The U.S. public health system has been starved for decades and lacks the resources to confront the worst health crisis in a century.
Marshaled against a virus that has sickened at least 2.6 million in the U.S., killed more than 126,000 people and cost tens of millions of jobs and $3 trillion in federal rescue money, state and local government health workers on the ground are sometimes paid so little, they qualify for public aid.
They track the coronavirus on paper records shared via fax. Working seven-day weeks for months on end, they fear pay freezes, public backlash and even losing their jobs.
Since 2010, spending for state public health departments has dropped by 16% per capita and spending for local health departments has fallen by 18%, according to a KHN and Associated Press analysis of government spending on public health. At least 38,000 state and local public health jobs have disappeared since the 2008 recession, leaving a skeletal workforce for what was once viewed as one of the world's top public health systems.
KHN, also known as Kaiser Health News, and AP interviewed more than 150 public health workers, policymakers and experts, analyzed spending records from hundreds of state and local health departments, and surveyed statehouses. On every level, the investigation found, the system is underfunded and under threat, unable to protect the nation's health.
Dr. Robert Redfield, the director of the Centers for Disease Control and Prevention, said in an interview in April that his "biggest regret" was "that our nation failed over decades to effectively invest in public health."
So when this outbreak arrived — and when, according to public health experts, the federal government bungled its response — hollowed-out state and local health departments were ill-equipped to step into the breach.
Over time, their work had received so little support that they found themselves without direction, disrespected, ignored, even vilified. The desperate struggle against COVID-19 became increasingly politicized and grew more difficult.
States, cities and counties in dire straits have begun laying off and furloughing their limited staff, and even more devastation looms, as states reopen and cases surge. Historically, even when money pours in following crises such as Zika and H1N1, it disappears after the emergency subsides. Officials fear the same thing is happening now.
"We don't say to the fire department, 'Oh, I'm sorry. There were no fires last year, so we're going to take 30% of your budget away.' That would be crazy, right?" said Dr. Gianfranco Pezzino, the health officer in Shawnee County, Kansas. "But we do that with public health, day in and day out."
Ohio's Toledo-Lucas County Health Department spent $17 million, or $40 per person, in 2017.
Jennifer Gottschalk, 42, works for the county as an environmental health supervisor. When the coronavirus struck, the county's department was so short-staffed that her duties included overseeing campground and pool inspections, rodent control and sewage programs, while also supervising outbreak preparedness for a community of more than 425,000 people.
When Gottschalk and five colleagues fell ill with COVID-19, she found herself fielding calls about a COVID-19 case from her hospital bed, then working through her home isolation. She only stopped when her coughing was too severe to talk on calls.
"You have to do what you have to do to get the job done," Gottschalk said.
Now, after months of working with hardly a day off, she says the job is wearing on her. So many lab reports on coronavirus cases came in, the office fax machine broke. She faces a backlash from the community over coronavirus restrictions and there are countless angry phone calls.
Things could get worse; possible county budget cuts loom.
But Toledo-Lucas is no outlier. Public health ranks low on the nation's financial priority list. Nearly two-thirds of Americans live in counties that spend more than twice as much on policing as they spend on nonhospital healthcare, which includes public health.
More than three-quarters of Americans live in states that spend less than $100 per person annually on public health. Spending ranges from $32 in Louisiana to $263 in Delaware, according to data provided to KHN and AP by the State Health Expenditure Dataset project.
That money represents less than 1.5% of most states' total spending, with half of it passed down to local health departments.
The share of spending devoted to public health belies its multidimensional role. Agencies are legally bound to provide a broad range of services, from vaccinations and restaurant inspections to protection against infectious disease. Distinct from the medical care system geared toward individuals, the public health system focuses on the health of communities at large.
"Public health loves to say: When we do our job, nothing happens. But that's not really a great badge," said Scott Becker, chief executive officer of the Association of Public Health Laboratories. "We test 97% of America's babies for metabolic or other disorders. We do the water testing. You like to swim in the lake and you don't like poop in there? Think of us."
But the public doesn't see the disasters they thwart. And it's easy to neglect the invisible.