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. She had a telemedicine appointment with her doctor.

Staring back from her screen was Dr Rogers Cain, who runs a tidy little family medical clinic a couple of blocks from the Trout River in north Jacksonville, a predominantly Black area where the coronavirus is running roughshod. Wilson, 81, was one of Cain’s patients who’d tested positive he had seven other COVID patients that morning before noon. Three of her grown children had contracted the virus, too.

Cain and Wilson are nervous. Over the past two decades, both watched as the county health department was gutted of money and people, hampering Duval’s ability to respond to outbreaks, including a small cluster of tuberculosis cases in 2012. And now they face the menace of COVID-19 in a city once slated to host this week’s Republican National Convention, in one of the states leading the latest US surge.

Florida is both a microcosm and a cautionary tale for America. As the nation starved the public health system intended to protect communities against disease, 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 to make it the nation’s third-most populous state, 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.

According to an analysis of state data, the state-run local health departments spent 41% less per resident in 2019 than in 2010, dropping from $57 to $34 after adjusting for inflation. Departments nationwide have also cut spending, but by less than half as much ? an average of 18%, according to data from the National Association of County and City Health Officials.

Even before the pandemic hit, that meant fewer investigators to track, trace and contain diseases such as hepatitis. It meant fewer public health nurses to teach people how to protect themselves from HIV/AIDS or the flu. When the wave of COVID-19 inundated Florida, the state was caught flat-footed when it mattered most, its main lines of defense eviscerated.

Now, confirmed cases have soared past 588,000 and deaths have risen to more than 10,000. Concerns over the virus prompted Republicans to cancel plans for an in-person convention in Jacksonville, opting for a pared-down version in North Carolina.

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 Governor Ron DeSantis and other political leaders. Voices within the health departments were muzzled.

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.

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.

Those failings are clear in Duval County, which had employed the equivalent of 852 full-time workers and spent $91 per person in 2008 but in 2019 had only 422 workers and spent just $34 per resident, according to the KHN/AP analysis of state data. That’s less than the typical list price of a single COVID test.

Former county health director Jeff Goldhagen said the county’s team has been dismantled to the extent that it could not really manage an outbreak. Yet it must. Cain’s private north Jacksonville medical clinic alone has had about 60 confirmed COVID cases and eight deaths. We are all on fire right now, he said. You have to have a fire department that is adequately equipped to put out the fire.”

Florida faced similar shortcomings around the time of the last great pandemic, the 1918 flu. Back then, according to a 1924 state report, public health workers faced too many demands and their efforts were to some extent scattered and transitory.

The state could have used at least three more district health officers, the report said: It is a source of regret and a matter of grave concern to public health workers that the funds available are not sufficient. County-based health departments began in 1930, providing more robust services closer to home.

About 50 years later, legislation created state-administered primary care programmes in which county health departments provided low-income Floridians with the type of basic health care and treatment most people now get at private doctors’ offices.

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