Deep cuts erode the foundations of US public health system, end progress, threaten worse to come

CHARLOTTE, N.C. — Americans are losing a vast array of people and programs dedicated to keeping them healthy. Gone are specialists who were confronting a measles outbreak in Ohio, workers who drove a van to schools in North Carolina to offer vaccinations and a program that provided free tests to sick people in Tennessee.

State and local health departments responsible for invisible but critical work such as inspecting restaurants, monitoring wastewater for new and harmful germs, responding to outbreaks before they get too big — and a host of other tasks to protect both individuals and communities — are being hollowed out.

''Nobody wants to go swim in a community pool and come out of it with a rash or a disease from it. Nobody wants to walk out their door and take a fresh breath of air and start wheezing," said Lori Tremmel Freeman, executive director of the National Association of County and City Health Officials.

But local health officials say they now have no choice but to do a lot less of it. The Trump administration is cutting health spending on an unprecedented scale, experts say, including pulling $11 billion of direct federal support because the pandemic is over and eliminating 20,000 jobs at national health agencies that in part assist and support local public health work. It's proposing billions more be slashed.

Together, public health leaders said, the cuts are reducing the entire system to a shadow of what it once was, threatening to undermine even routine work at a time when the nation faces the deadliest measles outbreak since at least the 1990s, rising whooping cough cases and the risk that bird flu could spread widely among people.

The moves reflect a shift that Americans may not fully realize, away from the very idea of public health: doing the work that no individual can do alone to safeguard the population as a whole. That's one of the most critical responsibilities of government, notes James Williams, county executive in Santa Clara County, California. And it goes beyond having police and fire departments.

"It means not having babies suffering from diseases that you vanquished. It means making sure that people have access to the most accurate and up-to-date information and decisions that help their longevity,'' Williams said. ''It means having a society and communities able to actually prosper, with people living healthy and full lives.''

Keeping communities healthy saves lives — and money

Just outside a Charlotte, North Carolina, high school in March, nurse Kim Cristino set out five vaccines as a 17-year-old girl in ripped jeans stepped onto a health department van. The patient barely flinched as Cristino gave her three shots in one arm and two in the other to prevent diseases including measles, diphtheria and polio.

Like many other teens that morning, the girl was getting some shots years later than recommended. The clinic's appearance at Independence High School gave her a convenient way to get up to date.

''It lessens the barriers for parents who would have to be taking off from work and trying to get their kids to a provider,'' Cristino said.

The vaccinations also help the community around her. The teen won't come down with a life-threatening disease and the whole community is protected from outbreaks — if enough people are vaccinated.

The Mecklenburg County department, with "Protecting and Promoting the Public's Health'' emblazoned on its van, is similar to other U.S. health departments. They run programs to reduce suicides and drug overdoses, improve prenatal health and help people stop smoking. They educate people about health and test for and treat diseases such as HIV and tuberculosis. Some, including Mecklenburg, operate medical and dental clinics too.

''You come to work every day and think: What's going to be my challenge today? Sometimes it's a new disease,'' said Raynard Washington, Mecklenburg's director. ''That's why having a backbone infrastructure is so important.''

What they do is cost-effective, experts have found. For every dollar spent on childhood immunizations, the country is estimated to save $11; on tobacco cessation, $2-$3; on asthma control, $70.

Disease prevention is unseen — and ignored

Critical care can be glamorous — surgeons, cardiologists and cancer doctors can pull off breathtaking medical feats to save lives at the last possible moment. Prevention work is low key. It's impossible to identify who was saved because, if it goes well, the person never knows when they've fended off a mortal threat with the invisible shield of public health.

''People don't appreciate it,'' said Dr. Umair Shah, former health director for Washington state. ''Therefore, they don't invest in it.''

State health departments are funded by a varying mix of federal and state tax money. Some states deliver services in a centralized way while others provide resources to local departments, which generally also get money from counties, cities or towns. Some large cities get direct federal funding for their health departments.

Mecklenburg — a large department with around 1,000 workers serving 1.2 million people — has an annual budget of around $135 million, while some metro hospitals have operating expenses in the billions. About 70% of the department's budget comes from local funds, which helps fill gaps in state and federal money. But Mecklenburg is still strapped for cash and resources.

At times, employees work 12- to 14-hour days, especially during outbreaks. Nurse Carmel Jenkins recalled responding to mpox exposures at a day care center — arriving before 5:30 a.m. to alert the children's parents and working late into the evening.

''Even though there may be limited resources, we still have a service to provide,'' said Jenkins, a director of clinical services for the department. ''We don't mind going above and beyond to be able to do that.''

Chaos in Washington puts ‘lives at risk'

In March, the Trump administration pulled $11 billion from state and local health departments without warning under the leadership of Health Secretary Robert F. Kennedy Jr., a longtime anti-vaccine activist and public health critic. The cuts abruptly ended COVID-era grants, which had also been approved for non-COVID work including vaccination and disease detection, tracking and testing.

A week later, thousands of people were laid off at the Centers for Disease Control and Prevention. Many had worked closely with state and local health departments to provide information, grants and other support.

The sudden, one-two punch delivered a serious blow to the system, public health leaders said in interviews, court filings and public testimony.

A Kennedy spokesman said in an email that America remains unhealthy compared with other developed nations and HHS is reorganizing what he said were ''broken systems'' and reprioritizing resources to ''centralize programs and functions that will improve our service to the American people.''

''These cuts are not about abandoning public health — they're about reforming it,'' spokesman Andrew Nixon said, adding: ''We reject the implication that HHS has turned its back on urgent health threats.''

HHS justified the grant cancellations by saying the money was for COVID and the pandemic is over. But most of the cuts were in areas that are especially important given today's health threats. The biggest chunk, more than $8.9 billion, involved epidemiology and laboratory capacity related to infectious diseases, while another $2 billion was related to immunizations. In some places, the cuts are on hold due to a federal judge's order in a lawsuit by states. But elsewhere, cuts are continuing.

In Mecklenburg, for example, 11 community health workers lost their jobs, meaning less outreach to groups like the Hispanic community. All eight employees dedicated to the mobile vaccine program were laid off.

In Columbus, Ohio — one of several communities in Republican-led states suing over the cuts — the health department had to lay off nine disease intervention specialists. This left it operating at 25% capacity in its disease tracing and investigation work just as it prepared to address a measles outbreak.

Kansas City, Missouri, will not be able to do its own testing for infectious diseases because the cut came just as the city was about to buy $500,000 worth of equipment. And Nashville had to end a program offering free flu and COVID tests and cancel plans to buy a van to deliver vaccinations.

The cities complained the cuts had created ''severe budget uncertainty'' and forced them to redirect their limited resources ''to respond to the resulting chaos.''

CDC staff cuts are also having a ripple effect on state and local departments. Children who are deaf or hard of hearing will no longer benefit from an early intervention program run by states after everyone who worked on the program at CDC was laid off. The team in the Office on Smoking and Health, which funds state tobacco hotlines that help people quit, was let go.

So was the CDC team that worked to reduce drownings, partly through funding low-cost swimming lessons in local communities. Drownings kill 4,000 people a year in the U.S.

''The experts who know the things that can be done to help prevent the No. 1 cause of death from children ages 1 to 4 have been eliminated,'' Connecticut state health commissioner Dr. Manisha Juthani told a Democratic congressional hearing in April, referring to drownings.

She said the abrupt and disorganized nature of the cuts leaves her department scrambling as officials try to understand what is being cut and to close important programs on the federal government's impractical timelines.

''The current uncertainty puts lives at risk,'' she said.

Public health funding is going bust — and about to get worse

The new cuts are especially damaging because health departments are funded differently than other government agencies meant to protect the public: Funding pours in during emergencies and slows to a relative trickle when they subside. Mecklenburg's Washington notes the contrast with fire departments, which are kept ready at all times, not scrambling to find firefighters and fire trucks when houses are already burning.

With health departments, ''there's a long-established pattern of boom-and-bust funding,'' said Dr. Steven Stack, Kentucky's public health commissioner and past president of the Association of State and Territorial Health Officials.

A temporary surge of money during the pandemic allowed some health departments to expand and strengthen programs. In Alabama, the influx of COVID money allowed the state to reopen a health department in largely rural Coosa County that closed a decade ago due to a lack of money. In California's Santa Clara County, a COVID-era lab grant paved the way for a new science branch with nearly 50 positions.

But by early this year, most of that money had disappeared, along with other COVID-era grants across the nation — some because they ended and some because the government rescinded them. Departments were again left brittle and vulnerable.

''We're facing funding cliff after funding cliff after funding cliff,'' said Dr. Sara Cody, Santa Clara County's health director. ''What really worries me is I felt that we had finally built the infrastructure in the public health department. ... We were still pretty trim, but we weren't just, like, bones.''

In Chicago, one-time COVID grants made up 51% of the health department budget, and their ending will push staff numbers below the pre-pandemic level of 588 — slowing responses to outbreaks and forcing officials to scale back food safety, violence prevention and other programs.

In Mecklenburg, the department lost 180 employees as COVID funds dried up. It also lost a wastewater monitoring partnership with the University of North Carolina at Charlotte that helped the county react quickly to changing COVID variants and could have also been used to detect new threats like bird flu.

The cuts are not over.

The Trump administration has proposed cutting billions more from CDC's budget, enough to cut the agency's spending in half. CDC sends about 80 percent of its budget to states and local communities.

Michael Eby, director of clinical services in Mecklenburg, said the relentless cuts to the system leave departments unable to respond to new pandemics and old diseases returning across the United States.

''Without the appropriate funding, we can't properly address these threats,'' he said. ''We're at risk of them getting out of control and really causing a lot of damage and death to individuals that we could have saved, that we could have protected.''

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Ungar reported from Charlotte and Louisville, Kentucky, and Smith reported from Providence, Rhode Island. Associated Press reporters Mary Conlon in Washington and Kenya Hunter in Atlanta contributed to this report.

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