Why public health may be facing a crisis
As PORT ANGELES, WASH. — she leaves work, Dr. Allison Berry keeps a vigilant eye on her rearview mirror, watching the vehicles around her, weighing if she needs to take a more circuitous route home. She must make sure nobody finds out where she lives.
When the pandemic first hit the northern edge of Washington’s Olympic Peninsula, Berry was a popular family physician and local health officer, trained in biostatistics and epidemiology at Johns Hopkins University. She processed COVID-19 test kits in her garage and delivered supplies to people in quarantine, leading a mobilization that kept her counties with some of the fewest deaths in the nation.
But this summer, as a delta variant wave pushed case numbers to alarming levels, Berry announced a mask mandate. In September, she ordered vaccination requirements for indoor dining.
By then, to many in the community, the enemy was not the virus. It was her.
Berry should be attacked “on sight,” one resident wrote online. Someone else suggested bringing back public hangings. Protestors showed up at her house, until they learned that Berry was no longer living there.
“The places where it is most needed to put in more stringent measures, it’s the least possible to do it,” Berry said. “Either because you’re afraid you’re going to get fired, or you’re afraid you’re going to get killed. Or both.”
State and local public health departments across the country have endured not only the public’s fury, but widespread staff defections, burnout, firings, unpredictable funding and a significant erosion in their authority to impose the health orders that were critical to the United States’ early response to the pandemic.
While the coronavirus has killed more than 700,000 in the U.S. in nearly two years, a more invisible casualty has been the nation’s public health system. Already underfunded and neglected even before the pandemic, public health has been further undermined in ways that could resound for decades to come. A New York Times review of hundreds of health departments in all 50 states indicates that local public health across the country is less equipped to confront a pandemic now than it was at the beginning of 2020.
The Times interviewed more than 140 local health officials, public health experts and lawmakers, reviewed new state laws, analyzed local government documents and sent a survey to every county health department in the country. Almost 300 departments responded. The examination showed that:
■ Public health agencies have seen a staggering exodus of personnel, many exhausted and demoralized, in part because of abuse and threats. The Times identified more than 500 top health officials who left their jobs in the past 19 months.
■ Legislators have approved more than 100 new laws — with hundreds more under consideration — that limit state and local health powers.
■ Large segments of the public have also turned against agencies, voting in new local government leaders who ran on pledges to rein in public health departments.
■ Billions of dollars have been made available to public health by the federal government, but most of it has been geared toward stemming the emergency, rather than hiring permanent staff or building long-term capability.
There are already signs that the growing shortfalls in public health could have lasting impacts beyond the pandemic.
More than 220 departments told the Times they had to temporarily or permanently abandon other public health functions to respond to the pandemic, leading to a spike in drug overdoses and a disturbing drop in reports of child abuse. Several health officials pointed to runaway infections of sexually transmitted diseases, with gonorrhea cases doubling and syphilis on pace to triple in one county in Pennsylvania.
During the pandemic, the federal government made tens of billions of dollars available to bolster testing, contact tracing and vaccinations.
In May, the Biden administration announced that it would invest an additional $7.4 billion from the COVID19 stimulus package to train and recruit public health workers.
But while health officials described the money as critical to helping them quickly build out teams after years of budget cuts, many of those new hires were temporary workers and much of the spending went to urgent needs such as testing and vaccinations.
And the funding is not permanent. Many local health officials said they expected
that the extra money would peter out over the next two to three years.
An erosion of authority
When the pandemic struck last year, Dr. Jennifer Bacani McKenney, the top public health officer for Wilson County, Kansas, began doing Facebook Live presentations and coordinated with hospitals, schools and churches. She helped implement a state lockdown, but when it came time to reopen businesses, she did it more slowly than her county commissioners desired.
The Kansas state Legislature, alarmed by the persistence and power of public health orders around the state, passed a series of laws that gutted the authority of health officials like McKenney. The new laws limited COVID-19 contact tracing, gave authority for health decisions to elected leaders and allowed anyone “aggrieved” by a mask mandate, business closure or limit on public gatherings the ability to sue the agencies that imposed the order.
“It was a huge slap in the face to all of us who are doing the public health work,” McKenney said.
New laws passed in at least 32 states similarly restrict the ability of health officials to impose mask and vaccine mandates; close churches, schools and businesses; conduct contact tracing; or apply penalties for violating health restrictions. Some limit the length of time that governors’ emergency orders can be in effect. Many require a legislative body to approve health orders.
The Times spoke with dozens of lawmakers who have introduced such legislation, most of whom shared a concern that health officials had overstepped their authority and required a check on that power.
Some of the new laws are so sweeping they contradict public health practices that stretch back decades. In Montana, new laws could make it harder to quarantine people with diseases like measles and will prevent hospitals from enforcing their usual requirement that staff members get a flu shot.
‘You’re going to pay’
Last fall, two days after signing an order requiring masks in public places, Dr. Vernon Miller, the health officer for Hot Springs County, Wyoming, found his staff huddled around the phone, listening to a voicemail.
“Well, Dr. Miller, you’ve got some nuts facing off against this whole goddamn town,” a man said in an eerily singsong voice. “You’re going to pay for this.”
Miller canceled the day’s appointments, sent the staff home and called the sheriff. Police arrested a local machinist, Connor Fairbairn, who, according to court documents, admitted he left the message.
Fairbairn told a deputy that he had wanted Miller “to feel the way the rest of us feel,” which was “helpless and insecure.”
Several health officials said they had installed security cameras, were getting police patrols at their houses or were now carrying pepper spray.
‘That chaotic mess’
The pandemic has already started to reshape the public health workforce in ways that could impair the ability to fight future pandemics.
Some of the most experienced staff members have walked out the door, and departments have struggled to find replacements. Few can compete financially with hospitals in the middle of a nationwide nursing shortage. In the past, health departments could lure workers with better hours and less heartache. That is no longer the case.
Kathy Emmons, the executive director of the Cheyenne-Laramie County Health Department in Wyoming, said her department had a turnover approaching 80% during the pandemic.
Sue Rhodes, the health department administrator in Marshall County, Kansas, was one of many officials who said finding people to do contact tracing had become a challenge with the public sometimes threatening or verbally abusing tracers.