.6%. Pfizer, another covid vaccine manufacturer, fell 2.6%. GSK, the producer of vaccines protecting against respiratory syncytial virus, hepatitis A and B, rotavirus, and influenza, fell just over 2%. French drug company Sanofi, vaccinate over 500 million annually, tumbled nearly 3.5%.

Exodus From the Agencies?

With uncertainty over the direction of their agencies, many older scientists at the NIH, FDA, and Centers for Disease Control and Prevention are considering retirement, said a senior NIH scientist who spoke on the condition of anonymity for fear of losing his job.

“Everybody I talk to sort of takes a deep breath and says, ‘It doesn’t look good,’” the official said.

“I hear of many people getting CVs ready,” said Arthur Caplan, a professor of bioethics at New York University. They include two of his former students who now work at the FDA, Caplan said.

Others, such as Georges Benjamin, executive director of the American Public Health Association, have voiced wait-and-see attitudes. “We worked with the Trump administration last time. There were times things worked reasonably well,” he said, “and times when things were chaotic, particularly during covid.” Any wholesale deregulation efforts in public health would be politically risky for Trump, he said, because when administrations “screw things up, people get sick and die.”

At the FDA, at least, “it’s very hard to make seismic changes,” former FDA chief counsel Dan Troy said.

But the administration could score easy libertarian-tinged wins by, for example, telling its new FDA chief to reverse the agency’s refusal to approve the psychedelic drug MDMA from the company Lykos. Access to psychedelics to treat post-traumatic stress disorder has grabbed the interest of many veterans. Vitamins and supplements, already only lightly regulated, will probably get even more of a free pass from the next Trump FDA.

‘Medical Freedom’ or ‘Nanny State‘

Trump’s health influencers are not monolithic. Analysts see potential clashes among Kennedy, Musk, and more traditional GOP voices. Casey Means, a “holistic” MD at the center of Kennedy’s “Make America Healthy Again” team, calls for the government to cut ties with industry and remove sugar, processed food, and toxic substances from American diets. Republicans lampooned such policies as exemplifying a “nanny state” when Mike Bloomberg promoted them as mayor of New York City.

Both the libertarian and “medical freedom” wings oppose aspects of regulation, but Silicon Valley biotech supporters of Trump, like Samuel Hammond of the Foundation for American Innovation, have pressed the agency to speed drug and device approvals, while Kennedy’s team says the FDA and other agencies have been “captured” by industry, resulting in dangerous and unnecessary drugs, vaccines, and devices on the market.

Kennedy and Casey Means want to end industry user fees that pay for drug and device rules and support nearly half the FDA’s $7.2 billion budget. It’s unclear whether Congress would make up the shortfall at a time when Trump and Musk have vowed to slash government programs. User fees are set by laws Congress passes every five years, most recently in 2022.

The industry supports the user-fee system, which bolsters FDA staffing and speeds product approvals. Writing new rules “requires an enormous amount of time, effort, energy, and collaboration” by FDA staff, Troy said. Policy changes made through informal “guidance” alone are not binding, he added.

Kennedy and the Means siblings have suggested overhauling agricultural policies so that they incentivize the cultivation of organic vegetables instead of industrial corn and soy, but “I don’t think they’ll be very influential in that area,” Caplan said. “Big Ag is a powerful entrenched industry, and they aren’t interested in changing.”

“There’s a fine line between the libertarian impulse of the ‘medical freedom’ types and advocating a reformation of American bodies, which is definitely ‘nanny state’ territory,” said historian Robert Johnston of the University of Illinois-Chicago.

Specific federal agencies are likely to face major changes. Republicans want to trim the NIH’s 27 research institutes and centers to 15, slashing Anthony Fauci’s legacy by splitting the National Institute of Allergy and Infectious Diseases, which he led for 38 years, into two or three pieces.

Numerous past attempts to slim down the NIH have failed in the face of campaigns by patients, researchers, and doctors. GOP lawmakers have advocated substantial cuts to the CDC budget in recent years, including an end to funding gun violence, climate change, and health equity research. If carried out, Project 2025, a policy blueprint from the conservative Heritage Foundation, would divide the agency into data-collecting and health-promoting arms. The CDC has limited clout in Washington, although former CDC directors and public health officials are defending its value.

“It would be surprising if CDC wasn’t on the radar” for potential change, said Anne Schuchat, a former principal deputy director of the agency, who retired in 2021.

The CDC’s workforce is “very employable” and might start to look for other work if “their area of focus is going to be either cut or changed,” she said.

Kennedy’s attacks on HHS and its agencies as corrupted tools of the drug industry, and his demands that the FDA allow access to scientifically controversial drugs, are closely reminiscent of the 1970s campaign by conservative champions of Laetrile, a dangerous and ineffective apricot-pit derivative touted as a cancer treatment. Just as Kennedy championed off-patent drugs like ivermectin and hydroxychloroquine to treat covid, Laetrile’s defenders claimed that the FDA and a profit-seeking industry were conspiring to suppress a cheaper alternative.

The public and industry have often been skeptical of health regulatory agencies over the decades, Grossman said. The agencies succeed best when they are called in to fix things — particularly after bad medicine kills or damages children, he said.

The 1902 Biologics Control Act, which created the NIH’s forerunner, was enacted in response to smallpox vaccine contamination that killed at least nine children in Camden, New Jersey. Child poisonings linked to the antifreeze solvent for a sulfa drug prompted the modern FDA’s creation in 1938. The agency, in 1962, acquired the power to demand evidence of safety and efficacy before the marketing of drugs after the thalidomide disaster, in which children of pregnant women taking the anti-nausea drug were born with terribly malformed limbs.

If vaccination rates plummet and measles and whooping cough outbreaks proliferate, babies could die or suffer brain damage. “It won’t be harmless for the administration to broadly attack public health,” said Alfredo Morabia, a professor of epidemiology at Columbia University and the editor-in-chief of the American Journal of Public Health. “It would be like taking away your house insurance.”

Sam Whitehead, Stephanie Armour, David Hilzenrath, and Darius Tahir contributed to this report.

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Holt works in Aberdeen, a city of about 28,000 surrounded by a sea of prairie, as a physician and the chief medical officer for the Great Plains Area Indian Health Service, one of 12 regional divisions of the federal agency responsible for providing health care to Native Americans and Alaska Natives in the U.S.

The response to this public health issue, she said, is not so different from the approach with the coronavirus pandemic — federal, state, local, and tribal groups need to “divide and conquer” as they work to test and treat residents. But they are responding to this crisis with fewer resources because federal officials haven’t declared it a public health emergency.

The public pleas for testing are part of health officials’ efforts to halt the outbreak that has disproportionately hurt Native Americans in the Great Plains and Southwest. , syphilis rates among Native Americans in its region soared by 1,865% from 2020 to 2022 — over 10 times the 154% increase seen nationally during the same period. The epidemiology center’s region spans Iowa, Nebraska, North Dakota, and South Dakota. The center also found that 1 in 40 Native American and Alaska Native babies born in the region in 2022 had a syphilis infection.

The rise in infections accelerated in 2021, pinching public health leaders still reeling from the coronavirus pandemic.

Three years later, the outbreak continues — the number of new infections so far this year is 10 times the full 12-month totals recorded in some years before the upsurge. And tribal health leaders say their calls for federal officials to declare a public health emergency have gone unheeded.

Pleas for help from local and regional tribal health leaders like Meghan Curry O’Connell, the chief public health officer for the Great Plains Tribal Leaders’ Health Board and a citizen of the Cherokee Nation, preceded a September letter from the National Indian Health Board, a Washington, D.C.-based nonprofit that advocates for health care for U.S. tribes, to to declare a public health emergency. Tribal leaders said they need federal resources including public health workers, access to data and national stockpile supplies, and funding.

According to data from the South Dakota Department of Health, have been documented this year in the state. Of those, 430 were among Native American people — making up 75% of the state’s syphilis cases, whereas the group accounts for just 9% of the population.

The numbers can be hard to process, O’Connell said.

“It’s completely preventable and curable, so something has gone horribly wrong that this has occurred,” she said.

The Great Plains Tribal Leaders’ Health Board first called on HHS to . O’Connell said the federal agency sent a letter in response outlining some resources and training it has steered toward the outbreak, but it stopped short of declaring an emergency or providing the substantial resources the board requested. The board’s now months-old plea for resources was like the recent one from the National Indian Health Board.

“We know how to address this, but we do need extra support and resources in order to do it,” she said.

Syphilis is a sexually transmitted infection that can result in life-threatening damage to the heart, brain, and other organs if left untreated. Women infected while pregnant can pass the disease to their babies. Those infections in newborns, called congenital syphilis, kill dozens of babies each year and can lead to devastating health effects in others.

Holt said the Indian Health Service facilities she oversees have averaged more than 1,300 tests for syphilis monthly. She said a recent decline in new cases detected each month — down from 92 in January to 29 in September — may be a sign that things are improving. But a lot of damage has been done during the past few years.

Cases of congenital syphilis across the country have more than tripled in recent years, according to the Centers for Disease Control and Prevention. In 2022, — the most in a single year since 1994.

The highest rate of reported primary and secondary syphilis cases in 2022 was among non-Hispanic American Indian or Alaska Native people, with 67 cases per 100,000, .

O’Connell and other tribal leaders said they don’t have the resources needed to keep pace with the outbreak.

Chief William Smith, vice president of Alaska’s Valdez Native Tribe and chairperson of the National Indian Health Board, told HHS in the organization’s letter that tribal health systems need greater federal investment so the system can better respond to public health threats.

Rafael Benavides, HHS’ deputy assistant secretary for public affairs, said the agency has received the letter sent in early September and will respond directly to the authors.

“HHS is committed to addressing the urgent syphilis crisis in American Indian and Alaska Native communities and supporting tribal leaders’ efforts to mobilize and raise awareness to address this important public health crisis,” he said.

Federal officials from the health department and the CDC and hosted workshops for tribes on how to address the outbreak. But tribal leaders insist a public health emergency declaration is needed more than anything else.

Holt said that while new cases seem to be declining, officials continue to fight further spread with what resources they have. But obstacles remain, such as convincing people without symptoms to get tested for syphilis. To make this easier, appointments are not required. When people pick up medications at a pharmacy, they receive flyers about syphilis and information about where and when to get tested.

Despite this “full court press” approach, Holt said, officials know there are people who do not seek health care often and may fall through the cracks.

O’Connell said the ongoing outbreak is a perfect example of why staffing, funding, data access, and other resources need to be in place before an emergency develops, allowing public health agencies to respond immediately.

“Our requests have been specific to this outbreak, but really, they’re needed as a foundation for whatever comes next,” she said. “Because something will come next.”

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The children, Deas said, often have been exposed to violence on hotel properties, exhibit aggression or anxiety from living in a crowded single room, and face food insecurity because some hotel rooms don’t have kitchens.

“Social trauma is the biggest challenge” when students first arrive, Deas said. “We hear a lot about sleep problems.” To meet students’ needs, Deas developed a schoolwide program featuring counselors, a food pantry, and special protocols for handling those who may fall asleep in class.

“Beyond the teaching, there’s a social part,” he said. “We have to find ways to support the families as well.”

Extended-stay hotels are often a last resort for low-income families trying to find housing. Nationally, more than 100,000 students lived in extended-stay hotels in 2022, according to the Department of Education, though officials say that is likely an undercount. Children living in hotels are considered homeless under federal law, and in some Atlanta-area counties about 40% of homeless students live in this kind of housing, according to local officials.

And with rising rents and evictions, and decreased access to federal public housing, the use of extended-stay hotels as a long-term option is becoming more frequent. Like other forms of homelessness, hotel living can lead to — or exacerbate — physical and mental health problems for children, say advocates for families and researchers who study homelessness.

In the Atlanta area, inspections of extended-stay hotels have revealed ventilation issues, insect infestations, mold, and other health threats. Children living there also can experience or witness crime and gun violence. The increasing use of extended-stay hotels is a warning sign, observers said, a reflection of the lack of sufficient affordable housing policy in the U.S.

And the crisis is having “lifelong consequences,” said Sarah Saadian of the National Low Income Housing Coalition. “The only way that we can really address that shortage is if there are significant federal resources at scale. Build more housing and bridge the gap between rents and wages.”

Often, evictions force families into hotels — and can keep them trapped there. Many landlords refuse to rent to people with evictions in their credit history, even if the tenant isn’t responsible for the displacement, said Joy Monroe, founder and CEO of the Single Parent Alliance & Resource Center, or SPARC, a nonprofit group in metro Atlanta that has helped hundreds of families move from hotels to apartments or rental homes.

Black women and other women of color, often with kids, are evicted at much higher rates and are more likely to find themselves living in extended-stay hotels, advocates say.

Some residents are also families fleeing domestic violence, they say.

Hotels often don’t require security deposits, application fees, or background checks, thus providing immediate relief for families seeking shelter. While there are higher-end options, the average rate for an economy-class extended-stay room was $56.68 a night during the first three months of 2024, according to the Highland Group, a research firm that focuses on the hotel sector — which works out to more than $1,700 a month.

And while the rooms offer respite from other forms of homelessness — like sleeping in a car or in a tent — a hotel “is no place to raise children,” said Michael Bryant, CEO of New Life Community Alliance, which helps families in South Dekalb, a part of metro Atlanta, move from hotels to homes.

Children living in hotels are often behind on vaccinations, and they may end up in the emergency room because of delays in care, said Gary Kirkilas, a pediatrician in Phoenix who helps children, teens, and families who are presently homeless or at risk of homelessness. About 75% of children with unstable housing whom he sees have at least one developmental delay, and others experience significant emotional and behavioral issues.

Tanazia Scott, who has bounced between two extended-stay hotels for several months, said her three children “feel depressed and upset” over hotel life.

An eviction sent Kassandra Norman, 58, and her two daughters into a months-long journey of staying in Atlanta-area hotels. For three months, they slept in a car outside a convenience store. “It’s hard to do homework in a car and in the hotel,” said 19-year-old Kazuri Taylor, Norman’s younger daughter.

Some hotels prohibit kids from playing outside in their parking lots, leading to additional stress, advocates say. That was the reason Yvonne Thomas, 45, and her family were evicted from an extended-stay hotel in DeKalb County, she said: “They put us out for nothing.”

And there are other problems. More than a dozen students at Dunaire Elementary live on an extended-stay property called Haven Hotel. In August, the hotel had “not maintained minimum life safety standards.” Roaches and spiders live in rooms and breezeways, according to state health inspection reports. Residents say they have been charged $1 for a roll of toilet paper.

The hotel’s owner and manager could not be reached for comment after multiple attempts.

“No one is talking about these families,” said Sue Sullivan, a community advocate and a volunteer with the Motel to Home coalition in Atlanta, who brings toys, bookbags, food, and toiletries on her hotel visits.

A February public health inspection at another DeKalb County hotel found several rooms with poor ventilation, insect infestation, and mold, among other potential health threats. In May, two people were fatally shot there.

Children who witness violence can develop anxiety, depression, and other disorders, said Charles Moore, director of the Urban Health Initiative at Emory University School of Medicine. “They can feel emotional aftershocks,” said Moore, who has visited Atlanta-area hotels.

Closing such hotels, however, can hurt families, given the shortage of affordable housing, the absence of national federal renter protections, and a dearth of places to go, said Terri Lewinson, an associate professor at the Dartmouth Institute for Health Policy and Clinical Practice. Extended-stay hotels do “offer a low-barrier option for families who have no other options,” she said.

To alleviate the housing problem, county officials and nonprofit organizations around the country have been creatively filling the gap. In the Seattle area, for example, King County officials purchased hotels and converted them into affordable housing, said Mark Skinner of the Highland Group.

In metro Atlanta, SPARC and the local United Way’s Motel to Home offer funding to help people transition into an apartment.

In DeKalb County, where Dunaire Elementary School is located, more than a third of the 1,300 homeless students live in hotels, according to Commissioner Ted Terry.

“I hope we can rescue the children,” he said. “It’s not a safe environment for them.”

Advocates who seek to help people living in hotels propose the construction of more affordable housing and stronger protections for renters against eviction. The federal government has failed to invest in repairs needed to maintain current public housing units, and 25-year-old legislation effectively prohibits the construction of new public housing.

It’s also “extremely fast, easy, and cheap” to evict tenants in Georgia, said Taylor Shelton, an associate professor of geosciences at Georgia State University, whose research focuses on social inequalities and urban spaces. “The playing field is tilted heavily toward landlords.”

Under such circumstances, the cycle of poverty is difficult to break, said Jamie Rush, a senior staff attorney at the Southern Poverty Law Center. “Most parents would want their kids in a safe, stable home,” Rush said. “You can’t budget your way out of poverty.”

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They showed that in 2023, for example, there were four active tuberculosis cases in Clark County, which includes Springfield, up from three in 2022. HIV cases had risen, but sexually transmitted illnesses overall were decreasing.

“I wouldn’t call it skyrocketing,” said Cook, noting that there were 190 active cases in 2023 in all of Ohio. “You hear the rhetoric. But as a whole, reportable infectious diseases to the health department are decreasing.”

Tensions are running high in this industrial town of about 58,000 people. Bomb threats closed schools and public buildings after GOP presidential nominee Donald Trump falsely claimed that Haitian immigrants — who he alleged were there illegally — were stealing and eating household pets. City and county officials disputed the claims the former president levied during his Sept. 10 debate with Vice President Kamala Harris, his Democratic opponent.

Trump was amplifying comments that — along with his claims about of this population — were broadly panned as false. When asked during a CNN interview about the debunked pet-eating rumor, Vance, a U.S. senator from Ohio, acknowledged that the image he created was based not on facts but on “firsthand accounts from my constituents.” He said he was willing “to create” stories to focus attention on how immigration can overrun communities.

But Ohio Gov. Mike DeWine, also a Republican, has said immigrants have been an economic boon to Springfield. Many began arriving because businesses in the town, which had seen its population decrease, needed labor.

Largely lost in the political rancor is the way Springfield and the surrounding area responded to the influx of Haitian immigrants. Local health institutions tried to address the needs of this new population, which had lacked basic public health care such as immunization and often didn’t understand the U.S. health system.

The town is a microcosm of how immigration is reshaping communities throughout the United States. In the Springfield area, Catholic charities, other philanthropies, volunteers, and county agencies have banded together over the past three to four years to tackle the challenge and connect immigrants who have critical health needs with providers and care.

For instance, a community health center added Haitian Creole interpreters. The county health department opened a refugee health testing clinic to provide immunizations and basic health screenings, operating on such a shoestring budget that it’s open only two days a week.

And a coalition of groups to aid the Haitian community was created about two years ago to identify and respond to immigrant community needs. The group meets once a month with about 55 or 60 participants. On Sept. 18, about a week after Trump ramped up the furor at the debate, a record 138 participants joined in.

“We have all learned the necessity of collaboration,” said Casey Rollins, director of Springfield’s St. Vincent de Paul, a nonprofit Catholic social services organization that has become a lifeline for many of the town’s Haitian immigrants. “There’s a lot of medical need. Many of the people have high blood pressure, or they frequently have diabetes.”

Several factors have led Haitians to leave their Caribbean country for the United States, including a devastating earthquake in 2010, political unrest after the 2021 assassination of Haiti’s president, and ongoing gang violence. Even when health facilities in the country are open, it can be too treacherous for Haitians to travel for treatment.

“The gangs typically leave us alone, but it’s not a guarantee,” said Paul Glover, who helps oversee the in Haiti. “We had a 3,000-square-foot clinic. It was destroyed. So was the X-ray machine. People have been putting off health care.”

An estimated 12,000 to 15,000 Haitian immigrants live in Clark County, officials said. About 700,000 Haitian immigrants lived in the United States in 2022, according to .

Those who have area are generally in the country legally under a federal program that lets noncitizens temporarily enter and stay in the United States under certain circumstances, such as for urgent humanitarian reasons, according to city officials.

The influx of immigrants created a learning curve for hospitals and primary care providers in Springfield, as well as for the newcomers themselves. In Haiti, people often go directly to a hospital to receive care for all sorts of maladies, and county officials and advocacy groups said many of the immigrants were unfamiliar with the U.S. system of seeing primary care doctors first or making appointments for treatment.

Many sought care at , a nonprofit, federally qualified health center that provides mental health, primary, and preventive care to people regardless of their insurance status or ability to pay. Federally qualified health centers serve medically underserved areas and populations.

The center treated 410 patients from Haiti in 2022, up more than 250% from 115 in 2021, according to Nettie Carter-Smith, the center’s director of community relations. Because the patients required interpreters, visits often stretched twice as long.

Rocking Horse hired patient navigators fluent in Haitian Creole, one of the two official languages of Haiti. Its roving purple bus provides on-site health screenings, vaccinations, and management of chronic conditions. And this school year, it’s operating a $2 million health clinic at Springfield High.

Many Haitians in Springfield have reported threats since Trump and Vance made their town a focus of the campaign. Community organizations were unable to identify any immigrants willing to be interviewed for this story.

Hospitals have also felt the impact. Mercy Health’s Springfield Regional Medical Center also saw a rapid influx of patients, spokesperson Jennifer Robinson said, with high utilization of emergency, primary care, and women’s health services.

This year, hospitals also have seen several readmissions for newborns struggling to thrive as some new mothers have trouble breastfeeding or getting supplemental formula, county officials said. One reason: New Haitian immigrants must wait six to eight weeks to get into a program that provides supplemental food for low-income pregnant, breastfeeding, or non-breastfeeding postpartum women, as well as for children and infants.

At Kettering Health Springfield, Haitian immigrants come to the emergency department for nonemergency care. Nurses are working on two related projects, one focusing on cultural awareness for staff and another exploring ways to improve communication with Haitian immigrants during discharge and in scheduling follow-up appointments.

Many of the immigrants are able to get health insurance. Haitian entrants generally , the state-federal program for the low-income and disabled. For hospitals, that means lower reimbursement rates than with traditional insurance.

During 2023, 60,494 people in Clark County were enrolled in Medicaid, about 25% of whom were Black, . That’s up from 50,112 in 2017, when 17% of the enrollees were Black. That increase coincides with the rise of the Haitian population.

In September, DeWine pledged $2.5 million to help health centers and the county health department meet the Haitian and broader community’s needs. The Republican governor has pushed back on the recent national focus on the town, saying the spread of false rumors has been hurtful for the community.

Ken Gordon, a spokesperson for the Ohio Department of Health, acknowledged the difficulties Springfield’s health systems have faced and said the department is monitoring to avert potential outbreaks of measles, whooping cough, and even polio.

People diagnosed with HIV in the county increased from 142 residents in 2018 to 178 to 2022, according to state health department data. Cook, the Clark County health commissioner, said the data lags by about 1.5 years.

But Cook said, “as a whole, all reportable infections to the health department are not increasing.” Last year, he said, no one died of tuberculosis. “But 42 people died of covid.”

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Indeed, it was a plotline on the . But for some it has been a tragedy.

People have died after drinking tea brewed from unwashed poppy seeds.

And after eating lemon poppy seed bread or an everything bagel, mothers reportedly have been separated from newborns because the women failed drug tests.

Poppy seeds come from the plant that and from which narcotics such as morphine and codeine are derived. During harvesting and processing, the seeds can become coated with the opium fluid.

Members of the House and Senate have “to prohibit the distribution and sale of contaminated poppy seeds in order to prevent harm, addiction, and further deaths from morphine-contaminated poppy seeds.” The bill was one of several on the agenda for a .

The day before the hearing, and reported on a woman who ate a salad with poppy seed dressing before giving birth, tested positive at the hospital for opiates, was reported to child welfare, and saw her baby taken into protective custody. Almost two weeks passed before she was allowed to bring her baby home, the story said.

“It’s not an urban legend: Eating poppy seeds can cause diners to test positive for codeine on a urinalysis,” the Defense Department in 2023.

The U.S. Anti-Doping Agency long ago issued a to athletes.

The Center for Science in the Public Interest, a watchdog group, in 2021 to limit the opiate content of poppy seeds. In May, after more than three years with no response, it to force action.

“So far the FDA has been negligent in protecting consumers,” said Steve Hacala, whose son died after consuming poppy seed tea and who has joined forces with CSPI.

The lawsuit was put on hold in July, after the FDA said it would respond to the group’s petition by the end of February 2025.

The FDA did not answer questions for this article. The agency generally does not comment on litigation, spokesperson Courtney Rhodes said.

A co-authored by CSPI personnel found more than 100 reports to poison control centers between 2000 and 2018 resulting from intentional abuse or misuse of poppy seeds, said CSPI scientist Eva Greenthal, one of the study’s authors.

Only rarely would baked goods or other food items containing washed poppy seeds trigger positive drug tests, doctors who have studied the issue said.

It’s “exquisitely doubtful” that the “relatively trivial” amount of morphine in an everything bagel or the like would cause anyone harm, said Irving Haber, a doctor who has , specializes in pain medicine, and signed the CSPI petition to the FDA.

On the other hand, tea made from large quantities of unwashed poppy seeds could lead to addiction and overdose, doctors said. The risks are heightened if the person drinking the brew is also consuming other opioids, such as prescription pain relievers.

Benjamin Lai, a physician who chairs a program on opioids at the Mayo Clinic in Rochester, Minnesota, said he has been treating a patient who developed long-term opioid addiction from consuming poppy seed tea. The patient, a man in his 30s, found it at a health food store and was under the impression it would help him relax and recover from gym workouts. After a few months, he tried to stop and experienced withdrawal symptoms, Lai said.

Another patient, an older woman, developed withdrawal symptoms under similar circumstances but responded well to treatment, Lai said.

Some websites tout poppy seed tea as offering health benefits. And some sellers “may use specific language such as ‘raw,’ ‘unprocessed,’ or ‘unwashed’ to signal that their products contain higher concentrations of opiates than properly processed seeds,” the CSPI lawsuit said.

Steve Hacala’s son, Stephen Hacala, a music teacher, had been experiencing anxiety and insomnia, for which poppy seed tea is promoted as a natural remedy, the lawsuit said. In 2016, at age 24, he ordered a bag of poppy seeds online, rinsed them with water, and consumed the rinse. He died of morphine poisoning.

The only source of morphine found in Stephen’s home, where he died, was commercially available poppy seeds, a medical examiner at the Arkansas State Crime Lab said in a letter to the father. The medical examiner wrote that poppy seeds “very likely” caused Stephen’s death.

Steve Hacala estimated that the quantity of poppy seeds found in a 1-liter plastic water bottle in his son’s home could have delivered more than 10 times a lethal dose.

Steve Hacala and his wife, Betty, have funded CSPI’s efforts to call attention to the issue. (The publisher of Â鶹ŮÓÅ Health News, David Rousseau, is on the .)

The lawsuit also cited mothers who, like those in the investigation by The Marshall Project and Reveal, ran afoul of rules meant to protect newborns. For example, though Jamie Silakowski had not used opioids while pregnant, she was initially prevented from leaving the hospital with her baby, the suit said.

Silakowski recalled that, before going to the hospital, she had eaten lemon poppy seed bread at Tim Hortons, a fast-food chain, CSPI said in its petition. “No one in the hospital believed Ms. Silakowski or appeared to be aware that the test results could occur from poppy seeds.”

People from child protective services made unannounced visits to her home, interviewed her other children, and questioned teachers at their school, she said in an interview.

While on maternity leave, she had to undergo drug testing, Silakowski said. “Peeing in front of someone like I’m a criminal — it was just mortifying.”

Even family members were questioning her, and there was nothing she could do to dispel doubts, she said. “Relationships were torn apart,” she said.

The parent company of Tim Hortons, Restaurant Brands International, which also owns Burger King and Popeyes, did not respond to questions from Â鶹ŮÓÅ Health News.

In July, The Washington Post reported that Trader Joe’s Everything but the Bagel seasoning was in South Korea because it contains poppy seeds. Trader Joe’s did not respond to inquiries for this article. The seasoning is listed for sale on the company’s website.

The U.S. says unwashed poppy seeds can kill when used alone or in combination with other drugs. While poppy seeds are exempt from drug control under the Controlled Substances Act, opium contaminants on the seeds are not, the agency says. The Justice Department has brought criminal prosecutions over the sale of unwashed poppy seeds.

Meanwhile, the legislation to control poppy seed contamination has not gained much traction.

The Senate bill, introduced by Sen. Tom Cotton (R-Ark.), has .

The House bill, introduced by Rep. Steve Womack (R-Ark.), . Though it was on the agenda, it didn’t come up at the recent hearing.

Healthbeat is a nonprofit newsroom covering public health published by and . Sign up for its newsletters .

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).