Fifteen years ago, Florida braced for a pandemic.
Officials knew as early as 2005 that an outbreak could devastate the state and infect much of the population. They wrote reports predicting a crisis remarkably similar to the one playing out now: a virus that could infect more than a million Florida residents.
And they responded in force, bolstering the state health department with resources and specialized workers to combat a potential crisis.
But that operation was dismantled by governors and lawmakers more worried about the bottom line, the Tampa Bay Times has found.
They slashed research funding, cut thousands of jobs and ignored gaps in the state’s defense against fast-spreading diseases.
Florida now has fewer epidemiologists per resident than most of the country and has cut back on statewide pandemic drills.
As coronavirus cases spike across Florida, there are signs that the weakened health department is unprepared.
The state needed to hire about 100 students and professors in a matter of days last month to assist its overloaded epidemiologists — public health experts who help control disease outbreaks.
That strained public health system has previously made serious errors when handling smaller and slower-moving outbreaks like tuberculosis and hepatitis A, according to government investigations and news reports. Public health workers failed to properly track down people who had contacted infected patients, mistakes that experts said prolonged outbreaks and likely increased hospitalizations.
The system that protects Florida against smaller outbreaks is the same one now deployed against the coronavirus pandemic, said Dr. Richard Hopkins, who served as acting state epidemiologist in 2012. “A pandemic is just a really big version of what people do every day,” he added.
Over the years, experts and state officials repeatedly raised alarms about Florida’s public health system. Ignored at the time, their warnings are enshrined in one agency report after another.
There’s the health department’s 2012 workforce development plan:
“Florida is facing a public health workforce crisis” that puts Floridians “at grave risk.”
There’s the agency’s 2017 budget request:
“There is a lack of sufficient individuals at the local level who have the skills to perform epidemiological analyses as well as manage the large volume of day-to-day reportable diseases, outbreaks.”
Dr. Leslie Beitsch, the health department’s deputy secretary until 2018, saw the toll that cuts were taking on the agency’s depleted staff. He said the potential consequences were clear.
“It may not have been predictable that we had a coronavirus variant,” Beitsch told the Times. “But a pandemic was predictable.”
Since coronavirus came to Florida, Tampa Bay Times reporters have worked tirelessly to document the effects and hold officials accountable.
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Most of the cuts were made under former Gov. Rick Scott, now a U.S. senator. In a statement, Scott spokesman Chris Hartline defended the cuts, saying: “The Democrats and their media partners believe that bigger government and more bureaucracy are the solution to every problem. People who actually know what they’re talking about realize that that’s not always the case. We’re certainly not going to apologize for making government more efficient and effective for Florida taxpayers.”
“He left the Department of Health and county health departments in a great position,” Hartline added.
Neither the Department of Health nor Gov. Ron DeSantis’ office would make someone available for an interview about the cuts or the state’s pandemic readiness.
By the end of 2018, Scott’s last year as governor, the number of positions at the agency had fallen by more than 20 percent. About 3,700 jobs were eliminated. DeSantis’ first budget last year cut nearly 600 more public health positions.
Most of the eliminated jobs were in the agency’s 67 county offices, where the effort to spot an outbreak begins.
“We’ve been starving our Department of Health here for a decade or more. We can’t pay decent salaries. There are significant staff shortages,” said Dr. Glenn Morris, director of the Emerging Pathogens Institute at the University of Florida.
Asked about pandemic preparation, he added: “Nobody is looking at that stuff. You’re just trying to survive day to day and keep your staff in place.”
Tracing the disease
The coronavirus is fast-spreading and dangerous. The disease it causes, COVID-19, is many times more likely to end in hospitalization or death than most strains of the flu, according to recent data. Public health systems around the world have been the first line of defense.
Some countries like South Korea immediately took aggressive action. They tracked the virus by testing as many people as possible. Teams of epidemiologists investigated early cases and performed “contact tracing,” a method of finding every person an infected patient has interacted with so they could be isolated.
DeSantis has used South Korea as an example in news conferences about the coronavirus’ spread in Florida. He argued for weeks that restrictive measures weren’t necessary, pointing to South Korea’s ability to control the disease.
But Florida’s public health workforce lacks important resources to tackle the outbreak in a similar fashion.
The state has shed hundreds of doctors, nurses and clinicians — people who could have staffed drive-through testing centers, answered local coronavirus helplines or examined patients outside of a hospital, experts told the Times.
As the virus began spreading throughout the state, Florida turned to universities for help. Students and professors were hired over a single weekend to do part-time work interviewing people over the phone and collecting their information. Some didn’t have infectious disease backgrounds.
Florida is now seeing a sharp increase in cases. The state reported more than 6,000 additional positive tests in the last week.
Steps like contact tracing are still important, Beitsch said. In areas like Tallahassee, where the spread is smaller, a strong epidemiological response could save lives.
A Department of Health spokesman said the agency is doing contact tracing for every confirmed case in the state. The spokesman did not say whether the agency was notifying every person who came in contact with an infected patient.
But local public health teams in Florida have struggled for years to perform these basic disease control measures during much smaller outbreaks.
Outbreaks amid cuts
Tuberculosis is an aggressive disease that attacks the lungs. In the worst cases, infected people cough blood and wither away until they die.
An outbreak had been raging in northeast Florida for about three years in 2012 when the state asked the federal Centers for Disease Control and Prevention to come to Duval County and help.
The federal agency discovered that the state’s investigation had been haphazard, the Palm Beach Post reported. State and regional epidemiology teams had failed to interview 3,000 individuals who may have made contact with infected patients, the federal scientists said.
The tuberculosis outbreak was the worst in America since the early 1990s, the Centers for Disease Control and Prevention said. Years after it started spreading, it still wasn’t under control.
The CDC submitted its findings to the state in April 2012. One week earlier, then-Gov. Scott authorized the closure of the state’s only specialized tuberculous treatment facility, which had helped manage the disease for 60 years.
Members of the Florida Legislature said that they approved the bill that closed the facility without being told there was an ongoing outbreak or that the federal government had been called to assist. There was no public announcement until years after the outbreak started, the Palm Beach Post found.
Even after the disease had spread beyond a limited cluster of homeless adults and infected two Jacksonville teenagers, the state waited months to inform the public.
Four years later, the Zika virus started to spread through Florida. The state knew that the outbreak was growing in South and Central America. State and local governments scrambled to hire temporary staff to test Floridians and kill Zika-spreading mosquitoes.
Then-Gov. Scott blamed Congress and touted his ability to free up millions in state funds for disease detection and vaccine development.
But within a year, Scott and the Legislature eliminated the special grants they themselves had created to develop vaccines and testing tools, two years before the funding was supposed to end.
Research teams at universities across the state had to abandon their work before they could develop a vaccine.
“This is where you get the politicians who during an emergency say, ‘Okay, let’s put money here,’ and then a year later say, ‘Okay, let’s pull it back,’ ” said Morris, UF’s director of the Emerging Pathogens Institute, which lost funding. “You can’t run public health like that.”
In 2019, thousands of hepatitis A cases popped up across Florida. The outbreak was declared a public health emergency. But in Martin County, officials misstepped in their first attempts to control the disease because epidemiologists investigated poorly, Treasure Coast Newspapers found after reviewing internal emails.
Workers didn’t interview all of the infected patients, the emails showed. They entered incorrect data into their systems and let unqualified employees conduct some of the investigations.
The epidemiologist who led the initial work was fired. But the state had known for years it didn’t have the right resources for a hepatitis outbreak.
In a 2016 hepatitis prevention plan, the health department warned of gaps in vaccination services, laboratory budgets and testing locations.
“Case managers and hepatitis coordinators are already overworked,” the report stated.
It was written 18 months before the state’s hepatitis A outbreak began.
‘The health department got nailed’
In 2005, Florida was pouring resources into pandemic preparedness.
The World Health Organization had just announced that governments across the globe were unprepared for a pandemic. The group said a fast-spreading virus could one day infect half the world’s population.
The CDC quickly published a new comprehensive plan on combating a national epidemic. The federal government pumped money to states to help them prepare.
The Florida Department of Health wrote risk assessments, plans to slow disease spread and protocols for continuing government operations during a widespread outbreak.
The agency hired more epidemiologists, especially in county health departments. It sent staff to specialized federal classes in Atlanta, said Dr. Bill Tynan, a former division director of emergency medical operations in the Florida Department of Health.
Tynan said pandemic preparation became a top priority. “It seemed like that was the only thing I did for two years,” he said.
Tynan and other state experts warned Florida’s agencies that millions of residents could be infected and hundreds of thousands could die. The government would need to employ tactics like social distancing and quarantines.
In 2006, state health agencies performed the country’s largest pandemic influenza simulation in Tampa. Federal officials watched on a live stream as local high school students acted as patients and emergency workers set up a treatment facility in the Florida State Fairgrounds to help overwhelmed hospitals.
Over the following decade, that urgency and attention disappeared, and the progress began to unravel.
When the Great Recession hit, cost-cutting became the top priority. Then came the H1N1 swine flu in 2009. State officials projected that millions could contract the disease and 5,000 could die. Instead, there were several thousand infections and 187 laboratory-confirmed swine flu deaths in Florida.
“We thought it would be COVID-19,” Hopkins said.
The public began to view the disaster modeling as overblown. So when Florida’s state government began slashing health-related funding, pandemic preparation became an easy target.
In 2010, under then-Gov. Charlie Crist, the state Department of Health was required to “conduct a comprehensive evaluation and justification review of each division.” Every dollar needed to be justified, with a focus on the “return on investment,” according to the review.
“It was my duty not to waste anyone’s money in any agency in government,” Crist told the Times Thursday. “So when you’re in the depths of the Great Recession, you better heighten your awareness of that.”
His successor, Scott, cut hundreds of those positions almost immediately after taking office. Within two years, $130 million had been slashed from the Department of Health.
“The health department got nailed,” Morris said.
Former Rep. Matt Hudson, the healthcare appropriations subcommittee chair, was among the lawmakers who spearheaded the cuts. It was one piece of a larger effort to shed government-funded health care services.
The same 2012 bill that closed Florida's tuberculosis hospital also overhauled the state Department of Health, removing from statute its duty to prevent the spread of diseases “to the fullest extent possible.” Hudson sponsored the bill. Scott signed it into law.
“Instead of being proactive, they decided the department would be reactive,” said state Sen. Janet Cruz, a Tampa Democrat who voted against the bill.
Hudson blamed cuts to health positions on the state’s surgeon generals, Florida’s top doctors. The jobs that were cut had been vacant for months, he said.
“The buck stops at them,” Hudson told the Times. “I see no reason why the state should provide resources for a position that doesn’t get filled when it could have been.”
Starting from behind
Florida is now facing a pandemic much like the one its experts predicted 15 years ago, with a frontline defense that is strained, underfunded and understaffed.
“The question is: do we have the right kind of military to fight?” said Dr. Marc Yacht, the former head of the department of health in Pasco County. “We neglected that force for a number of years so we find ourselves behind the eight ball.”
Florida has fewer public and private epidemiologists per resident than most other states, according to data from the U.S. Bureau of Labor Statistics.
In Florida, there is just over one epidemiologist per 100,000 residents. California has nearly 50 percent more per resident. Texas has nearly double. Tennessee has almost three times as many.
A clear reason for the shortage: These specialists earn less in Florida than in any other state tracked by the bureau, or D.C. and Puerto Rico.
An epidemiologist makes $21 an hour on average in the Sunshine State. Texas pays $34 an hour, Tennessee pays $41 and California pays $44.
State payroll records show one Florida epidemiologist has worked for the Department of Health for 11 years and earns $43,600 — about 35 percent less than the national average wage for that job.
In a 2019 budget request, the state’s health department also noted that the turnover rate in Florida’s laboratories had reached an alarming level. Forty percent of hires left within two years for higher paying, private-sector jobs.
The shortage of resources has made even the simplest tasks difficult.
Just four months ago, Sharon Watkins, Florida’s former chief of the Bureau of Epidemiology and the president of the Council of State and Territorial Epidemiologists, testified before the U.S. House of Representatives about the need for more resources.
She said her work in Florida was severely limited by an antiquated data system that made it difficult to answer basic questions from the public like “How many people have been tested?” and “Do I need a test?”
Attached to her written testimony was an example of a 2019 lab report. Florida’s test results were still shared as stacks of handwritten documents, she said.
The state had also stopped conducting practice scenarios to prepare for a pandemic emergency. By 2013, the state was conducting three exercises every year to test how it might respond to a chemical or biological terrorist attack or a disease outbreak, according to the federally funded National Health Security Preparedness Index.
That dropped to only one in 2017 and none in 2018, the most recent year included in the data.
The last official pandemic-specific statewide drill performed with the CDC was in 2011, according to the health department’s website.
Even then, experts identified problems. Participants didn’t follow written emergency plans. The communication team didn’t properly handle false rumors about the outbreak.
It’s not clear how seriously the exercise was taken. A report noted that some key state employees didn’t even bother to show up.
Times staff writer Allison Ross contributed to this report.
Full statement from Sen. Rick Scott’s office:
"The Democrats and their media partners believe that bigger government and more bureaucracy are the solution to every problem. People who actually know what they’re talking about realize that that’s not always the case. We’re certainly not going to apologize for making government more efficient and effective for Florida taxpayers. The majority of the positions you mentioned were vacancies that were dormant. Eliminating those positions had no impact on the Department’s ability to serve the public under Governor Scott. Any assertion that efficiencies that were made reduced the ability to respond under Governor Scott is false and misleading.
Under Governor Scott, Florida’s public health network was nationally recognized for its quality and efficiency. Florida is the first, and only, state in the nation to have its statewide health department and every county health department pass the rigorous, peer-reviewed accreditation process. Governor Scott guided Florida through numerous crises, including the Zika outbreak, and deftly managed state resources to serve the needs of Florida families. He left the Department of Health and county health departments in a great position to continue to do so."
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