JACKSON, Miss. — When the coronavirus first scythed through the nation in early 2020, few places needed help fighting it more than Scott County, Miss., a rural patch of chicken processing plants and pine forests an hour east of the state capital, Jackson.
The poverty rate for the county’s 28,000 residents was far above the nation’s. So, too, were rates of diabetes and other chronic illnesses that worsen the risk of severe Covid-19. Yet Mississippi’s health department, struggling under huge budget cuts ordered by the state’s Legislature, had deployed just two nurse practitioners to cover a quarter-million residents in Scott and eight other counties.
So when the Biden administration gave Mississippi $18.4 million in mid-2021 to hire public health workers — part of $2 billion in grants to bolster the Covid work force at state and local health agencies nationwide — it appeared that help had, at long last, arrived.
But as of January, 18 months later, Mississippi had spent just $3.6 million of its grant — less than a fifth. Its attempts to hire epidemiologists, nurses and other soldiers in the war against Covid had largely fallen flat. The state has lost one in 224 residents to Covid-19, one of the nation’s worst death rates, including 122 people in tiny Scott County alone.
Mississippi’s woes are an acute example of a larger public health failure that is reprised nearly every time a major health threat grabs headlines. The problem, experts say, is that Congress starves state and local health agencies of cash for even basic needs in quiet times. Then, when a crisis hits, it floods them with millions or even billions of dollars earmarked to battle the disease of the moment. And the sluggish machinery of Capitol Hill often ensures that most of the aid arrives only after the worst of the crisis has passed.
The $2 billion in Covid hiring grants is the latest example. Nationwide, states and localities had spent only $371 million of the money by December, or about 19 percent, according to the Centers for Disease Control and Prevention, the conduit for the funds.
Health departments found it nearly impossible to bulk up their skeletal staffs from a standing start. Seasoned workers, in high demand throughout the health care system, balked at taking jobs that were guaranteed only until the federal funds ran out. Health departments now face a July deadline to use the money, but uptake has been so slow that the C.D.C. is letting them ask for a one-year extension.
The record is replete with other such fumbles.
Six months after the World Health Organization declared the H1N1 influenza pandemic over in mid-2010, states and localities had used just a third of the $1.4 billion in federal funds they had received to combat it. The outbreaks of the Ebola virus in 2014 and the Zika virus in 2016 also led to funding windfalls, but health experts say most of the money arrived late.
In Mississippi, Dr. Thomas E. Dobbs, who ran the state’s health department from 2018 through last July, said some of the agency’s leftover Zika and Ebola money “basically rotted on the shelf” because it could not be shifted to other needs even though the threats had subsided.
When the coronavirus began spreading in Mississippi, “it felt like we were the U.S. before World War II, just totally unprepared,” he said. “We couldn’t hire anyone for months.”
The nation’s first Covid cases were detected in January 2020, but Congress did not authorize the funding that led to the $2 billion in grants until March 2021. When the C.D.C. pushed the money out the door that July, more than 600,000 people in the United States had already died.
“You don’t have anything up front,” Dr. Dobbs said. “You’re basically trying to survive off baling wire and duct tape. And then, once it’s almost over, a big pot of money comes in. It’s not only ridiculous, it’s wasteful and inefficient.”
More on the Coronavirus Pandemic
It is impossible to measure how much the staffing shortages worsened the pandemic’s toll, said Dr. Judith Monroe, who leads the C.D.C. Foundation, an independent nonprofit organization that tried to plug Covid staffing gaps.
But “at the end of the day,” she said, “it cost Americans their loved ones.”
At the root of chronic underfunding of public health, experts say, is a fundamental lack of understanding of its mission.
Workers at state and local health departments monitor and strive to limit a host of threats, including preventable injuries, infectious diseases and chronic ailments like diabetes. Those duties come atop a drumbeat of other more routine but essential tasks, such as restaurant inspections.
Success produces no headlines. And in lean times, health departments are easy targets for government cutbacks.
“Public health at its finest is prevention — it’s invisible to the public,” Dr. Monroe said, adding, “Nobody wakes in the morning saying, ‘I feel so grateful today I don’t have smallpox.’”
Public health is so overlooked that no one knows exactly how much money the nation’s roughly 2,800 state and local health departments spend or how many people they employ. Some states like Mississippi centralize their operations, while in others, counties exercise more control.
The result is a giant patchwork of services and systems. But experts generally agree on one point: In the run-up to the pandemic, public health agencies took a hit.
One study by academic researchers found that state public health spending either stagnated or declined from 2008 to 2018. The de Beaumont Foundation, a nonprofit health advocacy group, estimated that state and local health departments shed about 40,000 jobs between 2008 and 2019.
The C.D.C., which helps keep state and local health agencies afloat with billions of dollars annually in grants and other funding, also lost ground before the pandemic. In the decade that ended in 2019, the agency’s budget fell by 10 percent when adjusted for inflation, according to the Trust for America’s Health, a nonprofit advocacy group.
Public health experts have long argued that stable federal funding would give state and local health departments a sturdier foundation and would free officials from submitting endless grant applications. The Obama administration tried to answer those pleas by creating a dedicated fund for public health as part of the Affordable Care Act, which became law in 2010.
The fund started with $500 million, and its annual allotment was supposed to grow to $2 billion by 2015. But it was raided for other purposes, including during the Obama administration itself to help avert a cut in Medicare payments to physicians. The fund leveled off at about half of its $2 billion target.
Fax Machines, Mold and a Snake
Faced with falling revenues due to income and corporate tax cuts, Mississippi’s Republican-controlled state government put its health department on the chopping block. It reduced the agency’s state financing from $36 million in 2016 to about $19 million in 2018, former state officials said.
Republican legislators said fewer patients were seeking care at the more than 80 health clinics the department operates across the state. Dr. Mary Currier, who led the department from 2010 to 2018, said lawmakers were blind to the agency’s mission. “They don’t see it as important,” she said. “And so they don’t really care if it fails.”
Public health nurses left in droves. Some counties were forced to share nurse practitioners, and certain programs targeting chronic diseases, like screening for high blood pressure, were curtailed or abandoned, current and former officials said. County clinics cut hours, and infrastructure needs took a back seat.
Dr. Dobbs told state lawmakers in December 2021 that fax machines were ubiquitous and some clinics were beyond repair. He displayed a photo of Scott County’s clinic with a gaping hole in an exterior wall. Another photo featured a snake slithering across the floor. Shots of other clinics showed leaking ceilings, moldy doors and dilapidated bathrooms.
“Is this where you would want to take your family for health care services?” he asked.
The state also kept the wages of public health workers so low that as of 2020, about one-fourth of the health department’s jobs were unfilled, according to Dr. Dobbs, now the dean of the School of Population Health at the University of Mississippi Medical Center. The most highly trained epidemiologist could earn no more than $62,000 a year, he said — roughly $17,000 below the median salary in the profession. The agency employed only a handful of them when he took it over, he said.
“That left our foundations really weak coming into Covid,” Dr. Dobbs said.
Some states tapped money from a coronavirus relief package enacted in March 2020 to hire more public health workers. The C.D.C. also dispatched its own specialists to the field.
And it routed $290 million from that package and another one a year later to the C.D.C. Foundation, which recruited and dispatched 3,900 public health workers to the states, including 27 to Mississippi. That effort sidestepped obstacles like salary caps that hampered hiring by state and local agencies, although most workers only arrived after mid-2021.
The biggest effort — the $2 billion in hiring grants awarded in July 2021 — also came late. But the need was still pressing.
Covid vaccination shots had become available less than seven months earlier. The Delta variant was spreading, and Omicron, which would unleash a fresh wave of death and disease, lay ahead.
Mississippi’s vaccination rate was then, and still is, one of the country’s worst. Dr. Dobbs said that with more workers, “without a doubt we would have done a better job getting people vaccinated faster” and saved more lives.
But Michael S. Sparer, a professor at Columbia University’s Mailman School of Public Health who has been researching the $2 billion program, said that Mississippi, Indiana, Kentucky and other states struggled mightily to use the money, especially because of competition for staff from hospitals that could pay more.
By the end of last November, Washington State’s health department had spent less than $3 million of its $45.5 million grant, though like Mississippi, it has earmarked some of the unspent money for future use. “You’re not going to be able to get an epidemiologist just sitting on the side of the street,” said Dr. Umair A. Shah, who leads the agency.
Mississippi officials said that the $18.4 million grant allowed the health department to hire 157 new staff members but that the agency still had enough money for 97 new positions that remained vacant.
Dr. Daniel P. Edney, who replaced Dr. Dobbs last summer, declined to be interviewed for this article. Former officials say the agency tries to keep a low profile lest state lawmakers further tie its hands.
But in a November speech to the Mississippi Public Health Association, Dr. Edney said, “I need to hire 150 nurses today.” He added, “We need nurses and social workers and just about every position you can think of.”
A Fading Sense of Urgency
Many experts hoped that the loss of 1.1 million people in the United States to Covid would force a reckoning over the nation’s public health system.
“We’ve never really stepped back and asked, ‘How do we invest properly in a sustainable manner to make sure our public health system can respond in public health emergencies?’” said Dr. Julie Gerberding, who served as C.D.C. director under President George W. Bush.
The pandemic did produce some changes. Excluding one-time infusions of funds, the C.D.C.’s budget has grown at a faster rate during the Biden administration than it did for the previous decade.
Importantly, the C.D.C. reserved $3.2 billion in pandemic relief funds for state and local agencies to use in a more flexible fashion. The money, awarded in November, can be used over the next five years for a variety of essential needs, including more staff.
But experts say state and local agencies need far more — $4.5 billion more per year just to meet basic public health needs, the Trust for America’s Health says. The de Beaumont Foundation estimates that those agencies need to hire 80,000 more workers.
In an interview, Dr. Rochelle P. Walensky, the C.D.C.’s director, said the $3.2 billion program “is a terrific start, but I think the needs are so much greater than that.”
Yet the sense of urgency sparked by the pandemic is fading. The White House asked Congress to increase the C.D.C.’s budget for the 2023 fiscal year by 27 percent, but lawmakers agreed to a rise of only 9 percent.
“I’m just worried now, even now, when people are still affected by this pandemic, that they’re forgetting how bad it was, and how it didn’t have to be as bad as it was if we had more capacity,” said Dr. Anne Schuchat, who retired as the C.D.C.’s principal deputy director in mid-2021.
Particularly alarming to health experts is the exodus of public health workers. Many toiled to exhaustion during the pandemic. Some resigned after opponents of how the Covid fight was being waged threatened their safety.
At the Mississippi health department, 47 percent of positions were unfilled as of December — roughly twice the prepandemic vacancy rate, Dr. Dobbs said.
“We’re just way, way, way worse off from a public health preparedness perspective than we were before,” he said.
Kitty Bennett and Susan C. Beachy contributed research.