For months, Dr. Jennifer Avegno, the director of the New Orleans Health Department, has watched the threats come closer: Louisiana led the United States as seasonal flu cases surged to their highest rate in 15 years, and had the nation’s first death from bird flu. Then came a deadly measles outbreak in neighboring Texas. The number of Louisiana schoolchildren with exemptions to vaccine requirements doubled in a year.
During the Covid pandemic, Dr. Avegno worked with state officials to tame high infection rates and promote vaccines. But after taking office last year, Gov. Jeff Landry began carrying out a promise to remake public health after the state’s Covid response, which he thought was a disaster.
Mr. Landry, a Republican, created a position for a state surgeon general, appointing Dr. Ralph Abraham, a former congressman who had railed against the state’s “tyrannical” Covid response and argued that the real risk was not the virus itself but the vaccines against it.
So it was not entirely a surprise when Dr. Abraham announced last month that Louisiana would “no longer promote mass vaccination,” calling efforts to do so during Covid “an offense against personal autonomy that would take years to overcome.”
To Dr. Avegno, it was a blunt reminder of how the political aftereffects of the pandemic have left her field worse prepared in many ways to fight the next one.
“We’re in a very different world right now,” she said. “We are now prepared to throw the baby out with the bath water and leave ourselves incredibly vulnerable.”
Local public health officials like Dr. Avegno are the front line for responding to any disease outbreak. Five years after the pandemic began, many say that the entrenched politicization of Covid has left them with fewer tools to respond and fresh challenges:
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Suspicion about Covid vaccines has created hesitancy around all vaccines, and led to looser requirements. The number of children with exemptions from school immunization requirements increased in 41 states, the highest recorded level. In at least 36 states, vaccination rates for measles have fallen below 95 percent — the level needed to maintain herd immunity.
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New laws in a number of states limit local officials’ authority to not only issue broad mandates on masking or vaccines, but also take more targeted actions, like isolating people with tuberculosis or a highly contagious virus.
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The Trump administration has laid off hundreds of workers and vowed to cut budgets at the Centers for Disease Control and Prevention, which provides most of the funding for local departments, coordinates data collection on outbreaks and provides expert guidance.
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The administration has also withdrawn the United States from the World Health Organization, which communicates about outbreaks across the globe, and curtailed communications from federal health agencies. Local officials say those efforts are critical to fighting the confusion and disinformation that sowed so much anger during the pandemic. Some local health departments say that C.D.C. employees they have communicated with for years now sit mute in meetings.
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Trust in public health has dropped sharply: A KFF poll in January found that 54 percent of Americans and 46 percent of Republicans trusted local and state health officials to “make the right recommendations,” down 10 percentage points in each case from two years ago. A new Axios/Ipsos poll found that 62 percent of Americans trust health information from the C.D,C., down from 88 percent in March 2020.
Janet Hamilton, the executive director of the Council of State and Territorial Epidemiologists, said that mistrust in public health has made it harder to respond early. She compared fighting outbreaks to battling a blaze, and said lower vaccination rates are providing a path for them to spread.
“The line of gas that’s there, that the fire can travel along, exists in ways that it did not exist in 2019,” she said.
Local health officials no longer need police protection or to sleep away from home as some did when the public was revolting against mask mandates and other Covid restrictions. In interviews over the last month with two dozen local and state health officials, many acknowledged that public health authorities had made mistakes as they tried to respond to a novel, constantly changing virus — the first outbreak in more than a century that resulted in widespread lockdowns. They say they have learned from those missteps.
Many ruled out future lockdowns, closures or other blanket mitigation strategies.
“That ship has completely sailed,” said Dr. Anne Zink, who was Alaska’s chief medical officer during the pandemic. “And maybe for the best.”
Instead, she and others said, public health agencies need to be “really nimble” and respond with targeted interventions like tracking down individuals with an infectious disease, identifying their contacts and working to reduce the risk of further spread. This requires sufficient resources and detailed, up-to-date information about the threat.
Yet Dr. Sanmi Areola, director of the Metro Public Health Department in Nashville, worries that laws passed in response to the Covid-19 pandemic are so broad that they would limit the ability to fight a fast-moving threat. Tennessee, like several other states, now has a law stating that only the governor can order infected patients to isolate or exposed people to quarantine during a pandemic. Several states this year have proposed banning mRNA vaccines, the kind used against Covid, based on false assertions that they change recipients’ DNA.
Absent the powers public health officials once had, Dr. Areola said, “Public perception, right or wrong, is a very important piece. We have to invest in crafting messages and explaining the benefits.”
The biggest lesson, many health officials said, is the importance of clear communication.
Many have invested in new outreach campaigns. Erin Ourada, a public health administrator in North Dakota, said each of her agency’s roughly 30 staff members travel to at least one community meeting each month to share updates about the department’s work.
In Clackamas County, Ore., the health department tapped trusted community members to speak to specific groups, including Hispanic and Eastern European immigrants. As Oregon battled its largest measles outbreak in decades last year, they fanned out to address skepticism about vaccines.
Still, Dr. Sarah Present, the county’s health officer, worries about what she described as the moral injury to the field — the toll taken by the angry public confrontations, the threats, the friends who shied away. Like others, she has stopped telling strangers what she does, after people she met socially took it as an opportunity to debate vaccinations.
“I think that people’s exhaustion and the burnout in public health also makes us a little bit less prepared,” she said.
In Pima County, Ariz., which includes Tucson, Dr. Theresa Cullen set up the largest free Covid-19 testing program in the state and established mobile vaccination clinics to serve rural residents. But after Gov. Katie Hobbs nominated her to lead the state’s health department, she quickly became what one friend called a “voodoo doll” for public health.
At her confirmation hearing in 2023, one state senator blamed her for the depression and suicides of students during school closures; one person testified that Dr. Cullen’s agency had “terrorized” local businesses.
“I was taken aback by the ferociousness,” Dr. Cullen said in an interview. “Because I know why I wanted to do that job, and it was service.”
The governor withdrew her nomination, and Dr. Cullen stayed in Pima County. Others walked away from the stress. With them went a lot of experience: One study found that nearly half of all public health employees who were working at state and local agencies in 2017 had left by 2021.
“People who had been there for 20 years, people who have seen measles before or done a measles outbreak, those who worked through Ebola in the past, a lot of them are gone,” Dr. Zink said.
At the same time, public health challenges are increasing. Extreme heat and disasters like hurricanes and wildfires are demanding responses from local departments that are also confronting outbreaks of measles, whooping cough, syphilis, H.I.V. and TB.
The federal government sent billions of dollars in pandemic funding to state and local health departments. But that emergency money has all but dried up, leaving local departments with fewer resources to shore up staff, trace new viruses and expand vaccine campaigns.
“People don’t question the police and fire budgets — when you dial 911, you’re going to have a police officer come,” said Renae Moch, a public health officer in North Dakota. “Public health is kind of the same, but we don’t get the same respect. We’re here 24/7 too. Why do we have to keep showing our worth?”
Dr. Eric Chow, the interim health officer for Seattle’s health department, said the spread of bird flu from farms to humans is a top concern, as Washington has had more cases than most states. Though a vaccine is available, disseminating it would be difficult.
“To be able to stand up the access points, get the information out to people,” he said, “we’re going to require much more federal support.”
When the pandemic started, the C.D.C. was not sharing data on the outbreak. It was left to universities and private entities to create public dashboards.
In 2023, the C.D.C. created the Center for Forecasting and Outbreak Analytics, a network of centers that collect and distribute data and information. But there are fears that it will be the victim of budget cuts.
With the Trump administration reining in communications from health agencies, “there’s this massive gap in communication happening — within the C.D.C., between the C.D.C. and states, between the C.D.C. and academic research partners,” said Dr. Lauren Gardner, an infectious disease expert at Johns Hopkins. In January 2020, Dr. Gardner created an interactive Covid dashboard that members of the public and health officials around the world quickly came to rely on.
Local health departments “all have to be networked into something that’s overseeing things at a higher level — that’s the C.D.C.,” she said. And given the uncertainty around the agency, she added, “the C.D.C. is going to struggle to fulfill that role right now.”
Local officials say that without coordination with the federal government, it will be hard to act on the lessons they’ve learned from Covid.
“Public health credibility quickly went out the window when the public could see that we sometimes weren’t in the loop either,” said Ms. Ourada, in North Dakota. “That’s kind of what has brought us to where we are today, where we aren’t trusted members of the community anymore.”
