JACKSON, Miss. — When the coronavirus first scythed via the nation in early 2020, few locations wanted assist combating it greater than Scott County, Miss., a rural patch of rooster processing crops and pine forests an hour east of the state capital, Jackson.

The poverty price for the county’s 28,000 residents was far above the nation’s. So, too, had been charges of diabetes and different continual diseases that worsen the danger of extreme Covid-19. But Mississippi’s well being division, struggling underneath big finances cuts ordered by the state’s Legislature, had deployed simply two nurse practitioners to cowl a quarter-million residents in Scott and eight different counties.

So when the Biden administration gave Mississippi $18.4 million in mid-2021 to rent public well being employees — a part of $2 billion in grants to bolster the Covid work power at state and native well being companies nationwide — it appeared that assist had, in the end, arrived.

However as of January, 18 months later, Mississippi had spent simply $3.6 million of its grant — lower than a fifth. Its makes an attempt to rent epidemiologists, nurses and different troopers within the warfare in opposition to Covid had largely fallen flat. The state has misplaced one in 224 residents to Covid-19, one of many nation’s worst demise charges, together with 122 folks in tiny Scott County alone.

Mississippi’s woes are an acute instance of a bigger public well being failure that’s reprised practically each time a significant well being menace grabs headlines. The issue, specialists say, is that Congress starves state and native well being companies of money for even fundamental wants in quiet instances. Then, when a disaster hits, it floods them with thousands and thousands and even billions of {dollars} earmarked to battle the illness of the second. And the sluggish equipment of Capitol Hill usually ensures that many of the support arrives solely after the worst of the disaster has handed.

The $2 billion in Covid hiring grants is the newest instance. Nationwide, states and localities had spent solely $371 million of the cash by December, or about 19 p.c, in accordance with the Facilities for Illness Management and Prevention, the conduit for the funds.

Well being departments discovered it practically inconceivable to bulk up their skeletal staffs from a standing begin. Seasoned employees, in excessive demand all through the well being care system, balked at taking jobs that had been assured solely till the federal funds ran out. Well being departments now face a July deadline to make use of the cash, however uptake has been so sluggish that the C.D.C. is letting them ask for a one-year extension.

The file is replete with different such fumbles.

Six months after the World Well being Group declared the H1N1 influenza pandemic over in mid-2010, states and localities had used only a third of the $1.4 billion in federal funds that they had acquired to fight it. The outbreaks of the Ebola virus in 2014 and the Zika virus in 2016 additionally led to funding windfalls, however well being specialists say many of the cash arrived late.

In Mississippi, Dr. Thomas E. Dobbs, who ran the state’s well being division from 2018 via final July, mentioned a number of the company’s leftover Zika and Ebola cash “mainly rotted on the shelf” as a result of it couldn’t be shifted to different wants regardless that the threats had subsided.

When the coronavirus started spreading in Mississippi, “it felt like we had been the U.S. earlier than World Struggle II, simply completely unprepared,” he mentioned. “We couldn’t rent anybody for months.”

The nation’s first Covid instances had been detected in January 2020, however Congress didn’t authorize the funding that led to the $2 billion in grants till March 2021. When the C.D.C. pushed the cash out the door that July, greater than 600,000 folks in the US had already died.

“You don’t have something up entrance,” Dr. Dobbs mentioned. “You’re mainly making an attempt to outlive off baling wire and duct tape. After which, as soon as it’s virtually over, a giant pot of cash is available in. It’s not solely ridiculous, it’s wasteful and inefficient.”

It’s inconceivable to measure how a lot the staffing shortages worsened the pandemic’s toll, mentioned Dr. Judith Monroe, who leads the C.D.C. Basis, an unbiased nonprofit group that attempted to plug Covid staffing gaps.

However “on the finish of the day,” she mentioned, “it value Individuals their family members.”

Invisible Companies

On the root of continual underfunding of public well being, specialists say, is a basic lack of knowledge of its mission.

Employees at state and native well being departments monitor and attempt to restrict a number of threats, together with preventable accidents, infectious ailments and continual illnesses like diabetes. These duties come atop a drumbeat of different extra routine however important duties, akin to restaurant inspections.

Success produces no headlines. And in lean instances, well being departments are straightforward targets for presidency cutbacks.

“Public well being at its most interesting is prevention — it’s invisible to the general public,” Dr. Monroe mentioned, including, “No one wakes within the morning saying, ‘I really feel so grateful right this moment I don’t have smallpox.’”

Public well being is so neglected that nobody is aware of precisely how a lot cash the nation’s roughly 2,800 state and native well being departments spend or how many individuals they make use of. Some states like Mississippi centralize their operations, whereas in others, counties train extra management.

The end result is a big patchwork of companies and techniques. However specialists usually agree on one level: Within the run-up to the pandemic, public well being companies took successful.

One research by tutorial researchers discovered that state public well being spending both stagnated or declined from 2008 to 2018. The de Beaumont Basis, a nonprofit well being advocacy group, estimated that state and native well being departments shed about 40,000 jobs between 2008 and 2019.

The C.D.C., which helps preserve state and native well being companies afloat with billions of {dollars} yearly in grants and different funding, additionally misplaced floor earlier than the pandemic. Within the decade that resulted in 2019, the company’s finances fell by 10 p.c when adjusted for inflation, in accordance with the Belief for America’s Well being, a nonprofit advocacy group.

Public well being specialists have lengthy argued that steady federal funding would give state and native well being departments a sturdier basis and would free officers from submitting limitless grant functions. The Obama administration tried to reply these pleas by making a devoted fund for public well being as a part of the Inexpensive Care Act, which grew to become regulation in 2010.

The fund began with $500 million, and its annual allotment was presupposed to develop to $2 billion by 2015. But it surely was raided for different functions, together with throughout the Obama administration itself to assist avert a minimize in Medicare funds to physicians. The fund leveled off at about half of its $2 billion goal.

Fax Machines, Mould and a Snake

Confronted with falling revenues attributable to revenue and company tax cuts, Mississippi’s Republican-controlled state authorities put its well being division on the chopping block. It lowered the company’s state financing from $36 million in 2016 to about $19 million in 2018, former state officers mentioned.

Republican legislators mentioned fewer sufferers had been searching for care on the greater than 80 well being clinics the division operates throughout the state. Dr. Mary Currier, who led the division from 2010 to 2018, mentioned lawmakers had been blind to the company’s mission. “They don’t see it as essential,” she mentioned. “And they also don’t actually care if it fails.”

Public well being nurses left in droves. Some counties had been pressured to share nurse practitioners, and sure packages concentrating on continual ailments, like screening for hypertension, had been curtailed or deserted, present and former officers mentioned. County clinics minimize hours, and infrastructure wants took a again seat.

Dr. Dobbs instructed state lawmakers in December 2021 that fax machines had been ubiquitous and a few clinics had been past restore. He displayed a photograph of Scott County’s clinic with a gaping gap in an exterior wall. One other picture featured a snake slithering throughout the ground. Pictures of different clinics confirmed leaking ceilings, moldy doorways and dilapidated bogs.

“Is that this the place you’d wish to take your loved ones for well being care companies?” he requested.

The state additionally stored the wages of public well being employees so low that as of 2020, about one-fourth of the well being division’s jobs had been unfilled, in accordance with Dr. Dobbs, now the dean of the College of Inhabitants Well being on the College of Mississippi Medical Middle. Essentially the most extremely skilled epidemiologist might earn not more than $62,000 a 12 months, he mentioned — roughly $17,000 beneath the median wage within the career. The company employed solely a handful of them when he took it over, he mentioned.

“That left our foundations actually weak coming into Covid,” Dr. Dobbs mentioned.

Some states tapped cash from a coronavirus reduction package deal enacted in March 2020 to rent extra public well being employees. The C.D.C. additionally dispatched its personal specialists to the sector.

And it routed $290 million from that package deal and one other one a 12 months later to the C.D.C. Basis, which recruited and dispatched 3,900 public well being employees to the states, together with 27 to Mississippi. That effort sidestepped obstacles like wage caps that hampered hiring by state and native companies, though most employees solely arrived after mid-2021.

The largest effort — the $2 billion in hiring grants awarded in July 2021 — additionally got here late. However the want was nonetheless urgent.

Covid vaccination pictures had turn out to be obtainable lower than seven months earlier. The Delta variant was spreading, and Omicron, which might unleash a recent wave of demise and illness, lay forward.

Mississippi’s vaccination price was then, and nonetheless is, one of many nation’s worst. Dr. Dobbs mentioned that with extra employees, “indubitably we might have accomplished a greater job getting folks vaccinated quicker” and saved extra lives.

However Michael S. Sparer, a professor at Columbia College’s Mailman College of Public Well being who has been researching the $2 billion program, mentioned that Mississippi, Indiana, Kentucky and different states struggled mightily to make use of the cash, particularly due to competitors for employees from hospitals that would pay extra.

By the tip of final November, Washington State’s well being division had spent lower than $3 million of its $45.5 million grant, although like Mississippi, it has earmarked a number of the unspent cash for future use. “You’re not going to have the ability to get an epidemiologist simply sitting on the facet of the road,” mentioned Dr. Umair A. Shah, who leads the company.

Mississippi officers mentioned that the $18.4 million grant allowed the well being division to rent 157 new employees members however that the company nonetheless had sufficient cash for 97 new positions that remained vacant.

Dr. Daniel P. Edney, who changed Dr. Dobbs final summer season, declined to be interviewed for this text. Former officers say the company tries to maintain a low profile lest state lawmakers additional tie its fingers.

However in a November speech to the Mississippi Public Well being Affiliation, Dr. Edney mentioned, “I would like to rent 150 nurses right this moment.” He added, “We want nurses and social employees and nearly each place you possibly can consider.”

A Fading Sense of Urgency

Many specialists hoped that the lack of 1.1 million folks in the US to Covid would power a reckoning over the nation’s public well being system.

“We’ve by no means actually stepped again and requested, ‘How can we make investments correctly in a sustainable method to verify our public well being system can reply in public well being emergencies?’” mentioned Dr. Julie Gerberding, who served as C.D.C. director underneath President George W. Bush.

The pandemic did produce some modifications. Excluding one-time infusions of funds, the C.D.C.’s finances has grown at a quicker price throughout the Biden administration than it did for the earlier decade.

Importantly, the C.D.C. reserved $3.2 billion in pandemic reduction funds for state and native companies to make use of in a extra versatile vogue. The cash, awarded in November, can be utilized over the subsequent 5 years for a wide range of important wants, together with extra employees.

However specialists say state and native companies want way more — $4.5 billion extra per 12 months simply to satisfy fundamental public well being wants, the Belief for America’s Well being says. The de Beaumont Basis estimates that these companies want to rent 80,000 extra employees.

In an interview, Dr. Rochelle P. Walensky, the C.D.C.’s director, mentioned the $3.2 billion program “is a terrific begin, however I feel the wants are a lot better than that.”

But the sense of urgency sparked by the pandemic is fading. The White Home requested Congress to extend the C.D.C.’s finances for the 2023 fiscal 12 months by 27 p.c, however lawmakers agreed to an increase of solely 9 p.c.

“I’m simply apprehensive now, even now, when persons are nonetheless affected by this pandemic, that they’re forgetting how dangerous it was, and the way it didn’t must be as dangerous because it was if we had extra capability,” mentioned Dr. Anne Schuchat, who retired because the C.D.C.’s principal deputy director in mid-2021.

Significantly alarming to well being specialists is the exodus of public well being employees. Many toiled to exhaustion throughout the pandemic. Some resigned after opponents of how the Covid battle was being waged threatened their security.

On the Mississippi well being division, 47 p.c of positions had been unfilled as of December — roughly twice the prepandemic emptiness price, Dr. Dobbs mentioned.

“We’re simply approach, approach, approach worse off from a public well being preparedness perspective than we had been earlier than,” he mentioned.

Kitty Bennett and Susan C. Beachy contributed analysis.