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

A DECIMATED SURGE CAPACITY

As the public health director for the Kentucky River District Health Department in rural Appalachia, Scott Lockard is battling the pandemic with 3G cell service, paper records and one-third of the employees the department had 20 years ago.

He redeployed his nurse administrator to work round-the-clock on contact tracing, alongside the department’s school nurse and the tuberculosis and breastfeeding coordinator. His home health nurse, who typically visits older patients, now works on preparedness plans. But residents aren’t making it easy on them.

“They’re not wearing masks, and they’re throwing social distancing to the wind,” Lockard said in mid-June, as cases surged. “We’re paying for it.”

Even with more staff since the HIV outbreak, Indiana’s Scott County Health Department employees worked evenings, weekends and holidays to deal with the pandemic, including outbreaks at a food packing company and a label manufacturer. Indiana spends $37 a person on public health.

“When you get home, the phone never stops, the emails and texts never stop,” said Hall, the preparedness coordinator.

All the while, she and her colleagues worry about keeping HIV under control and preventing drug overdoses from rising. Other health problems don’t just disappear because there is a pandemic.

“We’ve been used to being able to ‘MacGyver’ everything on a normal day, and this is not a normal day,” said Amanda Mehl, the public health administrator for Boone County, Illinois, citing a TV show.

Pezzino, whose department in Kansas serves Topeka and Shawnee County, said he had been trying to hire an epidemiologist, who would study, track and analyze data on health issues, since he came to the department 14 years ago.

Finally, less than three years ago, they hired one. She just left, and he thinks it will be nearly impossible to find another.

While epidemiologists are nearly universal in departments serving large populations, hardly any departments serving smaller populations have one. Only 28% of local health departments have an epidemiologist or statistician.

Strapped departments are now forced to spend money on contact tracers, masks and gloves to keep their workers safe and to do basic outreach.

Melanie Hutton, administrator for the Cooper County Public Health Center in rural Missouri, pointed out the local ambulance department got $18,000, and the fire and police departments got masks to fight COVID-19.

“For us, not a nickel, not a face mask,” she said. “We got (5) gallons of homemade hand sanitizer made by the prisoners.”

Public health workers are leaving in droves. At least 34 state and local public health leaders have announced their resignation, retired or been fired in 17 states since April, a KHN/AP review found. Others face threats and armed demonstrators.

Ohio’s Gottschalk said the backlash has been overwhelming.

“Being yelled at by residents for almost two hours straight last week on regulations I cannot control left me feeling completely burned out,” she said in mid-June.

Many are putting their health at risk. In Prince George’s County, Maryland, public health worker Chantee Mack died after, family and co-workers believe, she and several colleagues contracted the disease in the office.

A DIFFICULT ROAD AHEAD

Pence, in an op-ed in The Wall Street Journal on June 16, said the public health system was “far stronger” than it was when coronavirus hit.

It’s true that the federal government this year has allocated billions for public health in response to the pandemic, according to the Association of State and Territorial Health Officials. That includes more than $13 billion to state and local health departments, for activities including contact tracing, infection control and technology upgrades.

A KHN/AP review found that some state and local governments are also pledging more money for public health. Alabama’s budget for next year, for example, includes $35 million more for public health than it did this year.

But overall, spending is about to be slashed again as the boom-bust cycle continues.

In most states, the new budget year began July 1, and furloughs, layoffs and pay freezes have already begun in some places. Tax revenues evaporated during lockdowns, all but ensuring there will be more.

At least 14 states have already cut health department budgets or positions or were actively considering such cuts in June, according to a KHN/AP review.

Since the pandemic began, Michigan temporarily cut most of its state health workers’ hours by one-fifth. Pennsylvania required more than 65 of its 1,200 public health workers to go on temporary leave, and others lost their jobs. Knox County, Tennessee, furloughed 26 out of 260 workers for eight weeks.

Frieden, formerly of the CDC, said it’s “stunning” that the U.S. is furloughing public health workers amid a pandemic.

The country should demand the resources for public health, he said, just the way it does for the military.

“This is about protecting Americans,” Frieden said.

Cincinnati temporarily furloughed approximately 170 health department employees.

Robert Brown, chair of Cincinnati’s Primary Care Board, questions why police officers and firefighters didn’t face similar furloughs at the time or why residents were willing to pay hundreds of millions in taxes over decades for the Bengals’ football stadium.

“How about investing in something that’s going to save some lives?” he asked.

In 2018, Boston spent five times as much on its police department as its public health department. The city recently pledged to transfer $3 million from its approximately $60 million police overtime budget to its public health commission.

Looking ahead, more cuts are coming. Possible budget shortfalls in Brazos County, Texas, may force the health department to limit its mosquito-surveillance program and eliminate up to one-fifth of its staff and one-quarter of immunization clinics.

Months into the pandemic response, health departments are still trying to ramp up to fight COVID-19. Cases are surging in states including Texas, Arizona and Florida.

Meanwhile, childhood vaccinations began plunging in the second half of March, according to a CDC study analyzing supply orders.

Officials worry whether they will be able to get kids back up to date in the coming months.

In Detroit, the childhood vaccination rate dipped below 40%, as clinics shuttered and people stayed home, creating the potential for a different outbreak.

Cutting or eliminating non-COVID activities is dangerous, said E. Oscar Alleyne, chief of programs and services at the National Association of County and City Health Officials.

Cuts to programs such as diabetes control and senior nutrition make already vulnerable communities even more vulnerable, which makes them more likely to suffer serious complications from COVID. Everything is connected, he said.

It could be a year before there’s a widely available vaccine. Meanwhile, other illnesses, including mental health problems, are smoldering.

The people who spend their lives working in public health say the temporary coronavirus funds won’t fix the eroded foundation entrusted with protecting the nation’s health as thousands continue to die.