Public health in America at a breaking point. The question is now 'Can it recover?'

Before the pandemic, America's public health system was the envy of the world. 

In late 2019, the Globe Health Security Index ranked the United States best among 195 nations in terms of being prepared to handle a public health crisis, well ahead of the next best country, the United Kingdom.

That changed fast. A study published by the National Center for Biotechnology Information less than a year later found the United States ranked "worst globally" in terms of numbers of COVID-19 cases and deaths.

To try to restore the nation's chronically underfunded public health system, the Biden administration invested nearly $8 billion last year in shoring up departments.

But two years to the day after the first confirmed case of COVID-19 in the USA, experts say it will take a lot more than that to repair America's public health system.

Even before COVID-19, health departments were "running on empty," taking money away from former top priorities to fund the current ones, said Dr. Leana Wen, former Baltimore health commissioner. "We were always robbing Peter to pay Paul."

Corpus Christi and Nueces County Public Health District offers the Pfizer COVID-19 vaccine to children 12-18 years old at the Greenwood Senior Center on May 14, 2021, in Texas.

Departments are so strapped that many don't even have the resources to think strategically about how to spend the new federal dollars, Wen said.

Living and working about an hour outside Austin, Texas, Robert Kirkpatrick hasn’t had a real vacation in two years and 70-hour workweeks aren't uncommon.

“After a while, I made a point to try to take some time off at least one day a week,” said Kirkpatrick, executive director of the Milam County Health Department. “For your own mental health, you have to take a small break.”

Kirkpatrick’s training over 25 years in the Texas Army National Guard helped him keep an even keel during the pandemic. But in some ways, it's been more difficult than his time in Iraq as a company commander.

Department of Public Health and Social Services workers collect information and nasal swap samples from Guam residents during free drive-thru coronavirus testing at the old Tiyan carnival grounds Jan. 28, 2021.

“Here I get to go home and see everything I was missing in the long hours of work,” he said.

As the pandemic enters its third year, public health departments are filled with similar stories: endless hours, thankless work and threats from the people they're trying to help.

When America arguably needs its public health workers more than ever, hundreds have quit local or state government since the pandemic began. Wednesday, Florida Gov. Ron DeSantis' administration put the county health director for the Orlando area on administrative leave for encouraging his staff to get vaccinated.  

Although applications are up at some schools of public health as much as 50%, it will take years to replace the expertise lost, said Dr. Megan Ranney, an emergency room physician and academic dean at Brown University's School of Public Health. 

According to the Centers for Disease Control and Prevention, a survey in July 2021 of 26,000 state, local or tribal public health workers found more than half reported mental health issues such as depression, anxiety or post-traumatic stress disorder, and 8% said they'd contemplated suicide.

In most states, COVID-19 has forced public health departments to neglect their other duties.

The Illinois Department of Public Health  administers coronavirus tests in the parking lot of a former Shop 'n Save store in Springfield on Feb. 8, 2021.

“We’ve lost ground in overdose deaths and HIV transmission,"  said Dr. Michael Kilkenny, executive director of the Cabell/Huntington Health Department in West Virginia.

"We did a minimal amount of vector surveillance and control for West Nile virus. … We sent nobody out to drag for ticks," he said. "We even brought someone out of retirement to do food handler classes because our usual sanitarians were on other jobs.”

Most people don't notice public health systems except in the rare situations when they don't work, but everyone benefits from clean water and air, safe restaurants, infection control and healthy babies – all routinely supported by public health departments.

"No one ever thanks you for not getting polio," said Thomas LaVeist, dean of the School of Public Health and Tropical Medicine at Tulane University in New Orleans.

The pandemic's challenges and the new funding have left America's public health system at a crossroads, many said. COVID-19 could be an opportunity. Or a lost chance.

Dr. Umair Shah, secretary of health for the state of Washington, said the pandemic has taught public health officials a lot about how to fight a pandemic, but he worries that typical crisis-thinking will mean those lessons will be lost before the next pandemic hits. 

"COVID puts public health at a decision point, where things can either be transactional or transformational," he said. “If we do not learn those lessons and transform our systems, including for health inequities, then shame on us.”

Running on empty

Almost two years ago, Dr. Mandy Cohen, who stepped down as secretary of the North Carolina Department of Health and Human Services in December, moved staff from essential services such as restaurant inspections and mental health care to cope with the demands of COVID-19. Her department remained in "crisis mode."

Dr. Mandy Cohen says COVID-19 put the North Carolina Department of Health and Human Services in "crisis mode."

The biggest lesson for her from the pandemic, Cohen said, is how different it is from the usual crises the department deals with, such as hurricanes. In those events, she said, she could get help from nearby states, but now, they're all in the same situation.

"There's no phone-a-friend when everyone is suffering," she said.

The pandemic made long-standing health problems more obvious, said Dr. Jerome Adams, who served as surgeon general during the Trump administration.

Adams, an anesthesiologist and first executive director of health equity initiatives at Purdue University in Indiana, said COVID-19 outcomes in the USA were worse than in many other countries, because Americans were unhealthy to begin with. Obesity, diabetes and smoking are all risk factors for severe cases of COVID-19, and 43% of Americans fit the definition for obesity.

Adams said he worries what will happen if the country doesn't realize the benefits of a robust public health system. 

"We see communities pulling back on public health – being more resistant to vaccination and prevention," Adams said. "That scares me."

Adams would like to see more money dedicated to health communication, which both the Trump and Biden administrations have struggled with, he said. Part of the problem, he said, is that CNN's health correspondent, Dr. Sanjay Gupta, has a bigger communication staff than he had as surgeon general of the United States.

Coronavirus testing is set up at an Alamogordo Public Schools health services event in New Mexico on Jan. 2, 2021.

"We need to market health messages the same way Nabisco markets Oreos," Adams said. "If we can get (people) to drink a Bud or buy a Ford or eat an Oreo, we should be able to help them better understand why and what they should be doing to keep themselves healthy."

Even within government, public health agencies are usually the last to be informed, said Pramod Dwivedi, health director of the Linn County Public Health Department in Cedar Rapids, Iowa. 

“We were always caught off guard,” Dwivedi said. “There were news conferences by the state that we weren’t told about. All these rapid changes happen without letting us know in advance. Then people start calling us, and we’re in no way prepared to defend that action.”

A financial imperative

Keeping people healthy is essential to a healthy economy, said Dr. Jody Heymann, professor of health policy and management and founding director of UCLA’s Fielding School of Public Health WORLD Policy Analysis Center.

"There’s no way we can save our economy without better investment in public health," she said. 

Summit County public health worker Marlene Martin asks a driver how many passengers are in her vehicle before handing out free coronavirus testing kits Jan. 8 in Akron, Ohio.

Before the pandemic, America spent more on health per capita than any other country in the world. "We’re more than 50% higher per capita than the next one on the list," she said.

At the same time, the World Health Organization ranked the USA 40th on life expectancy. "We’ve chronically underinvested in all the things that produce more life expectancy less expensively," Heymann said.

That underinvestment adds up to about $10 billion a year, said Dr. Anand Parekh, chief medical adviser of the Bipartisan Policy Center, a Washington-based think tank. Any spending authorized is simply a "down payment," he said.

It's easier to sell medicines than prevention, said Dr. Walter Orenstein, a global health expert at Emory University in Atlanta, where he directs vaccine policy and development.

"You get a therapeutic, you feel better, you know what happened. If I give you a vaccine, you never get ill and you never know how it changed your life," he said.

A sustained investment in public health is essential for combating health emergencies, he said.

"People don’t understand that investing in prevention costs (money)," he said. "It’s just not as expensive as not investing in prevention."

A public health worker administers drive-up coronavirus tests Dec. 28, 2021, at the Northwest Health Center COVID-19 Vaccination Site in Milwaukee.

Too often, dollars are allocated to public health when there's a crisis, then taken away when the crisis fades, many officials told USA TODAY.

During the Ebola outbreak in 2014, Arizona's public health department received two years' worth of funding. "More than you could possibly ever spend," said Will Humble, who directed the department and is executive director of the Arizona Public Health Association.

Then the money went away. Officials are worried that will happen again.

Adequate staffing remains the biggest need in public health, but departments can't hire if their spending comes with an expiration date.

"A lot of the county health officers here, they don’t want to create positions and then be forced to lay them off or have to go to their county board of supervisors to ask for permanent money to keep them on," Humble said. 

Staffing up isn't a waste of resources, said Michael Fraser, CEO of the Association of State and Territorial Health Officials. 

“Public health infrastructure doesn’t mean you have all these people sitting around with nothing to do," he said. "What about well-baby visits, STD contact tracing? There’s plenty to do.”

A medical team prepares to test people for the coronavirus at a drive-thru station in a parking lot in West Palm Beach, Fla., on March, 16, 2020.

Smaller counties can't add staff for the short term, Humble said. "They are freaking out. There’s just no way they can spend this much money on the workforce."

To keep a program going long-term requires a constituency that keeps pushing, he said. Otherwise, when there's a glut of funding, public health officials spend it on random things just to get it off the books.

“Constituents are asking about COVID-19 now, but in three years, they probably won't,” Humble said. “And then it will be, ‘People aren't calling me about that anymore, let's phase it out.’”

A squandered opportunity?

In 2018 and 2019, states and localities cut their public health funding by 15%, said Carolyn Mullen, chief of government affairs and public relations at the Association of State and Territorial Health Officials. 

“Our foundation was weak, and we were asked to build skyscrapers on it,” she said. 

report in October 2021 from the de Beaumont Foundation found that to provide basic, everyday services, state and local public health departments need to hire a minimum of 80,000 more full-time equivalent positions – an increase of nearly 80% – just to get back to where the workforce was a decade ago.

Another problem is that disease reporting systems, and funding, are siloed. Congress allocates money for HIV or tuberculosis or West Nile Virus, not for pathogens in general.

The Corpus Christi-Nueces County Public Health District offers vaccine at the Richard M. Borchard Regional Fairgrounds on Jan. 29, 2021, in Texas.

“We created great systems for COVID, but that didn’t build any capacity for the future," Fraser said. "It could potentially be built out, but I don’t know that the funding would allow that because it’s for COVID. That’s the issue.”

What's needed, Mullen said, “is long-term, sustainable, predictable funding that is not tied to one specific disease, so we can move away from this feast and famine.”

The demise of President Joe Biden’s Build Back Better infrastructure bill, which included substantial and long-term funding for public health, was a major blow, Fraser said.

“This is the way it’s been for public health forever," Fraser said. "It’s been two years, and that’s when a lot of these COVID dollars go away. We’re going to go back to where we were, and that’s what constantly happens.”

Parekh of the Bipartisan Policy Center said public health should be considered public infrastructure, alongside bridges and roads. 

Focusing on why public health is important to people's daily lives – for clean air, clean water and safe food – will help take it out of the realm of partisan politics, he said. "When public health is most successful, it is partnering with the communities that we're trying to serve to ensure that people be healthy and can achieve their goals."

In Indiana, Parekh said, the Republican governor created a bipartisan commission to strengthen public health. There needs to be more effort on both sides of the aisle, he said, "to ensure that the takeaway here is not that public health is trying to tell you what to do. It's got to be that public health is trying to support the public in achieving its goals and to create healthy environments and communities."

Building trust, Parekh said, will require sustained investment and people realizing that public health officials have their best interest at heart.

"There's a moment right now in our nation's history to think differently about public health," Parekh said. "The question is will we realize this opportunity at this moment. If not now, then when?"

A path forward

In Rhode Island, a group of business and civic leaders helped develop a plan to use the federal public health funding to address social needs. People can't be healthy if they're living in their car or on the streets, said Neil Steinberg, president and CEO of the Rhode Island Foundation.

"Now we have some funding to make a dent," he said. "I'm optimistic that these funds can be leveraged to improve it if used smartly, if used diligently and actually programs are implemented."

The focus is on programs that are sustainable, that won't go away in three years when the funding disappears, Steinberg said.

The Corpus Christi-Nueces County Public Health District administers 500 doses of vaccine to people at the American Bank Center on Feb. 2, 2021, in Texas.

His group has to wait to see whether the state Legislature will sign off on the suggestions, which could happen before June, he said.

Barbara Ferrer, who directs the Los Angeles Department of Public Health, said she knows exactly how to spend the new federal dollars she's getting: invest in equity-focused programs and support systems. 

To deliver vaccines, her department set up six sites across the county, and they're not leaving even after the pandemic ends, she said. 

Having access to the community through these sites helped the department better communicate with residents, better understand their problems and build trust, Ferrer said.

The sites created programs to subsidize healthy food, provide mental health services, prevent violence and lobby for better worker protections, so they can stay home and isolate when they get sick. 

These were all problems that have long needed addressing, Ferrer said, but the creation of the sites and the money to keep them going will make a major difference in the public health of Los Angeles.

The department set aside $10 million to create a grocery voucher program and $2 million to subsidize healthy food. "You can't tell people to eat healthy when they live in food deserts and there's no access to healthy foods," she said. There is $13 million to expand home visiting support for at-risk people and $7.5 million to expand community-based partnerships.

"I'm hoping we have taken advantage of the fact that when a tragedy that wreaks this much devastation occurs, there are opportunities where you move forward to fundamentally fix it," Ferrer said.

Back in Milam County, Texas, Kirkpatrick said he expects to get more abuse via phone calls, emails and even people on the street.

“I take it all with a grain of salt,” he said. “I know it’s because they’re scared. They don’t know, they’re trying to find answers. I’m going to try my best to provide those answers.”

The grueling hours, the public anger, the anguish of losing community members – they're all aspects of the commitment public health workers make to their community, Kirkpatrick said.

“When you sign up to do public service, be it military, law enforcement, firefighter, hospital worker or public health, it becomes part of you," he said. "And it’s what we do."

Contact Karen Weintraub at kweintraub@usatoday.com and Elizabeth Weise at eweise@usatoday.com.

Health and patient safety coverage at USA TODAY is made possible in part by a grant from the Masimo Foundation for Ethics, Innovation and Competition in Healthcare. The Masimo Foundation does not provide editorial input.