Editor’s note: This is the second in a series on the United States public health system and how the pandemic has taken its toll on the system.

A HISTORY OF DEPRIVATION

The local health department was a well-known place in the 1950s and 1960s, when Harris Pastides, president emeritus of the University of South Carolina, was growing up in New York City.

“My mom took me for my vaccines. We would get our injections there for free. We would get our polio sugar cubes there for free,” said Pastides, an epidemiologist. “In those days, the health departments had a highly visible role in disease prevention.”

The United States’ decentralized public health system, which matches federal funding and expertise with local funding, knowledge and delivery, was long the envy of the world, said Saad Omer, director of the Yale Institute for Global Health.

“A lot of what we’re seeing right now could be traced back to the chronic funding shortages,” Omer said. “The way we starve our public health system, the way we have tried to do public health outcomes on the cheap in this country.”

In Scott County, Indiana, when preparedness coordinator Patti Hall began working at the health department 34 years ago, it ran a children’s clinic and a home health agency with several nurses and aides. But over time, the children’s clinic lost funding and closed. Medicare changes paved the way for private services to replace the home health agency. Department staff dwindled in the 1990s and early 2000s. The county was severely outgunned when rampant opioid use and needle sharing sparked an outbreak of HIV in 2015.

Besides just five full-time and one part-time county public health positions, there was only one doctor in the outbreak’s epicenter of Austin. Indiana’s then-Gov. Mike Pence, now leading the nation’s coronavirus response as vice president, waited 29 days after the outbreak was announced to sign an executive order allowing syringe exchanges. At the time, a state official said that only five people from agencies across Indiana were available to help with HIV testing in the county.

The HIV outbreak exploded into the worst ever to hit rural America, infecting more than 230 people.

At times, the federal government has promised to support local public health efforts, to help prevent similar calamities. But those promises were ephemeral.

Two large sources of money established after Sept. 11, 2001 - the Public Health Emergency Preparedness program and the Hospital Preparedness Program - were gradually chipped away.

The Affordable Care Act established the Prevention and Public Health Fund, which was supposed to reach $2 billion annually by 2015. The Obama administration and Congress raided it to pay for other priorities, including a payroll tax cut. The Trump administration is pushing to repeal the ACA, which would eliminate the fund, said Carolyn Mullen, senior vice president of government affairs and public relations at the Association of State and Territorial Health Officials.

Former Iowa Sen. Tom Harkin, a Democrat who championed the fund, said he was furious when the Obama White House took billions from it, breaking what he said was an agreement.

“I haven’t spoken to Barack Obama since,” Harkin said.

If the fund had remained untouched, an additional $12.4 billion would eventually have flowed to local and state health departments.

But local and state leaders also did not prioritize public health over the years.

In Florida, for example, 2% of state spending goes to public health. Spending by local health departments in the state fell 39%, from a high of $57 in inflation-adjusted dollars per person in the late 1990s to $35 per person last year.

In North Carolina, Wake County’s public health workforce dropped from 882 in 2007 to 614 a decade later, even as the population grew by 30%.

In Detroit, the health department had 700 employees in 2009, then was effectively disbanded during the city’s bankruptcy proceedings. It’s been built back up, but today still has only 200 workers for 670,000 residents.

Many departments rely heavily on disease-specific grant funding, creating unstable and temporary positions. The CDC’s core budget, some of which goes to state and local health departments, has essentially remained flat for a decade. Federal money currently accounts for 27% of local public health spending.

Years of such financial pressure increasingly pushed workers in this predominantly female workforce toward retirement or the private sector and kept potential new hires away.

More than a fifth of public health workers in local or regional departments outside big cities earned $35,000 or less a year in 2017, as did 9% in big city departments, according to research by the Association of State and Territorial Health Officials and the de Beaumont Foundation.

Even before the pandemic, nearly half of public health workers planned to retire or leave their organizations for other reasons in the next five years. Poor pay topped the list of reasons.

Armed with a freshly minted bachelor’s degree, Julia Crittendon took a job two years ago as a disease intervention specialist with Kentucky’s state health department. She spent her days gathering detailed information about people’s sexual partners to fight the spread of HIV and syphilis. She tracked down phone numbers and drove hours to pick up reluctant clients.

The mother of three loved the work, but made so little money that she qualified for Medicaid, the federal-state insurance program for America’s poorest. Seeing no opportunity to advance, she left.

“We’re like the redheaded stepchildren, the forgotten ones,” said Crittendon, 46.

Such low pay is endemic, with some employees qualifying for the nutrition program for new moms and babies that they administer. People with the training for many public health jobs, which can include a bachelor’s or master’s degree, can make much more money in the private health care sector, robbing the public departments of promising recruits.

Dr. Tom Frieden, a former CDC director, said the agency “intentionally underpaid people” in a training program that sent early-career professionals to state and local public health departments to build the workforce.

“If we paid them at the very lowest level at the federal scale,” he said in an interview, “they would have to take a 10-20% pay cut to continue on at the local health department.”

As low pay sapped the workforce, budget cuts sapped services.

In Alaska, the Division of Public Health’s spending dropped 9% from 2014 to 2018 and staffing fell by 82 positions in a decade to 426. Tim Struna, chief of public health nursing in Alaska, said declines in oil prices in the mid-2010s led the state to make cuts to public health nursing services. They eliminated well-child exams for children over 6, scaled back searches for the partners of people with certain sexually transmitted infections and limited reproductive health services to people 29 and younger.

Living through an endless stream of such cuts and their aftermath, those workers on the ground grew increasingly worried about mustering the “surge capacity” to expand beyond their daily responsibilities to handle inevitable emergencies.

When the fiercest of enemies showed up in the U.S. this year, the depleted public health army struggled to hold it back.

Next week, the effects health care system problems have on employees and the future of the system.