JACKSONVILLE, Fla. – On a sweltering July morning, Rose Wilson struggled to breathe as she sat in her bed, the light from her computer illuminating her face and the oxygen tubes in her nose.
Wilson, a retiree who worked as a public health department nurse supervisor in Duval County for 35 years, had just been diagnosed with COVID-19-induced pneumonia.
Staring back from her screen was Dr. Rogers Cain, who runs a tidy little family medical clinic in north Jacksonville, a predominantly Black area where the coronavirus is running roughshod. Wilson, 81, was having a telemedicine appointment, one of eight COVID patients he saw in just the hours before noon.
Cain and Wilson are nervous. For years, both watched as the county health department was gutted of money and people, hampering Duval’s ability to respond to outbreaks. And now they face the menace of COVID-19 in one of the leading states in the latest U.S. surge.
Florida is both a microcosm and a cautionary tale for America. As the nation starved its public health system, staffing and funding fell faster and further in the Sunshine State, leaving it especially unprepared for the worst health crisis in a century.
Although Florida’s population grew by 2.4 million since 2010, a joint investigation by KHN and The Associated Press has found, the state slashed its local health departments’ staffing ― from 12,422 full-time equivalent workers to 9,125 in 2019, the latest data available.
The state-run local health departments spent 41% less per resident in 2019 than 2010, according to an analysis of state data, dropping from $57 to $34 after adjusting for inflation. Departments nationwide have also cut spending, but by less than half as much, according to data from the National Association of County and City Health Officials.
Even before the pandemic hit, that meant fewer disease investigators to track, trace and contain diseases such as hepatitis. When the wave of COVID-19 inundated Florida, its main lines of defense had been eviscerated.
Now, confirmed cases have soared past 588,000, and deaths surpassed 10,000. Concerns over the virus prompted Republicans to cancel plans for this week’s in-person national convention in Jacksonville.
Health experts blame the funding cuts on the Great Recession and choices by a series of governors who wanted to move publicly funded state services to for-profit companies.
And when the pandemic took hold, they say, residents got mixed messages about prevention strategies like wearing masks from Republican Gov. Ron DeSantis and other political leaders. Voices within the health departments were muzzled.
“The reality, unfortunately, is people are going to die because of the irresponsibility of the decisions being made by the people crafting the budgets,” said Ron Bialek, president of the Public Health Foundation, a nonprofit in Washington, D.C., that offers tools and training to improve public health.
State officials neither answered specific, repeated questions from The Associated Press and KHN about changes in public health funding, nor made staffers available for deeper explanations
Dr. Leslie Beitsch, a former deputy secretary of Florida’s state health department, said failing to prepare for a foreseeable disaster “is governmental malpractice.”
The nation’s pandemic response is only as good as the weakest link, he said. Since the virus respects no borders, other states feel the ripples of Florida’s failings.
Despite a move toward privatization in the 1990s, per-person spending on local public health rose until late in that decade, peaking at $59 when adjusted for inflation to 2019 dollars.
Beitsch said the downward trend continued under former Republican governors Charlie Crist and Rick Scott, fueled by a growing belief in shrinking government. Scott, now a U.S. senator, said through a spokesperson that he was unapologetic for health department cuts, which he characterized as a move toward “making government more efficient.”
The ability to manage disease outbreaks has been hampered in some Florida communities more than others due to this downsizing. Departments serving at least half a million residents spent just $29 on public health per person on average in 2019, compared with $90 per person in those serving 50,000 or fewer — a difference starker than the typical gap between larger and smaller departments nationally, according to a KHN-AP analysis.
Duval County’s health department spending was the equivalent of $34 per person, down 63% since 2008. Typically, about 22 workers, or 5% of the total staff, have been dedicated to preparing for and tracking disease outbreaks.
“Current events demonstrate how bad a decision” the deep cuts to public health were, said Dr. Marissa Levine, a professor of public health and family medicine at the University of South Florida. “It’s really come back to haunt us.”
Florida now has more than half a million COVID cases and 35,000 hospitalizations. Although DeSantis still hasn’t issued a mask mandate, some local governments, such as Jacksonville’s, have.
Chad Neilsen, director of infection prevention at University of Florida-Jacksonville, lauded the city’s mayor for the mask requirement, but pointed out that other counties have different rules and that the inconsistent messaging breeds confusion.
“We have to have one voice, and consistent leadership that is modeling behavior if we want to get people to change their behaviors,” said Dr. Jonathan Kantor, a Jacksonville epidemiologist and dermatologist.
Instead, experts in Florida said, public health workers have been silenced or told by top state officials what to say. Local health officials “are being told bluntly: ‘Shut up,’” said Patrick Bernet, an associate professor in health administration at Florida Atlantic University. “They literally cannot speak.”
Beitsch, who now chairs the department of behavioral sciences and social medicine at Florida State University, said this ― and similar dynamics nationally ― fuels the politicization of public health and undermining of science.
Meanwhile, the COVID caseload climbs.
With an unequipped public health system, Wilson, the retired public health nurse, said it falls to everyone to lead Jacksonville, and Florida, out of the crisis.
“My hope is that everybody begins to take this virus seriously, and wear their mask and stay social distancing,” said Wilson, whose condition has improved. “Eventually there will be a vaccine that will curtail this virus. But until then, it’s up to us to help do that. And if we’re not serious about it, then we’re doomed.”
Dearen is a writer for The Associated Press, and Ungar and Recht are writers for KHN.
This story is a collaboration between The Associated Press and KHN, which is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.