The United States' decentralizedpublic health system, which matches federal funding and expertisewith local funding, knowledge and delivery, was long the envy ofthe world.

The U.S. public health system has been starved for decades andlacks the resources to confront the worst health crisis in acentury.

Marshaled against a virus that has sickened at least 2.6 millionin the U.S., killed more than 126,000 people and cost tens ofmillions of jobs and $3 trillion in federal rescue money, state andlocal government health workers on the ground are sometimes paid solittle that they qualify for public aid.

They track the coronavirus on paper records shared via fax.Working seven-day weeks for months on end, they fear pay freezes,public backlash and even losing their jobs.

Related: States ramping up their armies of contacttracers

Since 2010, spending for state public health departments hasdropped by 16% per capita and spending for local health departments has fallen by 18%, according to a KHNand Associated Press analysis of government spending on publichealth. At least 38,000 state and local public health jobs havedisappeared since the 2008 recession, leaving a skeletal workforcefor what was once viewed as one of the world's top public healthsystems.

KHN and AP interviewed more than 150 public health workers,policymakers and experts, analyzed spending records from hundredsof state and local health departments, and surveyed statehouses. Onevery level, the investigation found, the system is underfunded andunder threat, unable to protect the nation's health.

Dr. Robert Redfield, the director of the Centers for DiseaseControl and Prevention, said in an interview in April that his"biggest regret" was "that our nation failed over decades toeffectively invest in public health."

So when this outbreak arrived — and when, according to publichealth experts, the federal government bungled its response —hollowed-out state and local health departments were ill-equippedto step into the breach.

Over time, their work had received so little support that theyfound themselves without direction, disrespected, ignored, even vilified. The desperate struggleagainst COVID-19 became increasingly politicized and grew moredifficult.

States, cities and counties in dire straits have begun layingoff and furloughing members of already limited staffs, and evenmore devastation looms, as states reopen and cases surge.Historically, even when money pours in following crises such asZika and H1N1, it disappears after the emergency subsides.Officials fear the same thing is happening now.

"We don't say to the fire department, 'Oh, I'm sorry. There wereno fires last year, so we're going to take 30% of your budgetaway.' That would be crazy, right?" said Dr. Gianfranco Pezzino,the health officer in Shawnee County, Kansas. "But we do that withpublic health, day in and day out."

Ohio's Toledo-Lucas County Health Department spent $17 million,or $40 per person, in 2017.

Jennifer Gottschalk, 42, works for the county as anenvironmental health supervisor. When the coronavirus struck, thecounty's department was so short-staffed that her duties includedoverseeing campground and pool inspections, rodent control andsewage programs, while also supervising outbreak preparedness for acommunity of more than 425,000 people.

When Gottschalk and five colleagues fell ill with COVID-19, shefound herself fielding calls about a COVID-19 case from herhospital bed, then working through her home isolation. She stoppedonly when her coughing was too severe to talk on calls.

"You have to do what you have to do to get the job done,"Gottschalk said.

Now, after months of working with hardly a day off, she said thejob is wearing on her. So many lab reports on coronavirus casescame in, the office fax machine broke. She faces a backlash fromthe community over coronavirus restrictions and there are countlessangry phone calls.

Things could get worse; possible county budget cuts loom.

But Toledo-Lucas is no outlier. Public health ranks low on thenation's financial priority list. Nearly two-thirds of Americanslive in counties that spend more than twice as much on policing asthey spend on non-hospital health care, which includes publichealth.

More than three-quarters of Americans live in states that spendless than $100 per person annually on public health. Spendingranges from $32 in Louisiana to $263 in Delaware, according to dataprovided to KHN and AP by the State Health Expenditure Dataset project.

That money represents less than 1.5% of most states' totalspending, with half of it passed down to local healthdepartments.

The share of spending devoted to public health belies itsmultidimensional role. Agencies are legally bound to provide abroad range of services, from vaccinations and restaurantinspections to protection against infectious disease. Distinct fromthe medical care system geared toward individuals, the publichealth system focuses on the health of communities at large.

"Public health loves to say: When we do our job, nothinghappens. But that's not really a great badge," said Scott Becker,chief executive officer of the Association of Public HealthLaboratories. "We test 97% of America's babies for metabolic orother disorders. We do the water testing. You like to swim in thelake and you don't like poop in there? Think of us."

But the public doesn't see the disasters they thwart. And it'seasy to neglect the invisible.

A history of deprivation

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

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

The United States' decentralized public health system, whichmatches federal funding and expertise with local funding, knowledgeand 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 tothe chronic funding shortages," Omer said. "The way we starve ourpublic health system, the way we have tried to do public healthoutcomes on the cheap in this country."

In Scott County, Indiana, when preparedness coordinator PattiHall began working at the health department 34 years ago, it ran achildren's clinic and a home health agency with several nurses andaides. But over time, the children's clinic lost funding andclosed. Medicare changes paved the way for private services toreplace the home health agency. Department staff dwindled in the1990s and early 2000s. The county was severely outgunned whenrampant opioid use and needle sharing sparked an outbreak of HIV in 2015.

Besides just five full-time and one part-time county publichealth positions, there was only one doctor in the outbreak'sepicenter of Austin. Indiana's then-Gov. Mike Pence, now leadingthe nation's coronavirus response as vice president, waited 29 daysafter the outbreak was announced to sign an executive orderallowing syringe exchanges. At the time, a state official said thatonly five people from agencies across Indiana were available tohelp with HIV testing in the county.

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

At times, the federal government has promised to support localpublic health efforts, to help prevent similar calamities. Butthose promises were ephemeral.

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

The Affordable Care Act established the Prevention and PublicHealth Fund, which was supposed to reach $2 billion annually by2015. The Obama administration and Congress raided it to pay forother priorities, including a payroll tax cut. The Trump administration is pushing to repealthe ACA, which would eliminate the fund, said Carolyn Mullen,senior vice president of government affairs and public relations atthe 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 fromit, 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 billionwould eventually have flowed to local and state healthdepartments.

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

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

In North Carolina, Wake County's public health workforce droppedfrom 882 in 2007 to 614 a decade later, even as the population grewby 30%.

In Detroit, the health department had 700 employees in 2009,then was effectively disbanded during the city's bankruptcyproceedings. It's been built back up, but today still has only 200workers 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, hasessentially remained flat for a decade. Federal money currentlyaccounts for 27% of local public health spending.

Years of such financial pressure increasingly pushed workers inthis predominantly female workforce toward retirement or theprivate sector and kept potential new hires away.

More than a fifth of public health workers in local or regionaldepartments outside big cities earned $35,000 or less a year in2017, as did 9% in big-city departments, according to researchby the Association of State and Territorial Health Officials andthe de Beaumont Foundation.

Even before the pandemic, nearly half ofpublic health workers planned to retire or leave theirorganizations for other reasons in the next five years. Poor paytopped the list of reasons.

Armed with a freshly minted bachelor's degree, Julia Crittendontook a job two years ago as a disease intervention specialist withKentucky's state health department. She spent her days gatheringdetailed information about people's sexual partners to fight thespread of HIV and syphilis. She tracked down phone numbers anddrove hours to pick up reluctant clients.

The mother of three loved the work but made so little money thatshe qualified for Medicaid, the federal-state insurance program forAmerica'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 thenutrition program for new moms and babies that they administer.People with the training for many public health jobs, which caninclude a bachelor's or master's degree, can make much more moneyin the private health care sector, robbing the public departmentsof promising recruits.

Dr. Tom Frieden, a former CDC director, said the agency"intentionally underpaid people" in a training program that sentearly-career professionals to state and local public healthdepartments 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 cutto continue on at the local health department."

As low pay sapped the workforce, budget cuts sappedservices.

In Alaska, the Division of Public Health's spending dropped 9%from 2014 to 2018 and staffing fell by 82 positions in a decade to426. Tim Struna, chief of public health nursing in Alaska, saiddeclines in oil prices in the mid-2010s led the state to make cutsto public health nursing services. They eliminated well-child examsfor children over 6, scaled back searches for the partners ofpeople with certain sexually transmitted infections and limitedreproductive health services to people 29 and younger.

Living through an endless stream of such cuts and theiraftermath, those workers on the ground grew increasingly worriedabout mustering the "surge capacity" to expand beyond their dailyresponsibilities to handle inevitable emergencies.

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

A decimated surge capacity

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

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

"They're not wearing masks, and they're throwing socialdistancing 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 ScottCounty Health Department employees worked evenings, weekends andholidays to deal with the pandemic, including outbreaks at a foodpacking company and a label manufacturer. Indiana spends $37 aperson on public health.

"When you get home, the phone never stops, the emails and textsnever stop," said Hall, the preparedness coordinator.

All the while, she and her colleagues worry about keeping HIVunder control and preventing drug overdoses from rising. Otherhealth problems don't just disappear because there is apandemic.

"We've been used to being able to 'MacGyver' everything on anormal day, and this is not a normal day," said Amanda Mehl, thepublic health administrator for Boone County, Illinois, citing a TVshow.

Pezzino, whose department in Kansas serves Topeka and ShawneeCounty, said he had been trying to hire an epidemiologist, whowould study, track and analyze data on health issues, since he cameto the department 14 years ago. Finally, less than three years ago,they hired one. She just left, and he thinks it will be nearlyimpossible to find another.

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

Strapped departments are now forced to spend money on contacttracers, masks and gloves to keep their workers safe and to dobasic outreach.

Melanie Hutton, administrator for the Cooper County PublicHealth Center in rural Missouri, pointed out the local ambulancedepartment got $18,000, and the fire and police departments gotmasks 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 stateand local public health leaders have announced their resignations,retired or been fired in 17 states since April, a KHN-AP reviewfound. 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 lastweek on regulations I cannot control left me feeling completelyburned out," she said in mid-June.

Many are putting their health at risk. In Prince George'sCounty, Maryland, public health worker Chantee Mack died after,family and co-workers believe, she and several colleaguescontracted the disease in the office.

A difficult road ahead

Pence, in an op-ed in The Wall Street Journal on June 16, said the publichealth system was "far stronger" than it was when the coronavirushit.

It's true that the federal government this year has allocatedbillions for public health in response to the pandemic, accordingto the Association of State and Territorial Health Officials. Thatincludes more than $13 billion to state and local healthdepartments, for activities including contact tracing, infectioncontrol and technology upgrades.

A KHN-AP review found that some state and local governments arealso pledging more money for public health. Alabama's budget fornext year, for example, includes $35 million more for public healththan it did this year.

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

In most states, the new budget year begins July 1, andfurloughs, layoffs and pay freezes have already begun in someplaces. Tax revenues evaporated during lockdowns, all but ensuringthere will be more. At least 14 states have already cut healthdepartment budgets or positions or were actively considering suchcuts in June, according to a KHN-AP review.

Since the pandemic began, Michigan temporarily cut most of itsstate health workers' hours by one-fifth. Pennsylvania requiredmore than 65 of its 1,200 public health workers to go on temporaryleave, 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 countryshould demand the resources for public health, he said, just theway it does for the military.

"This is about protecting Americans," Frieden said.

Cincinnati temporarily furloughed approximately 170 healthdepartment 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 topay hundreds of millions in taxes over decades for the Bengals' footballstadium.

"How about investing in something that's going to save somelives?" he asked.

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

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

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

Meanwhile, childhood vaccinations began plunging in the secondhalf of March, according to a CDC study analyzing supply orders. Officials worry whether theywill be able to get kids back up to date in the coming months. InDetroit, the childhood vaccination rate dipped below 40%, asclinics shuttered and people stayed home, creating the potentialfor a different outbreak.

Cutting or eliminating non-COVID activities is dangerous, saidE. Oscar Alleyne, chief of programs and services at the NationalAssociation of County and City Health Officials. Cuts to programssuch as diabetes control and senior nutrition make alreadyvulnerable communities even more vulnerable, which makes them morelikely to suffer serious complications from COVID. Everything isconnected, he said.

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

The people who spend their lives working in public health saythe temporary coronavirus funds won't fix the eroded foundationentrusted with protecting the nation's health as thousands continueto die.

KHN (Kaiser HealthNews) is a nonprofit news service covering health issues. It is aneditorially independent program of KFF (Kaiser Family Foundation),which is not affiliated with Kaiser Permanente.

Contributing to this report were: Associated Press writersMike Stobbe in New York; Mike Householder in Toledo, Ohio; LindsayWhitehurst in Salt Lake City, Utah; Brian Witte in Annapolis,Maryland; Jim Anderson in Denver; Sam Metz in Carson City, Nevada;Summer Ballentine in Jefferson City, Missouri; Alan Suderman inRichmond, Virginia; Sean Murphy in Oklahoma City, Oklahoma; MikeCatalini in Trenton, New Jersey; David Eggert in Lansing, Michigan;Andrew DeMillo in Little Rock, Arkansas; Jeff Amy in Atlanta;Melinda Deslatte in Baton Rouge, Louisiana; Morgan Lee in Santa Fe,New Mexico; Mark Scolforo in Harrisburg, Pennsylvania; and APeconomics writer Christopher Rugaber, in Washington, D.C.

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