Galvanized by what they’ve characterized as an overreach of covid-related health orders issued amid the pandemic, lawyers from the three overlapping spheres — conservative and libertarian think tanks, Republican state attorneys general, and religious liberty groups — are aggressively taking on public health mandates and the government agencies charged with protecting community health.

“I don’t think these cases have ever been about public health,” said , managing attorney for the Liberty Justice Center, a Chicago-based libertarian litigation group. “That’s the arena where these decisions are being made, but it’s the fundamental constitutional principles that underlie it that are an issue.”

Through lawsuits filed around the country, or by simply wielding the threat of legal action, these loosely affiliated groups have targeted individual counties and states and, in some cases, set broader legal precedent.

In Wisconsin, a won a case before the state Supreme Court stripping local health departments of to stem the spread of disease.

In Missouri, the Republican state attorney general waged a campaign against school mask mandates. Most of the dozens of cases he filed but nonetheless had a on school policies.

In California, a lawsuit brought by religious groups challenging a health order that limited the size of both secular and nonsecular in-home gatherings as covid-19 surged made it to the U.S. Supreme Court. There, the conservative majority, bolstered by three staunchly conservative justices appointed by President Donald Trump, issued an emergency injunction finding the order violated the freedom to worship.

Other cases have chipped away at the power of federal and state authorities to mandate covid vaccines for certain categories of employees or to declare emergencies.

Although the three blocs are distinct, they share ties with the , a conservative legal juggernaut. They also share connections with the , an umbrella organization for conservative and libertarian think tanks, and the SPN-fostered , described by president and founder Carrie Ann Donnell as “SPN for lawyers.” In the covid era, the blocs have supported one another in numerous legal challenges by filing amicus briefs, sharing resources, and occasionally teaming up.

Their legal efforts have gained traction with a federal judiciary transformed by Republican congressional leaders, who strategically stonewalled judicial appointments in the final years of Democratic President Barack Obama’s second term. That put his Republican successor, Trump, in position to fill hundreds of judicial vacancies, including the three Supreme Court openings, with candidates decidedly more friendly to the small-government philosophy long espoused by conservative think tanks.

“You have civil servants up against a machine that has a singular focus and that is incredibly challenging to deal with,” said Adriane Casalotti, chief of government and public affairs for the .

All told, the covid-era litigation has altered not just the government response to this pandemic. Public health experts say it has endangered the fundamental tools that public health workers have utilized for decades to protect community health: mandatory vaccinations for public school children against devastating diseases like measles and polio, local officials’ ability to issue health orders in an emergency, basic investigative tactics used to monitor the spread of infectious diseases, and the use of quarantines to stem that spread.

Just as concerning, said multiple public health experts interviewed, is how the upended legal landscape will impact the nation’s emergency response in future pandemics.

“This will come back to haunt America,” said , faculty director of Georgetown University’s O’Neill Institute for National and Global Health Law. “We will rue the day where we have other public health emergencies, and we’re simply unable to act decisively and rapidly.”

‘Legal Version’ of Navy SEAL Team 6

The entities pressing the public health litigation predate the pandemic and come to the issue motivated by different dynamics. But they have found common interest amid covid, following the sweeping steps public health officials took to stem the spread of a deadly and uncharted virus.

A coalition of state-based libertarian and conservative think tanks and legal centers, known as the State Policy Network, long has operated behind the scenes promoting a conservative agenda in state legislatures. A KHN analysis identified at least 22 of these organizations that operate in the legal arena. At least 15 have filed pandemic-related litigation, contributed amicus briefs, or sent letters threatening legal action.

Typically staffed by just a handful of lawyers, the organizations tend to focus on influencing policy at the state and county levels. At the core of their arguments is the notion that public health agencies have taken on regulatory authority that should be reserved for Congress, state legislatures, and local elected bodies.

“It’s not about public health, it’s about weakening the ability of government to regulate business in general.”

Edward Fallone, associate professor at Marquette University Law School

, which calls itself the “legal version” of the Navy SEAL Team 6, has filed a flurry of covid-related litigation. Among its victories is a ruling that found Democratic Gov. Tony Evers’ declaration of multiple states of emergency for the same event — in this case, the pandemic — was unlawful. It used the threat of litigation to get a Midwest health care system to as a factor in how it allocates covid therapeutics.

The Kansas Justice Institute, whose website indicates it is , persuaded a county-level health officer in that state to on the size of religious gatherings and stopped a school district from after sending letters laying out its legal objections.

Suhr, of the Liberty Justice Center, noted one of his group’s cases underpinned the Supreme Court’s decision crimping the ability of the Occupational Safety and Health Administration to mandate large-business owners to require covid vaccinations or regular testing for employees. The with the legal arm of Louisiana’s on behalf of a grocery store owner who did not want to mandate vaccines for his employees.

Republican attorneys general, meanwhile, have found in covid-related mandates an issue that resonates viscerally with many red-state voters. Louisiana Attorney General Jeff Landry joined a suit against over mask mandates, when the mandate was lifted. Florida Attorney General Ashley Moody sued the Biden administration over strict limits on cruise ships issued by the Centers for Disease Control and Prevention, arguing the CDC had no authority to issue such an order, and after the federal government let the order expire.

Texas Attorney General Ken Paxton the to sue the CDC over its air travel mask mandate. The case was put on hold after a Florida federal district judge in April invalidated the federal government’s transportation mask mandates in a case brought by the Health Freedom Defense Fund, a group focused on “bodily autonomy.” The Biden administration is fighting that ruling.

Missouri Attorney General Eric Schmitt has sued and sent to dozens of school districts over mask mandates, and set up a tips email address where parents could report schools that imposed such mandates. The have been dismissed, but Schmitt has claimed victory, telling KHN “almost all of those school districts dropped their mask mandates.” This year, legislators from his own political party grew so tired of Schmitt’s lawsuits that they from his budget.

“Our efforts have been focused solely on preserving individual liberties and clawing power away from health bureaucrats and placing back into the hands of individuals the power to make their own choices,” Schmitt, who is running for U.S. Senate, said in a written response to KHN questions. “I’m simply doing the job I was elected to do on behalf of all six million Missourians.”

Numerous Republican teamed up and won a Supreme Court decision staying the OSHA vaccine mandate for large employers, building on the legal arguments brought by Liberty Justice Center and others. That decision in the recent Supreme Court case rolling back the Environmental Protection Agency’s authority to regulate the carbon emissions that cause climate change.

A ‘Shared Ecosystem’

Religious liberty groups were drawn into the fray when states early in the pandemic issued broad restrictions on recreational, social, and religious gatherings, sometimes limiting attendance at worship services while keeping open hardware and liquor stores. Although their legal efforts were unsuccessful in the first months of the pandemic, they gained traction after Trump nominee Amy Coney Barrett, a stalwart conservative, was confirmed as a U.S. Supreme Court justice in October 2020, following the death of Justice Ruth Bader Ginsburg, a steadfast liberal.

Minnesota Gov. Tim Walz, a Democrat, rewrote an executive order after receiving a letter from the , a leading religious litigation group, announcing that Catholic and Lutheran churches would be opening with or without permission. In November 2020, the Supreme Court’s newly constituted majority prevented New York from enacting some covid restrictions through a shadow court docket.

“Courts started saying, ‘Show me the proof,’” said , Becket’s president and CEO. “And when you start saying that ‘casinos, good; churches, bad; Wall Street good; synagogue, bad,’ those things at some point require some explanation.”

In February 2021, Barrett joined other conservative justices in ruling against California in South Bay United Pentecostal Church v. Newsom, ending state and local bans on indoor worship services and leaving the state on the hook for $1.6 million in attorney’s fees to the conservative . That April, the high court struck down California and Santa Clara County rules limiting gatherings in private homes that prevented people from participating in at-home Bible study. Plaintiffs’ lawyers arguing that case had clerked for Barrett and Justice Clarence Thomas.

American Juris Link, meanwhile, helped build out for lawyers to reference and connected lawyers working on similar cases, Donnell said.

Peter Bisbee, head of the , a political fundraising machine, sits on American Juris Link’s board; Donnell said the two talk regularly. Bisbee said the groups have no formal connection but share a common cause of shrinking the “expansive regulatory administrative state.”

Liberty Justice Center’s Suhr said litigation groups like his operate in a “shared ecosystem” to curtail government overreach. “I have not been invited to any sort of standing weekly conference call where a bunch of right-wing lawyers get on the call and talk about how they’re going to bring down the public health infrastructure of America,” he said. “That’s not how this works.”

Still, he said, everyone knows everyone else, either through previous jobs or from working on similar cases. Suhr was for former Wisconsin Gov. Scott Walker, a Republican, and a deputy director of the student division of the Federalist Society.

‘It’s Not About Public Health’

No equivalent progressive state litigation network exists to defend the authority housed in government agencies, said , an associate professor at Marquette University Law School and expert in constitutional law.

The difference, he said, is funding: Private donors, corporate interests, and foundations with conservative objectives have the deep pockets and motivation to build coalitions that can strategically chip away at government oversight.

On the other side, he said, is often a county attorney with limited resources.

“It’s almost as if government authority is not getting defended, and it’s almost a one-sided argument,” he said. “It’s not about public health, it’s about weakening the ability of government to regulate business in general.”

Public health is largely a local and state endeavor. And even before the pandemic, many health departments had lost staff amid decades of underfunding. Faced with draining pandemic workloads and legislation from conservative forces aimed at stripping agencies’ powers, health officials often find it difficult to know how they can legally respond to public health threats.

And in states with conservative attorneys general, it can be even more complicated. In Missouri, a circuit court judge ruled last year that local public health officials to issue covid orders, describing them as the “unfettered opinion of an unelected official.”

Following the ruling, Schmitt declined the state health department’s and sent declaring mask mandates and quarantine orders issued on the sole authority of local health departments or schools “null and void.”

“Not being able to work with the schools to quarantine students — that really inhibited our ability to do public health,” said Andrew Warlen, director of Missouri’s Platte County Health Department, which serves the suburbs of Kansas City. “It’s one of the biggest tools we have to be able to contain disease.”

“You destroy government, and you destroy our emergency response powers and police powers — good luck. There will be no one to protect you.”

Connecticut Attorney General William Tong (D-Conn.)

The legal threats have fundamentally changed the calculus for what powers to use when, said , president and CEO of the de Beaumont Foundation, a nonprofit dedicated to improving community health. “Choosing not to use a policy today may mean you can use it a year from now. But if you test the courts now, then you may lose an authority you can’t get back,” he said.

By no means have the blocs won all their challenges. The Supreme Court recently declined to hear a Becket lawsuit on behalf of employees challenging a vaccine mandate for health care workers in New York state that provides no exemption for religious beliefs. For now, the legal principles that for nearly 120 years have allowed governments to require vaccinations in schools and other settings with only limited exemptions remain intact.

Several lawyers associated with these conservative groups told KHN they did not think their work would have a negative effect on public health. “I honestly think the best way for them to preserve the ability to protect the public health is to do it well, and to respect people’s rights while you do it,” said Becket’s Rienzi.

Connecticut Attorney General William Tong, a Democrat, decried the wave of litigation in what he called a “right-wing laboratory.” He said he has not lost a single case where he was tasked with defending public health powers, which he believes are entirely legal and necessary to keep people alive. “You destroy government, and you destroy our emergency response powers and police powers — good luck. There will be no one to protect you.”

As public health powers fade from the headlines, the groups seeking to limit government authority have strengthened bonds and gained momentum to tackle other topics, said , chair of the political science department at Marquette University. “Those connections will just keep thickening over time,” he said.

And the pressure against local governments shows no signs of stopping: Schmitt has set up a similar to his efforts on masking — but for parents to report educators for teaching critical race theory.

This story was produced by , which publishes , an editorially independent service of the .

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Los mosquitos les picaban y acosaban a plena luz del día. Buscó una fuente de agua en la que los insectos se podrían estar reproduciendo, y se fijó en una tubería recién excavada, destinada a drenar el agua del patio trasero hacia la parte delantera. Levantó la tapa y dentro encontró un pequeño charco en la línea de drenaje, que no tenía suficiente pendiente para vaciarse por completo.

Cogió una jeringuilla y sacó agua, sabiendo lo que iba a encontrar: las larvas del Aedes aegypti, una de las mayores amenazas para el ser humano en el planeta.

Ruiz sabía lo que buscaba porque está a cargo de un equipo recién formado que, durante el verano, recorre el norte del condado de Tulare para combatir la invasión del Aedes aegypti, un mosquito capaz de infectar a los humanos con enfermedades mortales como dengue, chikungunya, fiebre amarilla y zika.

Desde que se instaló en California hace menos de una década, Aedes aegypti se ha extendido rápidamente por todo el estado, y su territorio abarca ahora desde el desierto del condado Imperial, en la frontera entre Estados Unidos y México, hasta la ciudad de Redding, en el boscoso condado de Shasta, a unas 750 millas al norte.

Para luchar contra el aegypti, los distritos para el control de mosquitos recurren a las mismas herramientas que utilizaban hace décadas —pesticidas y la retirada de las fuentes de agua—, aunque el cambio climático y las prácticas agrícolas permiten que los mosquitos prosperen en lugares antes inhabitables.

Pero los funcionarios del condado de Tulare esperan que la región sea pronto un campo de pruebas para una nueva tecnología, incluido un mosquito modificado genéticamente, con el objetivo de prevenir el brote de enfermedades que ahora son comunes en regiones del Caribe, América Central y del Sur, donde el Aedes aegypti está muy extendido.

El peligro más inmediato de los mosquitos en el condado de Tulare proviene de un género diferente, el Culex, que suele picar al amanecer y al atardecer y que puede transmitir el virus del Nilo Occidental, la encefalitis de San Luis y el virus de la encefalomielitis equina occidental, todos los cuales pueden ser mortales.

En la última década, California ha registrado más de 4,000 casos de Nilo Occidental y al menos 220 muertes. Los distritos para el control de mosquitos de Tulare han invertido muchos recursos en esa batalla, incluyendo la liberación de una serie de productos químicos, el mantenimiento de un criadero de peces que se alimentan de larvas y, más recientemente, la compra de un dron para transportar pesticidas al interior de los campos de maíz.

Sin embargo, el Aedes aegypti sigue siendo una preocupación creciente y resulta mucho más difícil de combatir.

Para entender esta lucha, primero hay que comprender lo difícil de detectar que es el Aedes aegypti. Los mosquitos pueden poner sus huevos en espacios tan pequeños como un tapón de botella, y las hembras los distribuyen por múltiples lugares; los científicos suelen referirse a sus “hábitats crípticos”.

La mayoría de los huevos de mosquito necesitan agua para sobrevivir, pero los del Aedes aegypti pueden permanecer latentes durante meses, y revivir cuando finalmente llega el agua. Y un mosquito puede picar muchas veces, picando repetidamente a la misma persona o pasando de una a otra. Hasta convertirse en una amenaza letal si una de esas personas resulta ser portadora de dengue o de algún otro virus.

En un mundo cada vez más globalizado, las personas viajan a lugares donde el dengue es endémico y lo traen a Estados Unidos. Si un mosquito les pica, la enfermedad puede propagarse localmente. Eso es lo que ocurrió en los Cayos de Florida en 2020, donde más de 70 personas se infectaron antes de que se detuviera el brote.

California ha evitado hasta ahora los brotes locales de las enfermedades que transmite el Aedes aegypti. Pero ha importado casos —California ha registrado de dengue importado este año— y con la población de mosquitos en aumento, los expertos dicen que los brotes son solo cuestión de tiempo.

Aedes aegypti es un viajero frecuente, que recorre el mundo en la carga. Sin duda, se ha introducido en California millones de veces. Pero no fue hasta hace poco que se afianzó, dijo Chris Barker, profesor asociado de patología, microbiología e inmunología en la Universidad de California-Davis. Se detectó por primera vez en 2013 en tres ciudades de California: Menlo Park, Clovis y Madera.

Hoy, el Aedes aegypti se ha extendido por más de 200 ciudades de California y 22 condados. Y ha puesto a prueba a los distritos para el control de mosquitos. “Ha supuesto mucho trabajo extra, personal extra y demanda financiera extra”, explicó Barker. “E independientemente del riesgo de enfermedades, un gran problema es la molestia de las picaduras”.

Debido a la amenaza que suponen los mosquitos, cuando el Distrito de Control de Vectores y Mosquitos del Delta, donde trabaja Ruiz, detectó el aegypti en 2014, el distrito se apresuró a erradicar la amenaza. Su método de erradicación exigía buscar en cada rincón de la zona donde el Aedes aegypti había fijado su residencia y limpiar las fuentes de agua varias veces a la semana.

Según la subdirectora del distrito, Mir Bear-Johnson, la gente se sintió tan molesta por la dura campaña de erradicación que pasaron casi cinco años antes de que esa comunidad volviera a pedir ayuda. Lo cual es un problema, porque el distrito depende en parte de los informes de los residentes para saber dónde están los mosquitos.

La erradicación también fue pasajera. En 2015 se reintrodujo el Aedes aegypti, y esta vez los feroces mordedores se extendieron por Visalia, la mayor ciudad de la zona. Dado que el Aedes aegypti puede encontrarse ahora en todo el Valle Central, la erradicación ya no parece una opción, señaló Mustapha Debboun, un entomólogo que se trasladó desde el condado de Harris, Texas, en marzo de 2020 para dirigir el distrito del Delta.

Los mosquitos Aedes aegypti de la zona también son ampliamente resistentes a los piretroides, la familia de productos químicos más utilizados para matar a los mosquitos adultos. Los piretroides son muy utilizados por las empresas agrícolas de la zona, lo que probablemente contribuya a lo que Barker describió como una resistencia de casi el 100%.

Por eso Debboun y sus colegas están interesados en el mosquito modificado genéticamente. Su esperanza es que estos mosquitos reduzcan el número de Aedes aegypti salvajes, al cruzarse y producir una descendencia de corta vida.

La Agencia de Protección Ambiental de Estados Unidos (EPA) aprobó recientemente un ensayo en Tulare del mosquito transgénico, elaborado por una empresa llamada Oxitec. La empresa afirma que su producto libera solo mosquitos macho, que a diferencia de las hembras no pican. Los mosquitos han sido modificados genéticamente para ser portadores de un gen “autolimitante” que se transmite durante la cría y que, en teoría, impide que las crías sobrevivan hasta la edad adulta. Ya se han liberado en varios lugares, como Brasil y las Islas Caimán.

También se liberaron en los Cayos de Florida el año pasado. Allí, Oxitec se enfrentó a la oposición de algunos propietarios preocupados por los riesgos de liberar plagas genéticamente modificadas en la naturaleza. Los funcionarios locales pusieron el tema en la votación de 2016, y los residentes del condado, que para entonces se habían enfrentado tanto al dengue como al zika, votaron a favor.

Ahora, Oxitec y el distrito de mosquitos del Delta aguardan la autorización del Departamento de Regulación de Pesticidas de California para liberar los insectos en la naturaleza. El trabajo sería financiado por Oxitec, dijo Debboun, con la ayuda de su personal.

El objetivo es aprovechar las investigaciones anteriores, que demuestran que el Aedes aegypti transgénico reduce temporalmente la población de mosquitos silvestres, pero ha dejado a los científicos con interrogantes sobre los posibles efectos en el medio ambiente y sobre la eficacia del esfuerzo a largo plazo para reducir las enfermedades. Una de las incógnitas es si los mosquitos de Oxitec son realmente incapaces de producir una descendencia viable con las hembras silvestres.

Otra cuestión, apuntó Barker, el experto de la UC-Davis, es qué ocurre cuando los mosquitos de Oxitec se encuentran con la tetraciclina en la naturaleza. La tetraciclina es un antibiótico que se utiliza habitualmente para controlar las infecciones en la ganadería y la agricultura, dos elementos que abundan en el Valle Central.

Los mosquitos Oxitec se crían con una especie de interruptor que desactiva el gen autolimitador cuando entran en contacto con la tetraciclina. En el laboratorio, este interruptor permite a la empresa criar los mosquitos transgénicos. Si se activa en la naturaleza, la preocupación es que las crías de los mosquitos no mueran.

Por otra parte, Barker espera que California haga un seguimiento independiente del experimento. Es uno de los investigadores a los que les preocupa dejar ese análisis en manos de una empresa privada que depende de los beneficios. “Si una fuente independiente y la empresa están de acuerdo cuando se muestran los resultados finales, eso tiene mucho más poder y mucho más potencial para el futuro”, añadió Barker.

Rajeev Vaidyanathan, director de operaciones en Estados Unidos de Oxitec, expresó que el Distrito de Control de Vectores y Mosquitos del Delta de Tulare era uno de los distritos interesados en acoger el ensayo. Uno de los argumentos fue el entusiasmo de Debboun por las nuevas tecnologías.

Debboun había ayudado a realizar una prueba en Houston de un producto llamado MosquitoMate, que libera mosquitos macho infectados con la bacteria Wolbachia. Cuando los mosquitos MosquitoMate se reproducen con hembras silvestres, producen huevos que no eclosionan. Esos mosquitos también se probaron en el condado de Fresno en 2018 y 2019 y condujeron a una reducción del 95% en las hembras de Aedes aegypti, según . Sin embargo, ese distrito comunicó a que no tenía el dinero para continuar el proyecto por su cuenta.

“Estamos ante opciones fantásticas y brillantes”, indicó Eva Buckner, profesora de la Universidad de Florida que asesora a los distritos para el control de mosquitos de Florida. “Creo que tienen mucho potencial”. A Buckner le gustaría saber cuál sería la relación coste-beneficio para un uso generalizado por parte de las agencias gubernamentales, en comparación con otras intervenciones, una cuestión que la investigación de Tulare podría ayudar a determinar. E independientemente del precio, advirtió, no existe una bala de plata contra los mosquitos, que han perdurado en la Tierra durante millones de años.

Oxitec quería probar su tecnología en la árida California Central, señaló Vaidyanathan, porque así podría demostrar que puede funcionar en todo el suroeste invadido por el Aedes aegypti. Oxitec espera que sus mosquitos se vendan finalmente a los distritos para el control de mosquitos de Estados Unidos y directamente a los consumidores estadounidenses.

Esa opción ya está disponible en Brasil, a través de un servicio de suscripción para consumidores que cuesta entre $10 y $30 al mes. En el prototipo estadounidense, los mosquitos vendrían en una caja hexagonal decorada con los insectos. Si todo va según lo previsto, los consumidores solo tendrían que añadir agua y los mosquitos cobrarían vida.

esta historia fue producida por KHN, que publica , un servicio editorialmente independiente de la .

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Mosquitoes bit and harassed them in broad daylight. He looked around, trying to find a water source where they were breeding, and noticed a freshly dug pipe, meant to drain water from the backyard to the front. He lifted its cap and inside found a small puddle in the drainage line, which didn’t have enough slope to fully empty.

He grabbed a turkey baster and drew water, already knowing what he would find: the larvae of Aedes aegypti, one of the greatest threats to humans on the planet.

Ruiz knew what he was looking for because he is in charge of a newly formed team that spends the summer months traveling around northern Tulare County to combat the invasion of Aedes aegypti, a mosquito capable of infecting humans with the deadly diseases of dengue, chikungunya, yellow fever, and Zika.

Since gaining a foothold in California less than a decade ago, Aedes aegypti has spread quickly across the state, its territory now ranging from the desert terrain of Imperial County at the U.S.-Mexico border to the city of Redding in woody Shasta County, about 750 miles north.

To combat aegypti, mosquito control districts rely on the same tools they were using decades ago — pesticides and rooting out water sources — even as climate change and agricultural practices are allowing the mosquitoes to thrive in places previously uninhabitable.

But Tulare County officials hope the region will soon be a testing ground for a new generation of technology, including a genetically modified mosquito, as they try to prevent the kind of disease outbreaks now common in regions of the Caribbean and Central and South America where Aedes aegypti is widespread.

The most immediate mosquito danger in Tulare County comes from a different genus, Culex, a type that typically bites at dawn and dusk and can carry West Nile virus, St. Louis encephalitis, and western equine encephalomyelitis virus, all of which can be fatal. Over the past decade, California has registered more than 4,000 cases of West Nile and at least 220 deaths. Tulare’s mosquito control districts have poured extensive resources into that battle, including releasing a range of chemicals, maintaining a hatchery for larvae-eating fish, and, most recently, buying a drone to ferry pesticides deep into cornfields.

Aedes aegypti, however, is a growing concern, and much harder to combat.

To understand this fight, you first have to understand just how stealthy Aedes aegypti is. The mosquitoes can lay eggs in spaces as small as a bottle cap, and females spread their eggs across multiple locations — scientists often refer to their “cryptic habitats.” Most other types of mosquito eggs need water to survive, but Aedes aegypti’s can lie dormant for months, springing to life when water eventually does come. And one mosquito can bite many times over, snacking repeatedly on the same human or moving from one to the next. They become a lethal threat if one of those people happens to be carrying dengue or some other virus.

In an increasingly global world, people regularly travel to places where dengue is endemic and bring it back to the U.S. If a mosquito bites them, the illness can spread locally. That’s what happened in the Florida Keys in 2020, and more than 70 people were infected before the outbreak was stopped.

California so far has avoided local outbreaks of the diseases carried by Aedes aegypti. But it does import cases — California has registered of imported dengue this year — and with the mosquito population growing, experts say it’s likely only a matter of time.

Aedes aegypti is a frequent flyer, traveling the world in cargo. It no doubt has been introduced into California millions of times. But it wasn’t until recently that it took hold, said Chris Barker, an associate professor of pathology, microbiology, and immunology at University of California-Davis. It was first detected in 2013 in three California cities: Menlo Park, Clovis, and Madera.

Today, Aedes aegypti has spread across more than 200 California cities and 22 counties. And it has strained mosquito control districts. “It’s been a lot of extra work, extra staffing, extra financial demand,” said Barker. “And regardless of disease risk, a huge issue is the nuisance biting.”

Because of the threat the mosquitoes pose, when aegypti was detected in 2014 by the Delta Mosquito and Vector Control District, where Ruiz works, the district rushed to stamp out the menace. Its eradication method required searching every nook and cranny of the area where Aedes aegypti had taken up residence and cleaning out water sources multiple times a week. People were so annoyed by the full-court press, said the district’s assistant manager, Mir Bear-Johnson, that nearly five years passed before that community reached out again. Which was a problem, because the district partly relies on reports from residents to know where mosquitoes are.

The eradication was also short-lived. In 2015, Aedes aegypti was reintroduced, and this time the ferocious biters spread out across Visalia, the area’s largest city. Because Aedes aegypti can now be found all around the Central Valley, eradication no longer feels like an option, said Mustapha Debboun, an entomologist who moved from Harris County, Texas, in March 2020 to lead the Delta district.

Aedes aegypti mosquitoes in the area are also broadly resistant to pyrethroids, the family of chemicals most frequently used to kill adult mosquitoes. Pyrethroids are in heavy use among the area’s agricultural companies, likely contributing to what Barker described as nearly 100% resistance.

Which is why Debboun and colleagues are interested in the genetically modified mosquito. Their hope is that the engineered mosquitoes reduce the number of wild Aedes aegypti as they interbreed and produce short-lived offspring.

The U.S. Environmental Protection Agency recently approved a trial in Tulare of the engineered mosquito, which is made by a company called Oxitec. The company says its latest product releases only male mosquitoes, which unlike females do not bite. The mosquitoes are genetically modified to carry a “self-limiting” gene that is passed on during breeding and theoretically prevents the offspring from surviving to adulthood. They have been released in several places, including Brazil and the Cayman Islands.

They also were released in the Florida Keys last year. There, Oxitec faced pushback from some homeowners concerned about the unanticipated risks of releasing genetically modified pests into the wild. Local officials put the issue on the 2016 ballot, and county residents, who by then had confronted both dengue and Zika, voted to go forward.

Now, Oxitec and the Delta mosquito district are waiting for permission from the California Department of Pesticide Regulation to launch the insects. The work would be funded by Oxitec, Debboun said, with operational assistance from his staff.

The goal is to build on the earlier research, which shows that the modified Aedes aegypti temporarily reduces the wild mosquito population but has left scientists with questions about the broader effects on the environment and how well the effort works in the long run to reduce disease. Among the unknowns is whether the Oxitec mosquitoes are indeed incapable of producing viable offspring with wild females.

Another question, said Barker, the UC-Davis expert, is what happens when Oxitec’s mosquitoes encounter tetracycline in the wild. Tetracycline is an antibiotic commonly used to control infection in livestock and agriculture, both of which are found in abundance in the Central Valley. Oxitec mosquitoes are bred with a sort of off-switch that shuts down the self-limiting gene when they come into contact with tetracycline. In the lab, this off-switch allows the company to breed the engineered mosquitoes. If it is triggered in the wild, the concern is that the mosquitoes’ offspring wouldn’t die out.

On a broader level, Barker said, he hopes California will independently track the experiment. He is among the researchers concerned about leaving that analysis in the hands of a private company that stands to benefit. “If an independent source and the company are in agreement when all the results are done, that has much more power and much more potential for the future,” Barker said.

Rajeev Vaidyanathan, director of U.S. operations for Oxitec, said Tulare’s Delta Mosquito and Vector Control District was among several districts interested in hosting the trial. Among the selling points was Debboun’s enthusiasm for new technologies.

Debboun previously helped run a trial in Houston of a product called MosquitoMate, which releases male mosquitoes infected with the bacteria Wolbachia. When the MosquitoMate mosquitoes breed with wild females, they produce eggs that do not hatch. Those mosquitoes were also tested in Fresno County in 2018 and 2019 and led to a 95% reduction in female Aedes aegypti, according to . Even so, that mosquito district it didn’t have the money to continue the project on its own.

“These are the fantastic, glittery options,” said Eva Buckner, a University of Florida assistant professor who advises Florida’s mosquito control districts. “I think they have a lot of potential.” She wants to know what the cost-benefit ratio would be for widespread use by government agencies compared with other interventions — a question the Tulare research could help determine. And regardless of price, she cautioned, there’s not going to be a silver bullet for mosquitoes, which have endured on Earth for millions of years.

Oxitec wanted to test its technology in arid Central California, Vaidyanathan said, because it could show it can work throughout the Aedes aegypti-invaded Southwest. Oxitec hopes its mosquitoes eventually will be sold to mosquito control districts in the U.S., and directly to American consumers. That option is already available in Brazil, via a consumer subscription service that costs $10 to $30 a month. In the U.S. prototype, the mosquitoes would come in a hexagonal box decorated with playful insects. If all goes as planned, consumers would just add water, and the mosquitoes would spring to life.

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In 2012, 332 babies were born infected with the disease. In 2021, that number had climbed nearly sevenfold, to at least 2,268, according to preliminary estimates. And 166 of those babies died.

About 7% of babies diagnosed with syphilis in recent years have died; thousands of others born with the disease have faced problems that include brain and bone malformations, blindness, and organ damage.

For public health officials, the situation is all the more heartbreaking, considering that congenital syphilis rates reached near-historic modern lows from 2000 to 2012 amid ambitious prevention and education efforts. By 2020, following a sharp erosion in funding and attention, the nationwide case rate was more than seven times that of 2012.

“The really depressing thing about it is we had this thing back in the year 2000,” said William Andrews, a public information officer for Oklahoma’s sexual health and harm reduction service. “Now it’s back with a vengeance. We are really trying to get the message out that sexual health is health. It’s nothing to be ashamed of.”

Even as caseloads soar, the CDC budget for sexually transmitted disease prevention — the primary funding source for most public health departments — has been largely stagnant for two decades, its purchasing power dragged even lower by inflation.

Tuesday’s trends provides official data on congenital syphilis cases for 2020, as well as preliminary case counts for 2021 that are expected to increase. CDC data shows that congenital syphilis rates in 2020 continued to climb in already overwhelmed states like Texas, California, and Nevada and that the disease is now present in almost every state in the nation. All but three states — Maine, New Hampshire, and Vermont — reported congenital syphilis cases in 2020.

From 2011 through 2020, congenital syphilis resulted in 633 documented stillbirths and infant deaths, according to the new CDC data.

Preventing congenital syphilis — the term used when syphilis is transferred to a fetus in utero — is from a medical standpoint exceedingly simple: If a pregnant woman is diagnosed at least a month before giving birth, just a few shots of penicillin have a near-perfect cure rate for mother and baby. But funding cuts and competing priorities in the nation’s fragmented public health care system have vastly narrowed access to such services.

The reasons pregnant people with syphilis go undiagnosed or untreated vary geographically, according to data collected by states and analyzed by the CDC.

In Western states, the largest share of cases involve women who have received little to no prenatal care and aren’t tested for syphilis until they give birth. Many have substance use disorders, primarily related to methamphetamines. “They’ve felt a lot of judgment and stigma by the medical community,” said Dr. Stephanie Pierce, a maternal fetal medicine specialist at the University of Oklahoma who runs a clinic for women with high-risk pregnancies.

In Southern states, a found that the largest share of congenital syphilis cases were among women who had been tested and diagnosed but hadn’t received treatment. That year, among Black moms who gave birth to a baby with syphilis, 37% had not been treated adequately even though they’d received a timely diagnosis. Among white moms, that number was 24%. Long-standing racism in medical care, poverty, transportation issues, poorly funded public health departments, and crowded clinics whose employees are too overworked to follow up with patients all contribute to the problem, according to infectious disease experts.

Doctors are also noticing a growing number of women who are treated for syphilis but reinfected during pregnancy. Amid rising cases and stagnant resources, some states have focused disease investigations on pregnant women of childbearing age; they can no longer prioritize treating sexual partners who are also infected.

Dr. Eric McGrath, a pediatric infectious disease specialist at Wayne State University School of Medicine in Detroit, said that he’d seen several newborns in recent years whose mothers had been treated for syphilis but then were reexposed during pregnancy by partners who hadn’t been treated.

Treating a newborn baby for syphilis isn’t trivial. Penicillin carries little risk, but delivering it to a baby often involves a lumbar puncture and other painful procedures. And treatment typically means keeping the baby in the hospital for 10 days, interrupting an important time for family bonding.

McGrath has seen a couple of babies in his career who weren’t diagnosed or treated at birth and later came to him with full-blown syphilis complications, including full-body rashes and inflamed livers. It was an awful experience he doesn’t want to repeat. The preferred course, he said, is to spare the baby the ordeal and treat parents early in the pregnancy.

But in some places, providers aren’t routinely testing for syphilis. Although testing at some point during pregnancy, as of last year just 14 required it for everyone in the third trimester. The CDC recommends third-trimester testing in areas with high rates of syphilis, a growing share of the U.S.

After Arizona declared a statewide outbreak in 2018, state health officials wanted to know whether widespread testing in the third trimester could have prevented infections. Looking at 18 months of data, analysts found that nearly three-quarters of the more than 200 pregnant women diagnosed with syphilis in 2017 and the first half of 2018 got treatment. That left 57 babies born with syphilis, nine of whom died. The analysts estimated that a third of the infections could have been prevented with testing in the third trimester.

Based on the numbers they saw in those 18 months, officials estimated that screening all women on Medicaid in the third trimester would cost the state $113,300 annually, and that treating all cases of syphilis that screening would catch could be done for just $113. Factoring in the hospitalization costs for infected infants, the officials concluded the additional testing would save the state money.

And yet prevention money has been hard to come by. Taking inflation into account, CDC prevention funding for STDs has fallen 41% since 2003, according to an analysis by the National Coalition of STD Directors. That’s even as cases have risen, leaving public health departments saddled with more work and far less money.

Janine Waters, STD program manager for the state of New Mexico, has watched the unraveling. When Waters started her career more than 20 years ago, she and her colleagues followed up on every case of chlamydia, gonorrhea, and syphilis reported, not only making sure that people got treatment but also getting in touch with their sexual partners, with the aim of stopping the spread of infection. In a 2019 interview with KHN, she said her team was struggling to keep up with syphilis alone, even as they registered with dread congenital syphilis cases surging in neighboring Texas and Arizona.

By 2020, New Mexico had the highest rate of congenital syphilis in the country.

The covid-19 pandemic drained the remaining resources. across the country discontinued STD fieldwork altogether, diverting their resources to covid. In California, which for years has struggled with high rates of congenital syphilis, three-quarters of local health departments dispatched of their STD staffers to work on covid.

As the pandemic ebbs — at least in the short term — many public health departments are turning their attention back to syphilis and other diseases. And they are doing it with reinforcements. Although the Biden administration’s remains flat, the American Rescue Plan Act included $200 million to help health departments boost contact tracing and surveillance for covid and other infectious diseases. Many departments are funneling that money toward STDs.

The money is an infusion that state health officials say will make a difference. But when taking inflation into account, it essentially brings STD prevention funding back to what it was in 2003, said Stephanie Arnold Pang of the National Coalition of STD Directors. And the American Rescue Plan money doesn’t cover some aspects of STD prevention, including clinical services.

The coalition wants to revive dedicated STD clinics, where people can drop in for testing and treatment at little to no cost. Advocates say that would fill a void that has plagued treatment efforts since public clinics in the wake of the 2008 recession.

Texas, battling its own pervasive outbreak, will use its share of American Rescue Plan money to fill 94 new positions focused on various aspects of STD prevention. Those hires will bolster a range of measures the state put in place before the pandemic, including an updated data system to track infections, review boards in major cities that examine what went wrong for every case of congenital syphilis, and a requirement that providers test for syphilis during the third trimester of pregnancy. The suite of interventions seems to be working, but it could be a while before cases go down, said Amy Carter, the state’s congenital syphilis coordinator.

“The growth didn't happen overnight,” Carter said. “So our prevention efforts aren't going to have a direct impact overnight either.”

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Como operador de una planta de servicios públicos en Modesto, una ciudad de casi un cuarto de millón de habitantes en el Valle de San Joaquín, en California, Green ayuda a mantener el flujo de las alcantarillas de la ciudad y el tratamiento de sus aguas residuales a niveles de seguridad aceptables.

Pero en los últimos meses, Green y sus colegas han sumado a sus tareas la investigación de covid-19.

En la planta de tratamiento donde convergen las tuberías de alcantarillado de Modesto, se filtran los artículos más grandes, desde toallitas húmedas para bebés que no se deben tirar por el inodoro, hasta piezas de automóviles. Lo que queda se lleva a una tina gigante, donde los sólidos se depositan en el fondo.

Los investigadores extraen muestras de ese lodo oscuro de 3 pies de profundidad en busca del SARS-CoV-2, el virus que causa covid.

En todo el país, académicos, empresas privadas, departamentos de salud pública y operadores de plantas de tratamiento de aguas residuales han estado trabajando para perfeccionar esta nueva herramienta de salud pública, con usos que podrían ir mucho más allá de covid.

La vigilancia de aguas residuales no es un concepto nuevo, pero la escala y el alcance de la pandemia actual han hecho que la técnica saltara los estrechos muros de la investigación académica para un uso público más amplio, como una herramienta crucial para el seguimiento a nivel comunitario de los aumentos repentinos de casos de covid, y las nuevas variantes.

La vigilancia de las aguas residuales está resultando tan útil que muchos investigadores y funcionarios de salud pública dicen que debería convertirse en una práctica estándar en el seguimiento de enfermedades infecciosas, como ya ocurre .

Pero si eso sucede, y las comunidades  que puedan implementarla, depende de la capacidad de la nación para ampliar enormemente el enfoque y hacerlo viable tanto en comunidades ricas como pobres.

Al igual que muchas otras herramientas de salud pública, las pruebas de aguas residuales comenzaron primero en las grandes ciudades y campus universitarios con acceso a experiencia en investigación, equipos y dinero. El proyecto de Modesto ofrece una visión de los desafíos y oportunidades que implica hacer que esta tecnología esté disponible en comunidades con recursos más limitados.

“Se deberían inyectar más recursos en lugares que están desatendidos, ya que tienen una carga desproporcionada de enfermedad”, dijo Colleen Naughton, profesora de ingeniería en la Universidad de California-Merced que está ayudando a establecer pruebas en Merced, Modesto y en los pueblos agrícolas alrededor del Valle Central.

William Wong, director de servicios públicos de Modesto, supervisa las operaciones de agua y alcantarillado. Desde principios de la pandemia, ha querido monitorear las aguas residuales de la ciudad en busca de SARS-CoV-2. Es una extensión natural de su trabajo; la eliminación segura de los excrementos es la base tanto de la salud pública como de la sociedad moderna. “Siempre consideramos que lo que hacemos es proteger la salud pública”, dijo Wong.

Para la vigilancia de covid, las aguas residuales no están sujetas a las inconsistencias complicadas que vienen con las pruebas del coronavirus en humanos. La escasez de pruebas de covid ha sido un problema persistente durante la pandemia, derivada tanto de las deficiencias de la cadena de suministro como de la amplia variación en la respuesta de los gobiernos locales.

Los largos retrasos en los resultados de las pruebas pueden retrasar semanas a los funcionarios de salud en la detección y el seguimiento de las tendencias de la infección.

Más recientemente, han proliferado las pruebas caseras, cuyos resultados rara vez llegan a los departamentos de salud pública. Y para las personas que viven en comunidades de bajos recursos, existen incentivos para no hacerse ninguna prueba, dijo la doctora Julie Vaishampayan, oficial de salud del condado de Stanislaus, donde se encuentra Modesto.

Una prueba positiva puede ser un gran problema para las personas que no pueden ausentarse del trabajo o mantener a sus hijos fuera de la escuela.

Por el contrario, la vigilancia de aguas residuales es una empresa efectiva y de presupuesto relativamente bajo, menos dependiente del capricho humano. Todo el mundo hace caca, y alrededor del 80% de los estadounidenses depositan sus sólidos en un sistema de alcantarillado.

Docenas de proyectos de investigación en todo el país han demostrado que el método se puede usar para rastrear con precisión las tendencias de covid a lo largo del tiempo. Y debido a que las personas arrojan covid en sus heces antes de mostrar síntomas, los aumentos y disminuciones en las infecciones a nivel de vecindario y comunidad pueden aparecer en el lodo varios días antes de que aparezcan en las pruebas.

Otros problemas de salud también dejan su huella en el popó. Investigaciones recientes han encontrado que la vigilancia de aguas residuales es un método confiable para y la .

Los Centros para el Control y la Prevención de Enfermedades (CDC) le dijeron a KHN que pronto lanzarán estudios piloto para ver si las aguas residuales pueden revelar tendencias en infecciones resistentes a los antibióticos, enfermedades transmitidas por los alimentos y , una infección por hongos.

Hay lugares donde las aguas residuales pueden no ser una excelente manera de controlar el covid. Eso incluye comunidades sin alcantarillado; áreas con aguas residuales industriales, donde las técnicas de tratamiento pueden “esconder” el virus; y comunidades con grandes fluctuaciones de población, como los centros de esquí.

Pero cuando están disponibles, los datos ya han demostrado ser poderosos. Durante la oleada invernal causada por omicron, California, Colorado, Nueva York y Texas a través de las aguas residuales. Los funcionarios de salud del Valle Central han dicho que el monitoreo de las aguas residuales les ha asegurado que las disminuciones en los casos de covid son reales y no un reflejo distorsionado de las disminuciones en las pruebas informadas.

En Modesto, las aguas residuales también revelaron que la variante delta siguió siendo la cepa dominante hasta bien entrado enero, semanas después de que omicron conquistara otros lugares. Eso fue importante, dijo Vaishampayan, porque algunos de los tratamientos disponibles que no funcionan para omicron son efectivos contra delta.

Su departamento les dijo a los médicos locales que siguieran usando la gama completa de medicamentos, incluso después de que otras áreas habían reducido su arsenal de tratamientos.

Tener investigadores académicos que pusieran en marcha el programa hizo posible el esfuerzo, dijo Kristynn Sullivan, epidemióloga jefe del condado de Merced, donde se están estableciendo dos sitios de prueba.

“Estábamos interesados ​​en él teóricamente, pero absolutamente no habríamos tenido los recursos para perseguirlo”, dijo Sullivan. “Lo que esto nos permitió hacer es entrar en algo que es vanguardista, que es emocionante, con una participación bastante limitada”.

Agregó que por primera vez en su carrera de salud pública el dinero no es un impedimento. Lo que más le falta es gente: además de tener poco personal después de años de recortes presupuestarios, es difícil reclutar trabajadores para el área, dijo Sullivan, un problema compartido por los departamentos de salud rurales de todo el país.

Y la configuración requirió un esfuerzo considerable, dijo Naughton, el profesor de ingeniería que ayudó a construir programas de vigilancia en el norte del Valle Central. Involucró la coordinación del equipo de muestreo; hacer arreglos para refrigeradores, hieleras e hielo para conservar las muestras; navegar por complejo papeleo; coordinar mensajeros; y los análisis complejos necesarios para transformar los resultados del muestreo de lodos en datos de infección a nivel de población.

En , Naughton y sus colegas encontraron que las áreas urbanas de California tienen muchas más probabilidades de tener monitoreo de aguas residuales que las comunidades rurales. A través de la red de vigilancia que está estableciendo con sus colegas en UC-Davis, que abarca ocho nuevos sitios del Valle Central, Naughton espera ayudar a cambiar eso. La se paga con fondos de subvenciones estatales y federales, dinero de la Ley CARES y donaciones filantrópicas.

Casi 700 sitios en las tres cuartas partes de los estados ahora están informando datos al Sistema Nacional de Vigilancia de Aguas Residuales establecido por los CDC, incluidos más de 30 sitios de California. En muchos estados, sin embargo, los datos son escasos y esporádicos.

Aún así, tener esa red nacional será fundamental en el futuro, dijeron los funcionarios de salud, ya que los investigadores traducen los datos sin procesar en información utilizable y comparan las tendencias entre regiones. Pero se necesitará una voluntad pública sostenida y algunas actualizaciones para que siga siendo útil.

El programa de los CDC está financiado hasta 2025. La iniciativa del Valle Central tiene un año de financiación, aunque los investigadores esperan continuar con el proyecto hasta al menos 2023.

En Modesto, los trabajadores de servicios públicos dijeron que están felices de aprovechar el suministro de popó mientras haya financiación. “Me encanta ver cómo se utilizan los datos”, dijo Ben Koehler, superintendente de control de calidad del agua y operador principal de la planta de la ciudad. “La gente quiere saber que su trabajo tiene un propósito”.

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A utilities plant operator in Modesto, a city of nearly a quarter-million people in California’s San Joaquin Valley, Green helps keep the city’s sewers flowing and its wastewater treated to acceptable levels of safety. But in recent months, he and his colleagues have added covid-19 sleuthing to their job description.

At the treatment plant where Modesto’s sewer pipes converge, larger items, ranging from not-supposed-to-be-flushed baby wipes to car parts, are filtered out. What remains is ushered into a giant vat, where the solids settle to the bottom. It’s from that 3-feet-deep dark sludge that researchers siphon samples in their search for SARS-CoV-2, the virus that causes covid.

Across the country, academics, private companies, public health departments, and sewage plant operators have been working to hone a new public health tool, one with uses that could reach well beyond covid. Wastewater surveillance is not a new concept, but the scale and scope of the current pandemic have vaulted the technique over the narrow walls of academic research to broader public use as a crucial tool for community-level tracking of covid surges and variants.

Sewage surveillance is proving so useful that many researchers and public health officials say it should become standard practice in tracking infectious diseases, as is already the case in . But whether that happens — and which communities get access — depends on the nation’s ability to vastly scale up the approach and make it viable in communities rich and poor.

Like many other public health tools, wastewater testing initially took off in big cities and university towns with access to research expertise, equipment, and money. The Modesto project offers a glimpse of the challenges and opportunities involved in making this technology available in communities with more limited resources.

“You should be injecting more resources in places that are underserved since they have the disproportionate burden of disease,” said Colleen Naughton, an engineering professor at the University of California-Merced who is helping set up testing in Merced, Modesto, and surrounding Central Valley farm towns.

William Wong, director of utilities for Modesto, oversees water and sewage operations. Since early in the pandemic, he’s wanted to monitor the city’s sewage for SARS-CoV-2. It’s a natural extension of his work; the safe disposal of excrement is a foundation of both public health and modern society. “We always viewed what we do as protecting the public health,” Wong said.

For covid surveillance, wastewater isn’t subject to the tricky inconsistencies that come with testing for the coronavirus in humans. Covid testing shortages have been a persistent problem throughout the pandemic, stemming both from supply-chain shortfalls and wide variation in local governments’ response. Long delays in test results can leave health officials weeks behind in detecting and monitoring infection trends.

More recently, at-home tests, whose results rarely find their way to public health departments, have proliferated. And for people living in lower-resource communities, there are incentives not to test at all, said Dr. Julie Vaishampayan, the health officer for Stanislaus County, where Modesto is located. A positive test can be a huge problem for people who can’t take time off work or keep their kids out of school.

By contrast, sewage surveillance is an effective and relatively low-budget enterprise, less reliant on human whim. Everyone poops, as the saying goes, and around 80% of Americans deposit their solids into a sewer system.

Dozens of research projects around the country have shown that the method can be used to accurately track covid trends over time. And because people shed covid in their feces before they show symptoms, upticks and drop-offs in neighborhood- and community-level infections can appear in sludge several days before they show up in tests.

Other health issues leave their mark in poop as well. Recent research has found that wastewater surveillance is a reliable method for and the . The Centers for Disease Control and Prevention told KHN it will soon launch pilot studies to see whether sewage can reveal trends in antibiotic-resistant infections, foodborne illnesses, and , a fungal infection.

There are places where sewage may not be a great way to keep tabs on covid. That includes communities without sewers; areas with industrial sewage, where treatment techniques can mask the virus; and communities with huge fluctuations in population, such as ski towns.

But where available, the data has already proven powerful. During the winter surge caused by omicron, California, Colorado, New York, and Texas the variant via sewage. Central Valley health officials have said that sewage monitoring has assured them that declines in covid cases are real, and not a distorted reflection of declines in reported testing.

In Modesto, wastewater also revealed that the delta variant remained the dominant strain well into January, weeks after omicron had taken over elsewhere. That was important, Vaishampayan said, because some of the available treatments that don’t work for omicron are effective against delta. Her department told local doctors to keep using the full range of medicines, even after other areas had narrowed their treatment arsenal.

Having academic researchers get the program up and running made the endeavor possible, said Kristynn Sullivan, chief epidemiologist for Merced County, where two testing sites are being set up. “We were interested in it theoretically, but absolutely would not have had the resources to pursue it,” said Sullivan. “What this allowed us to do is step into something that is cutting-edge, that is exciting, with fairly limited involvement.”

For the first time in her public health career, Sullivan said, money is not the department’s limitation. What it lacks most is people: In addition to being short-staffed after years of budget cuts, it’s hard to recruit workers to the area, Sullivan said, a problem shared by rural health departments around the nation.

And the setup took considerable effort, said Naughton, the engineering professor helping build surveillance programs around the northern Central Valley. It involved coordinating sampling equipment; arranging for refrigerators, coolers, and ice to preserve the samples; navigating paperwork logjams; coordinating couriers; and the complex analyses needed to transform sludge sampling results into population-level infection data.

In a , Naughton and colleagues found that urban areas of California are much more likely to have wastewater monitoring than rural communities. Through the surveillance network she is setting up with colleagues at UC-Davis, encompassing eight new Central Valley sites, Naughton hopes to help change that. is paid for with funds from state and federal grants, CARES Act money, and philanthropic donations.

Nearly 700 sites in three-quarters of the states are now reporting data to the set up by the CDC, including more than 30 California sites. In many states, however, the data is sparse and sporadic. And experts worry the CDC’s dashboard can be misinterpreted because it reflects percentage changes in virus detection with only .

Still, having that national network will be critical going forward, said health officials, as researchers translate the raw data into usable information and compare trends across regions. But it will take sustained public will and some upgrades to keep it useful, a reality that has kept them from getting too excited about its prospects.

The CDC program is funded through 2025. The Central Valley initiative has one year of funding, though researchers hope to continue the project through at least 2023.

In Modesto, utility workers said they are happy to tap the poop supply for as long as the funding flows. “I love seeing the data used,” said Ben Koehler, water quality control superintendent and chief plant operator for the city. “People want to know that their work has purpose.”

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In a matter of days, Lags Medical, a sprawling network of privately owned pain clinics serving more than 20,000 patients throughout the state’s Central Valley and Central Coast, would shut its doors. Its patients, most of them working-class people reliant on government-funded insurance, were left without ready access to their medical records or handoffs to other physicians. Many patients were dependent on opioids to manage the pain caused by a debilitating disease or injury, according to that state health officials emailed to area physicians. They were sent off with one final 30-day prescription, and no clear path for how to handle the agony — whether from their underlying conditions or the physical dependency that accompanies long-term use of painkillers — once that prescription ran out.

The closures came on the same day that the California Department of Health Care Services suspended state Medi-Cal reimbursements to 17 of Lags Medical’s 28 locations, citing without detail “potential harm to patients” and an ongoing investigation by the state Department of Justice into “credible allegations of fraud.” In the months since, the state has declined to elaborate on the concerns that prompted its investigation. Patients are still in the dark about what happened with their care and to their bodies.

Even as the government remains largely silent about its investigation, interviews with former Lags Medical patients and employees, as well as KHN analyses of reams of Medicare and Medi-Cal billing data and other court and government documents, suggest the clinics operated based on a markedly high-volume and unorthodox approach to pain management. This includes regularly performing skin biopsies that industry experts describe as out of the norm for pain specialists, as well as notably high rates of other sometimes painful procedures, including nerve ablations and high-end urine tests that screen for an extensive list of drugs.

Those procedures generated millions of dollars in insurer payments in recent years for Lags Medical Centers, an affiliated network of clinics under the ownership of Dr. Francis P. Lagattuta. The clinics’ patients primarily were insured by Medicare, the federally funded program for seniors and people with disabilities, or Medi-Cal, California’s Medicaid program for low-income residents.

Taken individually, the fees for each procedure are not eye-popping. But when performed at high volume, they add up to millions of dollars.

Take, for example, the punch biopsy, a medical procedure in which a circular blade is used to extract a sample of deep skin tissue the size of a pencil eraser. The technique is commonly used in dermatology to diagnose skin cancer but has limited use in pain management medicine, usually involving a referral to a neurologist, according to multiple experts interviewed. These experts said it would be unusual to use the procedure as part of routine pain management.

In Lagattuta’s specialty — physical medicine and rehabilitation, a common pain management field — just six of the nearly 8,000 U.S. physicians treating Medicare patients billed for punch biopsies on more than 10 patients in 2019, the most recent year for which data was available. Four, including Lagattuta, were affiliated with Lags Medical.

Medicare and Medi-Cal data are organized differently, and each provides distinct insights into Lags Medical’s billing practices. For Medicare, KHN’s findings reflect the number of procedures and actual reimbursements billed through Lagattuta’s provider number. But the Medicare figures do not encompass services and billing amounts for other providers across the chain, nor reimbursements for patients enrolled in private Medicare Advantage plans.

KHN used Medi-Cal records to assess the volume of services performed across the entire chain. But the state could not provide totals for how much Lags Medical was reimbursed because of California’s extensive use of managed-care plans, which do not make their reimbursement rates public. Where possible, KHN estimated the worth of Medi-Cal procedures based on the set rates Medi-Cal pays traditional fee-for-service plans, which are public.

Lags Medical clinics performed more than 22,000 punch biopsies on Medi-Cal patients from 2016 through 2019, according to state data. Medi-Cal reimbursement rates for punch biopsies changed over time. In 2019 the state’s reimbursement rate was more than $200 for a set of three biopsies performed on patients in fee-for-service plans.

Laboratory analysis of punch biopsies was worth far more. Lags Medical clinics sent biopsies to a Lags-affiliated lab co-located at a clinic in Santa Maria, according to medical records and employee interviews. From 2016 through 2019, Lags Medical clinics and providers performed tens of thousands of pathology services associated with the preparation and examination of tissue samples from Medi-Cal patients, according to state records. The services would have been worth an estimated $3.9 million using Medi-Cal’s average fee-for-service rates during that period.

In that same period, Medicare reimbursed Lagattuta at least $5.7 million for pathology activities using those same billing codes, federal data shows.

Much of the work at Lags Medical was performed by a relatively small number of nurse practitioners and physician assistants, each juggling dozens of patients a day with sporadic, often remote supervision by the medical doctors affiliated with the clinics, according to interviews with former employees. Lagattuta himself lived in Florida for more than a year while serving as medical director, according to testimony he provided as part of an ongoing malpractice lawsuit that names Lagattuta, Lags Medical, and a former employee as defendants.

Former employees said they were given bonuses if they treated more than 32 patients in a day, a strategy Lagattuta confirmed in his deposition in the malpractice lawsuit. “If they saw over, like, 32 patients, they would get, like, $10 a patient,” Lagattuta testified.

The lawsuit, filed in Fresno County Superior Court, accuses a Lags Medical provider in Fresno of puncturing a patient’s lung during a botched injection for back pain. Lagattuta and the other named defendants have denied the incident was due to negligent treatment, saying, in part, the patient consented to the procedure knowing it carried risks.

Hector Sanchez, the nurse practitioner who performed the injection and is named in the lawsuit, testified in his own deposition that providers at the Lags Medical clinic in Fresno each treated from 30 to 40 patients on a typical workday.

According to Sanchez’s testimony and interviews with two additional former employees, Lags Medical clinics also offered financial bonuses to encourage providers to perform certain medical procedures, including punch biopsies and various injections. “We were incentivized initially to do these things with cash bonuses,” said one former employee, who asked not to be named for fear of retribution. “There was a lot of pressure to get those done, to talk patients into getting these done.”

In his own deposition in the Fresno case, Lagattuta denied paying bonuses for specific medical procedures.

Interviews with 17 former patients revealed common observations at Lags Medical clinics, such as crowded waiting rooms and an assembly-line environment. Many reported feeling pressure to consent to injections and other procedures or risk having their opioid supplies cut off.

Audrey Audelo Ramirez said she had worried for years that the care she was receiving at a Lags Medical clinic in Fresno was subpar. In the past couple of years, she said, there were sometimes so many patients waiting that the line wrapped around the building.

Ramirez, 52, suffers from trigeminal neuralgia, a rare nerve disease that sends shocks of pain across the face so severe it’s known as the “suicide disease.” Over the years, Lags Medical had taken over prescribing almost all her medications. This included not only the opioids and gabapentin she relies on to endure excruciating pain, but also drugs to treat depression, anxiety, and sleep issues.

Ramirez said she often felt pressured to get procedures she didn’t want. “They were always just pushing injections, injections, injections,” she said. She said staffers performed painful punch biopsies on her that resulted in an additional diagnosis of small fiber neuropathy, a nerve disorder that can cause stabbing pain.

She was among numerous patients who said they felt they needed to undergo the recommended procedures if they wanted continued prescriptions for their pain medications. “If you refuse any treatment they say they’re going to give you, you’re considered noncompliant and they stop your medication,” Ramirez said.

She said she eventually agreed to an injection in her face, which she said was administered without adequate sedation. “It was horrible, horrible,” she said. Still, she said, she kept going to the office because there weren’t many other options in her town.

Lagattuta, through his lawyer, declined a request from KHN to respond to questions about the care provided at his clinics, citing the state investigation. “Since there is an active investigation, Dr. Lagattuta cannot comment on it until it is completed,” attorney Matthew Brinegar wrote in an email. Lagattuta’s license remains in good standing, and he said in his deposition in the Fresno lawsuit that he is still seeing patients in California.

Experts interviewed by KHN noted that medical procedures such as injections can have a legitimate role in comprehensive pain management. But they also spoke in general terms about the emergence of a troubling pattern at U.S. pain clinics involving the overuse of procedures. In the 1990s and early 2000s, problematic pain clinics hooked patients on opioids, then demanded cash to continue prescriptions, said Dr. Theodore Parran, who is a professor of medicine at Case Western Reserve University and has served as an expert witness in federal investigations into pain clinics.

“What has replaced them are troubled pain clinics that hook patients with the meds and accept insurance, but overuse procedures which really pay well,” he said. For patients, he added, the consequences are not benign.

“I mean they are painful,” he said. “You’re putting needles into people.”

‘Knee Injections, Hip Injections, Foot Injections’

Before moving to California in 1998, Dr. Francis Lagattuta lived in Illinois and worked as a team doctor for the Chicago Bulls during its 1995-96 championship season. Out West, he opened a clinic in Santa Maria, a Latino-majority city along California’s Central Coast known for its strawberry fields, vineyards, and barbecue. From 2015 to 2020, the chain grew from a couple of clinics in Santa Barbara County to dozens throughout California, largely in rural areas, as well as far-flung locations in Washington state, Delaware, and Florida.

The California portion of the chain is organized as more than two dozen corporations and limited liability corporations owned by Lagattuta. His son, Francis P. Lagattuta II, was a manager for the company.

On the Lags Medical website and in conversation with employees, the elder Lagattuta claimed he was of diagnosing and treating small fiber neuropathy. Much of the website has now . But pages available via an archival site claim he had pioneered to pain management that made minimal use of opioids and surgeries, instead emphasizing testing, injections, mental health, diet, and exercise. “In keeping with his social justice values, Dr. Lagattuta plans to share these findings to the rest of the world, hopefully to help solve the opioid crisis, and end suffering for millions of people struggling with pain,” once highlighted on the website.

Numerous Lags Medical patients interviewed by KHN said that even when they were given punch biopsies and a subsequent diagnosis of neuropathy, their treatment plan continued to involve high doses of opioid medications.

Dr. Victor C. Wang, chief of the division of pain neurology at Brigham and Women’s Hospital in Boston, said punch biopsies are occasionally used in research but are not a standard part of pain medicine. Instead, small fiber neuropathy is usually diagnosed with a simple clinical exam.

“The treatment is going to be the same whether you have a biopsy or not,” said Wang. “I always tell the fellows, you can do this test or that one, but is it really going to change the management of the patient?”

Ruby Avila, a mother of three in Visalia, remembers having the punch biopsies done at least three times during her four years as a Lags Medical patient. “I have scars down my leg,” she said. Each time, she said, providers removed a set of three skin specimens that were used to diagnose her with small fiber neuropathy.

Avila, 37, who has lived with pain since childhood, had found it validating to finally have a diagnosis. But after learning more about how common the biopsies were at Lags Medical, she was shaken. “It’s overwhelming to hear that they were doing it on a lot of people,” she said.

Sanchez, the nurse practitioner named in the Fresno lawsuit, spoke of other procedures that garnered bonuses: “Trigger point injections, knee injections, hip injections, foot injections for plantar fasciitis and elbow injections” all qualified for $10 bonuses, he said in his testimony.

Two former employees, who asked not to be named, echoed Sanchez, saying they were incentivized to do certain procedures, including injections and punch biopsies.

In his testimony in the Fresno case, Lagattuta denied paying bonuses for procedures. “It was only for the patients,” he said. “We never did it based on procedures.”

Incentive systems for a specific procedure are “completely unethical,” said Dr. Michael Barnett, an assistant professor of health policy at Harvard. “It’s like giving police officers a quota for speeding tickets. What do you think they’re going to do? I can’t think of any justification.”

Dr. Carl Johnson, 77, is a pathologist who directed Lags Medical’s Santa Maria lab from 2018 to 2021. Johnson said the only specimens he looked at came from punch biopsies, the first time in his long career as a pathologist that he had been asked to run such an analysis. On an average day, he said, he examined the slides of about 40 patients, searching for signs of small fiber neuropathy. Lagattuta gave him papers to read on peripheral neuropathy and assured him they were on the cutting edge of care for pain patients. Johnson said he “never thought there was anything untoward going on” until he arrived on his last day and was told to pack up his belongings because the entire operation was shutting down.

Lags Medical performed other procedures at rates that also set them apart. From 2015 through 2020 — the span for which KHN had state data — Lags Medical performed more than 24,000 nerve ablations, a procedure in which part of a nerve is destroyed to reduce pain, on Medi-Cal patients. That’s more than 1 in 6 of all nerve ablations billed through Medi-Cal during that period.

An analysis of federal data also shows Lagattuta was an outlier. For example, in 2018 he billed Medicare for nerve ablations more often than 88% of the doctors in his field who performed the procedure.

Lags Medical also used the in-house lab to run drug tests on patients’ urine samples. From 2017 through 2019, Lags Medical facilities often ordered the most extensive — and expensive — set of drug tests, which check for the presence of at least 22 drugs, according to state and federal data.

For perspective, in 2019, more than 23,000 of the most extensive drug tests were ordered on Medi-Cal patients under Lagattuta’s provider number, more than double the number tied to the next highest biller. The next five top billers were all lab companies.

Overall, from 2017 through 2019, nearly 60,000 of the most extensive drug tests were billed to Medicare and Medi-Cal under Lagattuta’s provider number. Medicare reimbursed Lagattuta $5.4 million for these tests during that period. Using state fee-for-service rates, the testing billed to Medi-Cal would have been worth an estimated $6.3 million. That doesn’t include less extensive drug screens or those billed under other providers’ numbers.

Pain management experts described the use of extensive screening as unnecessary in routine pain treatment; the overuse of such tests has been the subject of numerous Medicare investigations in recent years.

Private pain clinics like Lags Medical are only loosely regulated and generally are not required to hold a special license from the state. But the physicians who work there are regulated by the Medical Board of California.

In December 2019, a patient who’d visited clinics in both Visalia and the Central Coast against Lagattuta with the medical board claiming, among other things, that she received biopsies that were not properly performed, that she underwent excessive testing, and that positive drug tests had been falsified. The medical board had another pain management doctor review more than 300 pages of documents and found “no deviations from the standard of care” and “did not find any over testing, or improperly performed biopsies.”

He did, however, find some record-keeping problems, including numerous procedures in which patient consent was not documented. He also found instances in which procedures were performed and repeated without documentation that they were effective. The patient who filed the complaint was given a medial branch nerve block in November 2014, followed by a radiofrequency ablation in December, and another in February. No improvements for the patient were ever noted in the charts, the investigating doctor found.

The medical board chalked it up to a record-keeping error and fined Lagattuta $350.

A Halfway-Normal Life

On a warm evening in late July, Leah Munoz drove her power wheelchair around the long plastic tables at the Veterans Memorial Building in Hanford, a dusty farm town in California’s Central Valley. Senior bingo night was crowded with gray-haired players waiting for the game to begin. She found an empty spot and carefully set out $50 worth of bingo cards, alongside her collection of 14 brightly colored daubers.

Munoz, 55 and a mother of six, said she has suffered from a litany of illnesses — thyroid cancer, breast cancer, lupus, osteoarthritis — that leave her in near-constant pain. She’s been playing bingo since she was a little girl, and said it helps distract from the pain and calm her mind. She looks forward to this event all week.

Munoz was a Lags Medical patient for about four years and, while her pain never disappeared, the opioids prescribed provided enough relief for her to continue doing the things she loved. “There’s a difference between addiction and dependence. I need it to live a halfway-normal life,” Munoz said.

After Lags Medical closed in May, her primary care doctor initially refused to refill her opioid prescriptions. She said she called the Lags Medical offices to try to get a copy of her medical records to prove her need, and even showed up in person. But she said she was unable to get them. As the pills dwindled and the pain surged, Munoz said, it became hard to leave her home. “I missed a lot of bingo, a lot of grocery shopping, a lot of going to my grandkids’ birthday parties. You miss out on life,” she said. Ultimately, she said, her primary care doctor referred her to another pain clinic, and she was able to resume her prescription.

Even with pain medications, Munoz said, she never received true relief during her time as a patient at Lags Medical. She said she felt coerced to get several injections, none of which seemed to help. “If I didn’t get the procedures, I didn’t get the pain medication,” she said. Her husband, Ramon, a landscaper who was also a patient, received an injection there that he said left him with permanent stiffness in his neck.

Munoz knows at least five other people at bingo night who were former patients at Lags Medical. One of them, Rick Freeman, came over to her table to chat. He swayed back and forth as he walked, his knees, he explained, swollen after 35 years living with HIV. At Lags Medical, Freeman said, he felt pressured by staff to receive injections if he wanted to continue receiving his opioid prescriptions. “If you don’t cooperate with them, they would reduce your meds down,” he said.

At the front of the room, Gail Soto, who ran the event, sold bingo cards to the latecomers. Soto, 72, said she injured her back while working an administrative job at a construction company years ago and suffers from spinal stenosis, rheumatoid arthritis, and fibromyalgia. She, too, was a patient at Lags Medical for years. In addition to her opioid prescription, Soto said, she received repeated injections and three nerve ablations. At first, the ablations helped, but what staff members didn’t tell her, she said, was that the nerves they destroyed could grow back. Ultimately, she said, the procedures left her in worse pain.

Soto’s biggest concern is the spinal stimulator that she said Lags Medical surgically inserted into her back five years ago. She said the doctors told her the device would work so well that she would no longer need her pain pills. She said they didn’t explain that the device would work only two hours a day, and on one side of her body. She remained in too much pain to give up her meds, she said, and, five years later, the battery is failing.

Soto sleeps in a recliner chair in her three-bedroom mobile home in Lemoore, another small city near Hanford. It’s well kept but humble, and she and her husband keep a collection of wind chimes on the front porch that create a wave of gentle music when a breeze passes by. The couple take good care of each other and their two beloved Chihuahuas, but life has become increasingly difficult for Soto.

As the battery on her spinal stimulator has started to fail, she said, she has sudden electrical pulses that shoot up her body. “My husband says sometimes when I sleep that my body will just jump up in the air,” she said. But now that Lags Medical is closed, she said, she can’t find a doctor willing to remove the device. “Most doctors are telling me right now, ‘We can’t, because we didn’t [put it in]. We don’t want nothing to do with that.’”

Waitlists and Withdrawal

Audrey Audelo Ramirez said she picked up her final refill from Lags Medical on June 4 and by July 4 had no meds left to treat her pain. Ramirez said she called every pain management clinic in Fresno, but none were taking new patients.

“They left us all high and dry,” she said. “Everybody.”

In the weeks that followed the closures, county officials throughout the Central Valley saw a flood of patients on high doses of opioids in search of new providers, they said. Patients couldn’t access their medical records, so other providers had no idea what their treatments had been.

“We had to create a crisis response to it because there was no organized response at that time,” said Dr. Rais Vohra, the interim health officer for Fresno County.

Fresno County’s health system is already lean, Vohra said. Toss in this abrupt closure and you end up in the kind of crisis rarely seen in other fields of medicine: “You’d never do this with a cancer clinic,” he said. “You’d never abruptly stop chemo.”

The state asked Dr. Phillip Coffin, director of substance abuse research for the San Francisco Department of Public Health, to run provider training and persuade doctors to take on new patients. Many practices have rules against taking new patients on opioids, or will refuse to prescribe doses above certain thresholds.

“We know that when you stop prescribing opioids, some people end up with death from suicide, overdose, increased illicit opioid use, pain exacerbations. It’s really important to have a continuity, and that is not really possible in the current opioid-prescribing culture,” Coffin said. The threat to patients is so severe that the FDA in 2019 against cutting patients off from prescription opioids.

Gina, a retired nurse who asked to be identified by only her first name for fear she’d be discriminated against by other doctors, had been a Lags Medical patient for six years. She said she called every practice she could find in her Central Coast town, and was put on a waiting list at one. Suffering from a severe case of scoliosis, she started rationing the pain pills she had come to rely on.

When she finally secured an appointment, she said, she was told by the doctor she was on “some very strong meds” and he would fill only one of her two prescriptions. “You’re like a criminal,” she said. “You’re branded as ‘we don’t trust you.’”

She started experiencing withdrawal symptoms — sweating, lost appetite, sleeplessness, anxiety. Worst of all, her pain “came back with a vengeance,” she said.

“I think about this, what I’d have been like if I’d never gone through pain management. I sometimes wonder if I’d be better off.”

As for Ramirez, her primary care doctor finally secured an appointment for her at another pain clinic, she said. It was in the same space as the old Lags Medical clinic, and she said she recognized many of the staff members. But now there was a new name: Central California Pain Management. From her perspective, it was as if nothing had changed. And she still doesn’t know whether she needs to worry about the care she received during more than four years at Lags Medical.

The new clinic’s owner, Dr. Ashok Parmar, said that he is leasing the space and that Lagattuta is his landlord. Parmar said he doesn’t do punch biopsies, nor does he diagnose small fiber neuropathy. After all, he said, he would treat the pain the same way, with or without the diagnosis.

How We Did This

KHN evaluated the billing practices of physicians and clinics associated with Lags Medical Centers using data from both Medicare and Medi-Cal.

KHN did multiple analyses using that show, for each medical practitioner or lab, every procedure or service billed to the federal government, along with the number of times a procedure was performed, the number of Medicare beneficiaries who received specific services, and how much Medicare reimbursed. The Part B records include billings from 2015 through 2019, the most recent years available. The records are limited to beneficiaries who have traditional fee-for-service Medicare rather than private Medicare Advantage plans. Medicare suppressed data in cases in which a provider performed a procedure on 10 or fewer beneficiaries in a year.

KHN analyzed Medicare billing records for a range of specific procedures, comparing Dr. Francis P. Lagattuta’s billings with those of other practitioners who also identified themselves in the records as Physical Medicine and Rehabilitation specialists.

Through a public records request, KHN also obtained data from the California Department of Health Care Services for a range of specific medical procedures performed on state Medi-Cal recipients by all California providers from 2015 through 2020, as well as every service rendered through Medi-Cal under Lagattuta’s provider number during that time. The Medi-Cal data is organized to show both the rendering and billing provider for a procedure, allowing KHN to look across the network of Lags Medical clinics. To calculate services provided at Lags Medical Centers, KHN included services performed under Lagattuta’s provider number, as well as active provider numbers of organizations with a mailing address associated with Lags Medical clinics that listed Dr. Francis P. Lagattuta or another Lags employee as their authorized official. DHCS suppressed data for instances in which a provider performed a procedure fewer than 11 times on Medi-Cal patients in a year.

The Medi-Cal data did not include reimbursement amounts for procedures, so KHN obtained historical reimbursement amounts from DHCS to calculate the value of the services based on the fee-for-service reimbursement rate in July of each year. Care received by patients with Medi-Cal is generally reimbursed by the state in one of two ways: a fee-for-service model, in which physicians are reimbursed for services according to a set fee schedule that is public; or a managed-care model, in which the state pays insurers a monthly fee per patient, and the insurers reimburse providers amounts that are not public. Only a small percentage of Lags Medical services were reimbursed through fee-for-service plans during the years reviewed. As a result, the values of procedures calculated by KHN are meant to convey a general estimate of their worth. All estimates are calculated using .

KHN senior correspondent Jordan Rau and Phillip Reese, an assistant professor of journalism at California State University-Sacramento, contributed to this report.

This story was produced by , which publishes , an editorially independent service of the .

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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Work can mean different things: going to doctor’s appointments, building her comfort level with eating at a restaurant, or listening to Timothio recount stories about the past. Right now, the pair are working on using the internet, so there’s a lot of time spent on web searches.

“Is Billy Graham still alive?” Timothio asked. “We Googled that,” Hayden replied, reminding her the answer is “no.” “I’m sorry I won’t get to meet him,” Timothio said, her voice wistful.

Timothio loves religions, their rituals, and says she’s been baptized many times, including as a Latter-day Saint and a Jehovah’s Witness. She also has practiced as a Hindu and joined the Hare Krishnas for a while. She’s joined so many spiritual groups over the years, she said, because she loves that feeling of rebirth, a new start. “It’s like you can see God looking at you: ‘Finally getting your shit together, huh, Diane?’”

Early in the pandemic, county workers found Timothio, now 76, at a low-budget motel in rough shape. She was showing signs of dementia and had trouble walking because of osteoporosis in a hip. In recent years, her only real medical care had come via the local emergency room, where she was a regular visitor. She’d recently left an apartment after a fire. Then there was covid-19, and the hotel she was staying in wanted her out. Timothio had nowhere to go.

Rural, isolated, and immense, Del Norte is home to one of the nation’s largest undammed rivers and some of the world’s only remaining acres of virgin redwood forest. Fewer than 28,000 people are spread across the county’s 1,000 square miles, land mostly owned by the state or the federal government.

Coastal Highway 101 runs right through Crescent City, the county’s only real town. People who are homeless in the region tend to gravitate here because it’s hard to survive anywhere else. “People need to eat,” said Heather Snow, the county’s director of health and human services.

By California standards, the homeless population in Del Norte is small. According to the most recent survey, there were about 250 people without shelter in 2020. That is almost certainly an underestimate, but, still, the figure pales in comparison to cities in the Bay Area and Southern California, with their tens of thousands living unsheltered.

California’s spiraling housing crisis is often understood through the lens of its big cities, where the sheer number of people who need assistance can quickly capsize the programs designed to move people into housing. But before the pandemic, helping people find shelter in Del Norte had been an insurmountable problem for Snow and her colleagues, as well.

There’s not enough housing in general in Del Norte, let alone for people with precarious finances. Snow lived 30 minutes north, in Brookings, Oregon, when she started her job six years ago. It took years to find somewhere closer to live. And there’s never been a homeless shelter anywhere in the county, as far as she knows.

For several years, Snow has used county funds to rent rooms at a local motel to temporarily house people at risk of becoming homeless. Sometimes they’d been released from a psychiatric medical hold or were trying to get out of an abusive relationship. Sometimes they needed a temporary sober-living environment. The county spent $820,000 on those rooms from July 2015 through June 2020. “It was a public health emergency before is the truth,” Snow said. “People just didn’t see it that way.”

After the pandemic came to town, Snow and her colleagues began using the motel to house people like Timothio who were at high risk for serious illness and had no safe place to live, as well as people who needed a safe place to quarantine after a covid exposure.

That’s how Reggie and Sandy Montoya ended up there with their 25-year-old son, Cruz. They’d lost their home well before the pandemic began and were making do in a fifth-wheel trailer that was parked behind a restaurant. In May 2020, Cruz was exposed to one of the earliest covid cases in the county at his job at a nonprofit program for disabled adults, and public health workers quickly realized his home wasn’t suitable for quarantining. They brought the whole family to the motel.

Since then, it has become home, and for as long as they want it to be. In October 2020, the state awarded Del Norte County $2.4 million to buy the 30-room motel and turn it into affordable housing through Project Homekey, a statewide initiative spearheaded by Gov. Gavin Newsom to help counties buy old motels and other buildings and turn them into permanent housing. Snow said there’s enough space to accommodate about 17% of Del Norte County’s homeless residents and families.

The motel is nestled in a median between the north- and southbound lanes of Highway 101 and is flanked by grocery stores, fast-food restaurants, a laundromat, and a drugstore. It’s not far from the police station and county health services. To Snow, it’s an ideal location for people like the Montoyas who don’t have a car.

In the application to the state, Snow provided documents showing the county could maintain the program for decades, explaining how the site would be run and who would get housing. “I have my master’s in social work. I’m not a real estate tycoon,” Snow said. “This is out of my comfort zone, but it’s what the situation is calling for.”

County officials had to agree to the purchase, and the political pushback was quick to foment, Snow said. A small group of residents staged protests, and city officials asked the county to deny the purchase, saying, among other things, that they didn’t want to lose the motel’s contribution to the tax base. Ultimately, though, Project Homekey’s design worked to Snow’s benefit, offering a lot of money and a narrow window in which to accept it. Snow got to work explaining her vision to county supervisors, and four of the five voted “yes.”

Today, the 30 motel rooms in Del Norte are among the more than 7,000 new housing units the state says it has created through Project Homekey in two years. In late January, the Newsom administration announced that an additional $14 billion will be spent in 2022 on a mix of housing units and mental health treatment.

Some people have stayed at The Legacy, as the county renamed the motel, and then moved on to new homes after finding their footing. Others have housing vouchers and jobs but can’t find another place to live. And some, like the Montoyas, have become long-term tenants.

Sandy, 54, and Reggie, 60, have been together nearly 40 years. They met in Sandy’s hometown of Santa Rosa and had been together for several years when Reggie heard the salmon fishing was awesome farther north and came up to try his hand in the Klamath River. They eventually moved to Crescent City, where they’ve lived for two decades, working odd jobs. They’ve had several homes over those years, and many periods without one. Reggie described himself as chronically homeless and said health crises, bouts of depression, and drug use have knocked the couple down from time to time.

Reggie and Sandy have concerns about living in The Legacy. They loathe living under someone else’s rules, and after all the months of eating out of a microwave, Sandy desperately misses Reggie’s cooking. “His biscuits and gravy is heavenly. His lasagna is out of this world,” she said.

Some of the other tenants use drugs, and they’ve seen violent outbursts, like the time in December when a neighbor’s tires were slashed. Early on, a woman upstairs thumped around in boots at all hours of the night. After an initial confrontation, they worked it out, eventually becoming friends. But then she moved out and fatally overdosed on fentanyl, they said. They miss her immensely.

Even with all that, they describe their new home as a godsend. “I make it out like a horror show,” Reggie said. “But if it wasn’t for this place, I would probably be dead right now.”

Their room has sheltered them from the cold, wet winters and from the virus. A coming remodel will transform the rooms into functional apartments with kitchens. Their dogs can stay, and they are saving up for a car. Reggie loves that the county therapist he’s seeing for depression always knows where to find him.

Timothio also moved in early in the pandemic. It did not go well initially. Her thoughts were disorganized, and she couldn’t take care of basic tasks like bathing. Several months into her stay, she had trashed her room and was barely getting by.

That’s when Snow and her colleagues from the behavioral health department got involved, navigating through layers of bureaucracy to obtain Timothio’s medical records, get her signed up for government assistance, and ultimately have her placed under county conservatorship. They coaxed her to doctor’s appointments and helped her get on medication for mental health issues.

Timothio began sharing with Hayden details of her traumatic and complicated past. The abusive family members. The children she lost custody of decades before. The violence she’d experienced over decades spent unsheltered. The bouts of deep depression. She uses a refrain when she tells those stories: “I’ve been raped, robbed, and mugged, left for dead on the side of the road.”

These days feel calmer. “I just want to stay in one spot,” Timothio said. Hayden had brought her watermelon and grapes, two of her favorite foods, and they were watching old black-and-white Westerns on TV, researching actors and musicians famous in the 1950s.

Timothio recently looked at a photograph of herself from the early days at the motel, sprawled on a bed, sheets askew, surrounded by candy and dirt. She told Hayden she didn’t recognize the woman in it. That wasn’t her anymore.

Hayden stayed a couple of hours and before she left reminded Timothio that a home health aide would come the next day to assist her with chores. Hayden marveled at how, just a few months before, Timothio wouldn’t let anyone in her room. Now, the room was clean, and Timothio was taking her medication and voluntarily going to doctor’s appointments. True, she still wore sunglasses inside and kept the blinds drawn tight. But she felt safe enough to welcome strangers into her home.

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Al igual que otros laboratorios de salud pública en California encargados de las pruebas y la vigilancia de enfermedades a gran escala, el laboratorio de Ventura recibió dinero federal y estatal para nuevos equipos y contrataciones a corto plazo para reforzar su respuesta ante covid-19. Pero el financiamiento fue temporal y Von Bargen, la directora, no pudo usarlo para aumentar los salarios de sus empleados, quienes podían ganar más dinero en el sector privado, con menos trabajo.

Las operaciones se deterioraron aún más en octubre, después que el laboratorio perdiera su licencia para realizar pruebas de rutina que verifican el agua del océano del condado en busca de bacterias mortales. Parece haber sido un error administrativo: el papeleo de la licencia cambió y el personal normalmente responsable de presentar la solicitud había renunciado.

“La mayor amenaza para [los laboratorios de salud pública] en este momento no es el próximo patógeno emergente”, dijo Donna Ferguson, directora del laboratorio de salud pública en el condado de Monterey, “sino que los laboratorios cierren por la falta de personal”.

En todo California, los departamentos de salud pública están perdiendo personal experimentado debido a los retiros, el agotamiento, la política partidista y los trabajos mejor pagos. Incluso antes de que la pandemia de coronavirus drenara los departamentos, la cantidad de personal se había reducido con los presupuestos del condado.

Pero la disminución se ha acelerado durante el último año y medio, incluso cuando se han recibido millones de dólares en dinero federal.

Enfermeras de salud pública, microbiólogos, epidemiólogos, funcionarios de salud y otros miembros del personal que defienden a la población contra enfermedades infecciosas como la tuberculosis y el VIH, inspeccionan los restaurantes y el trabajo para mantener la salud de las comunidades están abandonando el campo.

Es un problema que los aumentos temporales de financiación no pueden solucionar.

La fuga de cerebros está socavando la supervisión de la salud comunitaria a todo nivel, grande y pequeño. Las personas que trabajan en los laboratorios de salud pública, por ejemplo, realizan pruebas complejas para detectar enfermedades mortales que requieren capacitación especializada de la que carecen la mayoría de los laboratorios comerciales.

Si bien su trabajo es en gran parte invisible para el público, afectan a casi todos los aspectos de la sociedad. Los laboratorios de salud pública toman muestras de los mariscos para asegurarse de que sean seguros para comer. Supervisan el agua potable y desarrollan pruebas para detectar amenazas emergentes para la salud, como virus resistentes a los antibióticos. También realizan pruebas para detectar enfermedades graves, como el sarampión y covid. Y, por lo general, lo hacen a una fracción del costo de los laboratorios comerciales, y más rápido.

Los directores de laboratorios públicos generalmente deben tener un doctorado y deben tener las credenciales adecuadas para que sus laboratorios estén certificados.

Ferguson dijo que se siente como si hubiera una puerta giratoria en su laboratorio, ya que los recién graduados universitarios se unen durante unos meses para ganar experiencia, con un salario inicial de $19 la hora, y luego pasan a trabajos mejor pagados en hospitales. Es casi imposible contratar personal calificado para puestos de medio tiempo, como los creados con ráfagas temporales de fondos, debido a la capacitación requerida. En California, muchos puestos de laboratorio requieren un certificado de microbiólogo experto en salud pública del Departamento de Salud Pública.

California tiene 29 laboratorios de salud pública, en comparación con casi 40 antes de la recesión de 2008. Un laboratorio en Merced ha estado sin director durante meses y podría cerrar pronto.

Si bien no hay un recuento oficial de cuánto se ha reducido el campo, casi todos los laboratorios carecen de miembros clave entre su personal, dijo Godfred Masinde, presidente de la Asociación de Directores de Laboratorios de Salud Pública de California, director del laboratorio de San Francisco y director interino del laboratorio del condado de Fresno. Docenas de puestos de microbiólogos de salud pública están vacantes en todo el estado.

“Ahora tenemos financiación; tenemos equipo”, dijo Masinde. “Pero no tenemos el personal para operarlo”.

Su laboratorio de San Francisco generalmente realiza 100,000 pruebas para gonorrea y clamidia cada año, y entre 150 y 200 pruebas para sífilis todos los días, dijo Masinde. Si bien California también tiene laboratorios estatales, señaló, simplemente no tienen la capacidad para relevar a los laboratorios cerrados del condado.

Los condados también están luchando para contratar y retener personal para otros puestos. Una encuesta informal realizada por los directores de enfermería de salud pública de California encontró que al menos 84 enfermeras de salud pública han dejado sus trabajos desde marzo de 2020. Muchas se jubilaron, parte de una fuerza laboral canosa que enfrenta el desafío de reclutar enfermeras en un campo gris que requiere una acreditación especial.

Las enfermeras de salud pública están capacitadas en enfermería y salud comunitaria y, a menudo, trabajan con familias o grupos comunitarios, no solo con clientes individuales.

Realizan visitas domiciliarias después del parto, trabajan en el desarrollo de la primera infancia y ayudan a responder a los brotes de enfermedades infecciosas. “Por lo tanto, brindan un enfoque más holístico y también abordan los determinantes sociales de la salud”, dijo Michelle Curioso, directora de enfermería de salud pública del condado de Kern y presidenta de los directores de enfermería de salud pública de California. Al igual que el personal de laboratorio, las enfermeras de salud pública deben estar especialmente certificadas para trabajar en departamentos de salud pública.

En California, el salario anual promedio de una enfermera registrada es de más de $120,000, según la Oficina de Trabajo y Estadísticas, mientras que los puestos de trabajo de enfermera de salud pública en varios condados ofrecen salarios a partir de $65,000.

La escasez de enfermeras ha sido particularmente grave en las zonas rurales de California. En el condado de Butte, varias enfermeras de salud pública se jubilaron antes de lo esperado, dijo Monica Soderstrom, directora de enfermería de salud pública de Butte. Y dos enfermeras jóvenes que se tomaron una licencia por embarazo decidieron no regresar después de encontrar trabajos con salarios más altos. “Ha sido difícil cubrir nuestros puestos vacantes”, afirmó Soderstrom, “ya que competimos con hospitales y clínicas que pagan bonificaciones de inicio debido a las necesidades de personal por covid”.

La pérdida de los principales líderes de salud del condado (directores de departamentos y funcionarios de salud encargados de liderar la respuesta a la pandemia en las comunidades locales) ha sido particularmente grave, reflejando una tendencia nacional.

Diecisiete de los 58 condados de California han perdido a su oficial de salud desde marzo de 2020, y al menos 27 han perdido a un director o subdirector. El director y el subdirector del Departamento de Salud Pública estatal también renunciaron.

La experiencia colectiva perdida con esas salidas es difícil de exagerar.

Tomemos, por ejemplo, al doctor Robert Bernstein, quien se mudó a California en 2018 para convertirse en oficial de salud del condado rural de Tuolumne después de más de dos décadas trabajando en salud pública para los Centros para el Control y la Prevención de Enfermedades (CDC), la Organización Mundial de la Salud (OMS) y el Departamento de Salud de Florida.

En California, los funcionarios de salud deben ser médicos y están encargados de hacer cumplir los estatutos estatales y locales, y de proteger al público de los peligros para la salud.

En marzo de 2020, justo cuando la pandemia estaba haciendo su primer aumento en todo el estado, la junta de supervisores del condado le pidió a Bernstein que renunciara. Según Bernstein, los supervisores estaban molestos porque había ordenado vacunas contra la rabia para dos niños mordidos por murciélagos, incluido un murciélago que dio positivo por rabia, en contra de los deseos de sus padres. El condado se negó a comentar sobre el asunto, diciendo que está legalmente prohibido discutir asuntos de personal.

Bernstein se mudó al condado de Butte y se convirtió en funcionario de salud después de que su predecesor renunciara en mayo de 2020. Observó cómo sus colegas en los condados vecinos, comenzaban a renunciar uno tras otro, luego de enfrentar amenazas públicas por haber emitido órdenes relacionadas con covid.

En algunas comunidades, los funcionarios de salud pública también enfrentaron un rechazo humillante por parte de los funcionarios electos locales, incluso cuando los líderes policiales se negaban abiertamente a cumplir sus directivas de salud.

“Podrías, como funcionario de salud pública, tener la autoridad y la responsabilidad de recomendar o incluso ordenar ciertas acciones de salud pública”, dijo Bernstein, “pero necesitas una asociación con los que tienen la autoridad para llevarlas a cabo”.

En septiembre de este año, Bernstein estaba desilusionado con la dinámica y la idea de que su familia podría verse atrapada en el rencor de por covid. “Acabo de decidir que, como padre de trillizos de 16 años, no necesito que ni yo ni los niños sean amenazados de ninguna manera, y puedo hacer un buen trabajo de salud pública a nivel estatal, federal o incluso internacional”, dijo Bernstein.

Michelle Gibbons, directora ejecutiva de la Asociación de Ejecutivos de Salud de los Condados de California, dijo que los departamentos locales están viendo los efectos en cascada de esas deserciones de alto nivel, y los gerentes de nivel medio dudan en pasar a puestos de alto nivel, a pesar de que los altos funcionarios pueden obtener salarios de más de $200,000 .

El presupuesto estatal de este año incluyó $3 millones para una evaluación de la infraestructura de salud pública de California, y los líderes de salud pública creen que mostrará que la dotación de personal y la capacitación son problemas importantes.

Aún así, el presupuesto no incluyó fondos adicionales a largo plazo para los departamentos de salud. En medio de titulares negativos y un bombardeo de cabildeo, el gobernador Gavin Newsom finalmente acordó agregar $300 millones al año para la salud pública, un acuerdo de apretón de manos que no está programado para comenzar hasta julio.

Los defensores advierten que el momento es importante: muchos trabajadores de salud pública están esperando a que sus comunidades superen la pandemia y se irán una vez que mejore. “Veremos una gran ola de jubilaciones cuando esto termine”, dijo Kat DeBurgh, directora ejecutiva de la Asociación de Oficiales de Salud de California.

En el condado de Ventura, Von Bargen, agotado por la pandemia, ha estado tratando de jubilarse durante un año. No quería abandonar el laboratorio por el que luchó tanto por mantener abierto, y le tomó tanto tiempo encontrar un reemplazo. Su sucesor comenzará a principios del próximo año, momento en el que Von Bargen también se unirá a las filas de ex empleados de salud pública.

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Like other public health laboratories in California charged with broad-scale disease testing and surveillance, the Ventura lab received federal and state money for new equipment and short-term hires to bolster its response to covid-19. But the funding was temporary, and Von Bargen, the director, could not use it to increase the salaries of her employees, who could earn more money doing less work in the private sector.

Operations deteriorated further last month, after the lab lost its license to run routine tests that check the county’s ocean water for deadly bacteria. It appears to have been a clerical error: The licensing paperwork changed, and the staff typically responsible for submitting the application had quit.

“The biggest threat to [public health labs] right now is not the next emerging pathogen,” said Donna Ferguson, director of the public health lab in Monterey County, “but labs closing due to lack of staffing.”

Across California, public health departments are losing experienced staffers to retirement, exhaustion, partisan politics and higher-paying jobs. Even before the coronavirus pandemic throttled departments, staffing numbers had shrunk with county budgets. But the decline has accelerated over the past year and a half, even as millions of dollars in federal money has poured in. Public health nurses, microbiologists, epidemiologists, health officers and other staff members who fend off infectious diseases like tuberculosis and HIV, inspect restaurants and work to keep communities healthy are abandoning the field. It’s a problem that temporary boosts in funding can’t fix.

The brain drain is sapping community health oversight in ways big and small. The people who staff public health labs, for example, run complex tests for deadly diseases that require specialized training most commercial labs lack. While their work is largely unseen by the public, they touch almost every aspect of society. Public health labs sample shellfish to make sure it is safe for eating. They monitor drinking water and develop tests for emerging health threats such as antibiotic-resistant bacteria. They also test for serious diseases, such as measles and covid. And they typically do it at a fraction of the cost of commercial labs — and faster.

Public lab directors are typically required to hold doctorates, and they must have appropriate credentials for their labs to be certified.

Ferguson said it feels like there’s a revolving door on her lab, as recent college graduates join for a few months to gain experience, at a starting pay of $19 an hour, and then move on to higher-paying jobs at hospitals. It’s all but impossible to hire qualified staffers for part-time roles, like the ones created with temporary bursts in funding, because of the training required. In California, many lab positions require a public health microbiologist certificate from the Department of Public Health.

California has 29 public health labs, down from nearly 40 before the 2008 recession. A lab in Merced has been without a director for months and could soon close. While there’s no official count of how much the field has shrunk, nearly every lab is missing key staff members, said Godfred Masinde, who is president of the California Association of Public Health Laboratory Directors, lab director for San Francisco and filling in as lab director in Fresno County. Dozens of public health microbiologist positions are unfilled around the state.

“We have funding now; we have equipment,” Masinde said. “But we don’t have the staff to run the equipment.”

His San Francisco lab typically runs 100,000 tests for gonorrhea and chlamydia each year, and 150 to 200 tests for syphilis every day, Masinde said. While California also has state-run labs, he noted, they simply don’t have the capacity to pick up the slack for shuttered county labs.

Counties are struggling to recruit and retain staffers for other positions as well. An informal survey conducted by the California Directors of Public Health Nursing found that at least 84 public health nurses have left their jobs since March 2020. Many retired, part of a graying workforce challenged with recruiting nurses into an obscure field requiring special accreditation.

Public health nurses are trained in nursing and community health, and often work with families, or community groups, not just individual clients. They do home visits after births, work on early childhood development and help respond to outbreaks of infectious disease. “So providing more of a holistic approach, and also addressing the social determinants of health,” said Michelle Curioso, public health nursing director for Kern County and president of the California Directors of Public Health Nursing. Like lab staffers, public health nurses must be specially certified to work in public health departments.

In California, the average annual salary for a registered nurse is more than $120,000, according to the Bureau of Labor and Statistics, while public health nurse job postings in several counties offer salaries starting around $65,000.

Nursing shortages have been particularly severe in rural California. In Butte County, several public health nurses retired earlier than expected, said Monica Soderstrom, Butte’s director of public health nursing, and two young nurses who went on pregnancy leave decided not to return after finding jobs with higher wages. “It has been difficult to fill our vacant positions,” said Soderstrom, “as we are competing with hospitals and clinics paying sign-on bonuses due to covid staffing needs.”

The loss of top county health leaders — department directors and health officers charged with leading the pandemic response in local communities — has been particularly stark, mirroring a sobering national trend. Seventeen of California’s 58 counties have lost their health officer since March 2020, and at least 27 have lost a director or assistant director. The director and deputy director of the state Department of Public Health also resigned.

The collective expertise lost with those departures is hard to overstate.

Take, for example, Dr. Robert Bernstein, who moved to California in 2018 to become health officer for rural Tuolumne County after more than two decades working in public health for the federal Centers for Disease Control and Prevention, the World Health Organization and the Florida Department of Health, among other organizations. In California, health officers must be physicians, and are charged with enforcing state and local statutes and protecting the public from health hazards.

In March 2020, just as the pandemic was making its first surge across the state, Bernstein was asked to resign by the county board of supervisors. According to Bernstein, supervisors were upset that he had ordered rabies vaccines for two children bitten by bats — including a bat that tested positive for rabies — against their parents’ wishes. The county declined to comment on the matter, saying it is legally prohibited from discussing personnel matters.

Bernstein moved to Butte County and became health officer after his predecessor resigned in May 2020. Bernstein watched as colleagues in neighboring counties, facing menacing public threats over covid-related health orders, began quitting, seemingly one after the next. In some communities, public health officers also faced rude and derisive pushback from local elected officials, even as law enforcement leaders openly refused to carry out their health directives.

“You might, as a public health officer, have the authority and responsibility to recommend or even mandate certain public health actions,” Bernstein said, “but you need a partnership with those in authority to carry [them] out.”

By September this year, Bernstein was disillusioned with the dynamic and the notion that his family could get caught up in the covid rancor. “I just decided that as a dad of 16-year-old triplets, I don’t need me or the kids to be threatened in any way, and I can do good public health work at the state level or federal level or even international level,” Bernstein said.

Michelle Gibbons, executive director of the County Health Executives Association of California, said local departments are seeing the cascading effects of those top-level defections, with midlevel managers hesitant to move into senior positions, even though top officials can command salaries of more than $200,000.

The state budget this year included $3 million for an assessment of California’s public health infrastructure, and public health leaders believe it will show that staffing and training are major issues. Still, the budget did not include additional long-term funding for health departments. Amid negative headlines and a lobbying blitz, Gov. Gavin Newsom eventually agreed to add $300 million a year for public health, a handshake deal not scheduled to begin until July.

Advocates warn that the timing matters: Many public health workers are hanging on to see their communities through the pandemic and will leave once it ebbs. “We’re going to see a huge wave of retirements when this is over,” said Kat DeBurgh, executive director of the Health Officers Association of California.

In Ventura County, Von Bargen, exhausted by the pandemic, has been trying to retire for a year. She didn’t want to abandon the lab she fought so hard to keep open, and it took that long to find a replacement. Her successor will start early next year, at which point Von Bargen, too, will join the ranks of former public health employees.

This story was produced by , which publishes , an editorially independent service of the .

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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