PORT ANGELES, Wash. — As 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, Dr. 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, Dr. 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.
Dr. Berry should be attacked “on sight,” one resident wrote online. Someone else suggested bringing back public hangings. “Dr. Berry, we are coming for you,” a man warned at a public meeting. An angry crowd swarmed into the courthouse during a briefing on the Covid-19 response one day, looking for her, and protesters also showed up at her house, until they learned that Dr. 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,” Dr. 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 America’s early response to the pandemic.
While the coronavirus has killed more than 700,000 in the United States 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.
“We have learned all the wrong lessons from the pandemic,” said Adriane Casalotti, chief of public and government affairs for the National Association of County and City Health Officials, an organization representing the nearly 3,000 local health departments across the nation. “We are attacking and removing authority from the people who are trying to protect us.”
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, discussing their concerns over long-term funding, staffing, authority and community support. 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. Dozens of departments reported that they had not staffed up at all, but actually lost employees. About 130 said they did not have enough people to do contact tracing, one of the most important tools for limiting the spread of a virus. 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. That overhaul of public health gives governors, lawmakers and county commissioners more power to undo health decisions and undermines everything from flu vaccination campaigns to quarantine protocols for measles.
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. In Idaho, commissioners last month appointed a new physician representative to the health board in the Boise region who advocates unapproved treatments for Covid-19 and refers to coronavirus vaccinations as “needle rape.” “We have heard from the voters,” Ryan Davidson, one of the commissioners, said.
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. Most of the departments that responded to The Times’s survey said they were worried about their funding levels, which in most cases had been decreasing or flat before the pandemic. About three dozen departments said their budgets were the same or smaller than they were at the beginning of the pandemic.
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. Oswego County, N.Y., recorded a surge in lead poisoning. In Texas, requests for exemptions to the usual suite of required childhood immunizations have risen sharply.
Mandates and mobilizations to protect public health have long been part of American life; colonists issued quarantine laws and fines for disobeying them as early as the 1700s. Public health departments later delivered vaccines to halt diseases such as smallpox and polio, upgraded water systems to limit typhoid and cholera, curbed sexually transmitted diseases and helped guarantee the safety of food in restaurants.
But not since the flu pandemic of 1918 has the country faced a disease outbreak that called for unelected health officials to impose widespread mask mandates and business closures.
As scientists helped overcome many infectious diseases, the focus on keeping Americans healthy turned more to individualized treatment for ailments such as heart disease and cancers, said David Rosner, a historian at Columbia University who specializes in the history of public health.
Many, particularly in conservative circles, have increasingly embraced individual rights over collective responsibilities, a trend that Dr. Rosner said is undercutting the notion of a social contract in which people work together to achieve a greater good.
“It’s a depressing moment,” he said. “What makes a society if you can’t even get together around keeping your people healthy?”
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 Covid-19 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. The new funding often came routed through states or grant programs with conditions, like a short time frame for spending money or time-consuming requirements for state or county approvals. Some departments said they had to lay off employees at inopportune times over the past year because grants had run out of money.
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. They likened the Covid-19 funds to the money that flowed into health departments after the 9/11 attacks but then vanished when political priorities changed.
Dozens of departments said that, in order to be prepared for more surges or a future pandemic, what they truly needed was a higher baseline of qualified, permanent employees. Instead, they purchased equipment or, more frequently, hired temporary staff, knowing they would need to let them go when the money dried up.
A health official in Berrien County, Mich., said it was so time-consuming to get approval from the county to hire temporary staff members in the fall of 2020 that, when her department received more funding later, she focused instead on quicker purchases, like software. When the virus closed in, she had to pull existing employees off their regular duties.
“If a ship is sinking, throwing treasure chests of gold at the ship is not going to help it float,” said Melissa Lyon, public health director for Erie County, Pa.
A steady erosion of authority
When the pandemic struck last year, Dr. Jennifer Bacani McKenney, the top public health officer for Wilson County, Kan., 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 Dr. 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,” Dr. McKenney said.
The Wilson County commissioners, emboldened with new powers over much of what she does, have discussed replacing Dr. McKenney, saying she focused too much on health and not enough on businesses, she said. The public grew so hostile toward her that she at one point had her elementary-age children sit away from the windows when they did their homework.
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.
“It’s a very dangerous situation when you decide to take away anybody’s rights,” said Bob Rommel, a Republican lawmaker in Florida. He drafted a bill, whose main provisions were incorporated into a law that took effect this summer, allowing the governor to squelch local health orders deemed too restrictive.
Citing that law, Gov. Ron DeSantis’s government, which has been aggressive in slapping down local restrictions, fined Leon County $3.5 million this month for mandating Covid-19 vaccinations for its employees — $5,000 for each person required to get a shot. The state has threatened to levy millions of dollars more in fines for similar county mandates.
In Bismarck, N.D., the state capital, the health director Renae Moch credited a state mask mandate last year with curbing a devastating outbreak.
Cases have recently surged again, but a new state law bars the state government from requiring masks. Ms. Moch would need to get approval from her city commissioners before ordering a local mandate, a hurdle she regards as insurmountable.
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 such as measles and will prevent hospitals from enforcing their usual requirement that staff members get a flu shot.
Jim Murphy, an epidemiologist who worked in leadership roles at Montana’s Department of Public Health and Human Services for three decades before retiring this summer, said the department had enjoyed the support of governors from both parties — until Gov. Greg Gianforte took office this year, pledging to reopen the economy.
The new administration immediately raised questions about how Covid-19 deaths were being counted and whether testing was accurate. Health department officials, Mr. Murphy said, were left out of conversations over changes to public health laws.
“The dialogue and the problem-solving approach was completely gone,” Mr. Murphy said. “We don’t have a lot of say in this anymore.”
In Gallatin County, Ron Marshall, a state representative who owns a vape store, said he had been battling the local health board’s ban on indoor vaping. But after passage of a new law restricting local public health authority, he said, the board relented and told him that it would no longer enforce the ban.
Mr. Marshall said other local boards were also easing off on health orders. “They were out of control,” he said. “I think a lot of them are still trying to figure out how hard they got spanked.”
‘You’re going to pay for this’
Last fall, two days after signing an order requiring masks in public places, Dr. Vernon Miller, the health officer for Hot Springs County, Wyo., found his staff huddled around the phone, listening to a voice mail.
“Well Dr. Miller, you’ve got some nuts facing off against this whole goddamn town,” a man said in an eerily sing-song voice. “You’re going to pay for this.”
Dr. Miller canceled the day’s appointments, sent the staff home and called the sheriff. The police arrested a local machinist, Connor Fairbairn, who, according to court documents, admitted he left the message and wished he could take it back.
Mr. Fairbairn, who through his lawyer declined to comment, told a deputy that he had wanted Dr. Miller “to feel the way the rest of us feel,” which was “helpless and insecure.”
Public meetings have turned into battlegrounds. In California, a health officer resigned after a resident announced her home address at one meeting. In Nevada, a woman warned ominously that those protesting health orders made the meals, changed the tires and filled the prescriptions of local officials. “We’re everywhere,” she said. “I’m not the one who should be scared.” In Michigan, a man shouted another warning: “There’s a lot of good guys out there ready to do bad things!”
Several health officials said they had installed security cameras, were getting police patrols at their houses or were now carrying pepper spray.
The threats have come not just from members of the public. In Klickitat County, Wash., the sheriff announced over the summer that his office would “arrest, detain and recommend prosecution” of any government official enforcing health restrictions that he deemed unconstitutional.
Erinn Quinn, the county’s public health director, said she suspended some outreach work and thought seriously about resigning. “It was the first time I truly gave pause to my career in public health,” she said. But she resolved to push back.
Two weeks later, dozens of people held a rally for the sheriff, who was later hospitalized with Covid-19.
‘Who wants to work there?’
The pandemic has already started to reshape the public health work force 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 percent during the pandemic.
In January, hundreds of people gathered at the State Capitol to protest health orders and burn masks. A few days later, red paint was spattered across almost every entrance to the county health department.
Ms. Emmons worried that for people privately wondering whether to stay or quit, the job had changed too much.
“They didn’t join our department to Covid-test 10 hours a day or to give vaccinations 10 hours a day,” she said. “We were asking people to completely change their work priorities.”
Sue Rhodes, the health department administrator in Marshall County, Kan., 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. She has been trying to hire an extra nurse to help with the work. But she has had no luck.
“Everybody looks at public health now and says, ‘Who wants to work there?’” she said. “Who wants to work in that chaotic mess?”
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