Time and again, the state’s infectious disease experts said this would happen: a pandemic would strike South Carolinians and upend our lives.
Year after year, they planned for it. They did drills, wrote guidelines, stockpiled supplies.
And over and over, they saw their budgets cut and ranks thinned, even as they warned that shortfalls jeopardized the state’s preparedness and severely limited its ability to contain an outbreak.
Unable to win new funding to prepare for a pandemic, South Carolina’s public health system has become one of the most depleted in the nation, hampering the state’s capacity to manage the coronavirus outbreak and recovery, a Post and Courier investigation found.
The state Department of Health and Environmental Control has lost 20 percent of its infectious disease staff since the Great Recession. Federal data show that its public health workforce has been cut deeper in the last two decades than counterparts in the South, including Alabama, Georgia and Mississippi.
Now, as COVID-19 cases grow and the state’s economy reels, this diminished workforce faces the biggest public health crisis in a century.
Experts say investigating the virus’ spread here could require thousands of workers, far more than DHEC’s diminished ranks today.
Meantime, the agency has been forced to pull in retired disease experts to relieve its staff. And now with so many cases, the agency's disease detectives have lost their chances to identify and contain specific outbreaks.
DHEC's staffing is a case study in how state leaders have failed to acknowledge a serious but invisible threat to South Carolinians. Deep budget cuts a decade ago steered the state's attention away from a risk that was far-off but predictable.
It wasn’t always this way.
'A critical issue'
South Carolina's health leaders planned for a pandemic in the early 2000s with a new urgency. The U.S. was alarmed about the potential for a public health crisis.
Anthrax attacks in 2001 put the nation on edge for an intentional effort to harm Americans’ health. Bird flu flare-ups in the following years were a potent reminder: It was a matter of time before the nation would face a new and dangerous virus.
So the federal government sent money to the states to get ready for a public health emergency. South Carolina got $20 million to prepare for a flu pandemic, and in 2004, it finished the first draft of a plan that's guiding the state's response to the coronavirus.
The federal money paid for an aggressive planning effort. Dr. Robert Ball, a top DHEC infectious disease official until 2012, recalls about 150 people working on the agency’s plan. South Carolina started hosting other Southern states for annual summits to make plans for the entire region. And it made sure every part of the state was ready, according to annual reports on its progress.
DHEC said in 2006 that it held 45 training exercises with county governments, one for nearly all of South Carolina’s 46 counties. The next year it ran 15 more. Over those two years, it ran at least six statewide exercises to practice different parts of the plan.
Those kinds of drills were essential, said Dr. Jeff Engel, who was North Carolina’s state epidemiologist at the time. They revealed a plan’s weaknesses, and they made sure emergency responders knew each other before they faced a crisis together.
“They have to be done continuously,” Engel said. “When you’re in an emergency, you’re not shaking hands and meeting people for the first time.”
The efforts paid off when the state faced the world’s last pandemic, the 2009 swine flu outbreak. That disease was less severe than COVID-19, the illness caused by the new coronavirus, but officials were proud of their preparedness.
Their efforts to contain the swine flu pandemic “show the value of planning and preparedness,” DHEC concluded in a report to the state Legislature.
But DHEC wasn’t boasting to lawmakers. It was pleading with them.
The money that paid for its preparations was about to dry up.
South Carolina’s public health leaders realized they needed more than a one-off planning effort, which is what Congress had paid for. They needed to keep their plans current and keep practicing for an emergency.
And they wanted to move the state away from the boom-and-bust cycle of federal funding, which would shoot up after each public health scare and eventually dwindle.
“The programs get cut and aren’t often restored,” said Max Learner, who was South Carolina’s director of public health preparedness until 2012. “The fact is public health is invisible. It’s in the background until you really need it, and you better hope you got something there.”
They took that case to the state Legislature.
In 2006 and 2007, DHEC told lawmakers that lower federal funding was “causing instability in the department’s preparedness efforts.”
In 2008, it cautioned that “sustenance of state emergency preparedness, for pandemics and other disasters, is becoming a critical issue.”
That year and again in 2009, it reported that it had cut staff because the state hadn’t stepped in to fill federal cuts. Funding shortages had “jeopardized preparedness efforts,” it said.
Seven years in a row, it asked the Legislature for money to keep preparing. That money did not come. Year after year, the agency reminded lawmakers that its emergency planning depended on federal money alone.
Without new funding, “the ability to respond to a large-scale infectious disease event would be severely limited,” DHEC wrote in 2012.
But by then, it was facing an even bigger challenge: The money it got from the state for public health work was dwindling, too.
The cutting begins
The Great Recession gutted budgets across state government. DHEC wasn’t spared.
Neither were its efforts to control infectious disease.
The agency lost half its state funding for preventing infectious diseases, costing more than 100 jobs for people who investigate all kinds of outbreaks, from hospital infections and HIV to tuberculosis and the flu.
Earl Hunter ran DHEC when the cuts came. A longtime agency staffer, he was tasked with slashing its operations and navigating the loss of more than $60 million in state money in just two years.
The cuts were so deep that he felt DHEC had little choice but to focus on the problems it dealt with every day — things like inspecting restaurants and testing drinking water, not planning for a pandemic.
The agency took steps to limit the damage, by continuing to make updates to its pandemic plan and training more people on the basics of investigating a disease outbreak in case the existing staff was overwhelmed, Hunter said. But mitigating the blow didn’t eliminate it.
“Some things you’ve got to fund right away because the harm could happen right then, versus planning for a pandemic that may or may not happen,” Hunter said in an interview. “Which one do you prioritize the highest when you’ve got limited funds?”
After the cuts came, the government was slow to rebound. Agencies were asked not to request more money from the Legislature, records show; if they wanted to spend money on something new, they were told to cut other programs to pay for it.
So for three years at the end of Hunter’s tenure, DHEC didn’t ask for more money. At the time, Hunter wrote that he wasn’t open to “cannibalizing existing, important programs.”
Instead, he sent the Legislature and the governor a yearly list of “critical needs,” explaining that even if they would go unmet, it was DHEC’s job to tell them what the state was up against. “If we don't, who will?” he wrote.
No. 1 on the list, two years in a row, the agency said its top need was money to plan for public health emergencies and pandemics.
The money didn’t come. But a buzzsaw did.
'A tremendous loss'
Catherine Templeton arrived at DHEC with a reputation for aggressively cutting costs in state government.
She’d been Gov. Nikki Haley’s pick to run the Department of Labor, Licensing and Regulation, a sprawling agency that enforces workplace safety, inspects elevators and oversees dozens of industries, from funeral directors to hairdressers. She’d later boast that in one year, she cut its spending by a quarter. When Templeton ran for governor in 2018, she touted herself as “conservative buzzsaw” for state government.
At DHEC, Templeton found another wide-reaching agency, one she called “very, very disorganized.”
And she moved to restructure the agency in ways that frustrated longtime staffers. She consolidated the regional offices that monitored public health, for instance, a move that pushed some employees out of the agency.
“At that time, there was a tremendous loss of agency knowledge,” Learner, the former public health preparedness director, said.
In her run for governor, Templeton boasted that she’d slashed its budget. But in truth, DHEC had already faced its deepest cuts by the time she arrived. DHEC wouldn’t get much smaller, though it would continue to shrink.
“Everyone was sure I was going to wipe DHEC clean, and I didn’t do that,” Templeton said in a recent interview.
Instead, DHEC inherited Templeton’s cost-cutting ambitions as South Carolina’s economy was rebounding and the state budget was recovering. When DHEC was poised to rebound, she was loath to ask for more money, the agency’s budget requests show.
DHEC’s long list of “critical needs” gave way to small requests, like a few million dollars to clean up a bankrupt landfill or pull abandoned chemical tanks out of the ground. One year, she made a single request for funding — to upgrade the agency’s technology.
DHEC stopped requesting money to plan for pandemics and public health disasters like it had under Hunter. The agency’s infectious disease workforce stopped shrinking, but after losing a third of its staff, low staffing set in as the agency’s new normal.
State Sen. Thomas Alexander, R-Walhalla, who chairs the Senate subcommittee that controls DHEC’s budget, said the agency was one of many slashed in the recession. But when it came time to rebuild, he said lawmakers depended on agency directors to tell them what they needed.
“Public health is critical, and certainly this puts the spotlight on how important it is to us day in and day out,” Alexander said.
When Templeton’s successor, Catherine Heigel, took over in 2015, morale throughout the agency was “low,” she said.
Things were particularly bad in public health. The agency had lost more than a third of its infectious disease staff from its high before the recession to its low point then.
Heigel asked for more money to give nurses raises, address tuberculosis outbreaks and hire four more epidemiologists, professionals who study infectious disease. Without more staff, the agency said its response to outbreaks of disease would be delayed.
Like Templeton, Heigel didn’t specifically request money to prepare for a pandemic. She said her budget requests were meant to rebuild the agency, but she had to be strategic: She knew that she couldn’t go to legislators with a complete list of all the needs the agency had. DHEC would have to pick its shots.
DHEC won funding for the extra epidemiologists. But even so, when the Council of State and Territorial Epidemiologists surveyed state health departments a year later, it found that South Carolina's staffing was relatively low. Other states its size had, on average, twice as many epidemiologists per resident, the group found.
“We did a lot of rebuilding, but we had a long way to go,” Heigel, who resigned from the agency in 2017, said.
A crushing challenge
South Carolina's coronavirus outbreak started with a trickle. At first, there were only a few known infections.
DHEC announced just a few cases a day in the first weeks of the outbreak, and it could explain where many of them came from. They were found in people who'd just gotten back from Italy or visited with friends who turned out to be sick. DHEC set out to retrace their steps and find out who they might have exposed.
But troubling signs soon emerged. Infections erupted in places such as the small city of Camden, east of Columbia, and cases couldn't be linked to one another. The virus was moving from resident to resident, spreading throughout the community, and it snuck across the state.
Soon it would be found in every county, large and small. Thousands would fall ill and dozens would die. The outbreak's true extent is still a mystery.
Early on, officials like Dr. Linda Bell, the state epidemiologist, assured the public that they should "continue their daily routines." Within days, as the breadth of the virus's spread across the state became clear, schools were closed, restaurants were shuttered, and people were urged to be vigilant about keeping their distance from others.
By the end of the month, DHEC abandoned its effort to track down everyone at risk of catching COVID-19, saying the virus was too widespread for its staff to keep up.
DHEC’s infectious disease staffing has rebounded modestly in the past few years, but its workforce is not what it used to be.
It’s smaller than it was before the Great Recession, meaning the state has fewer people to hunt down disease in a state that has a half-million more residents. South Carolina today has just 340 full-time positions in its budget dedicated to tracking infectious diseases, compared to 428 before the recession. (DHEC says that including temporary and hourly workers, its infectious disease workforce includes 475 people.)
Staffing has fallen in all areas of public health. Federal data show that South Carolina’s public health workforce has been slowly dwindling since the turn of the century, falling more than a third in all. Only Florida and Idaho have fared worse.
“The tragedy is that we have lost workers but the workload has increased. We have fewer workers doing the job of many,” said state Rep. Gilda Cobb-Hunter, the top Democrat on the House’s budget-writing committee. “These budget chickens have come home to roost and all of us will pay for it.”
The state’s infectious disease workforce normally focuses its attention on infections like HIV and tuberculosis, trying to stop outbreaks before they become widespread.
Their day-to-day work is similar to the task DHEC will soon face with COVID-19: to quickly detect when someone has been infected and track down everyone who might be at risk, a process known as contact tracing.
“Doing the things we need to do as a state to address the routine outbreaks absolutely puts us in the position we need to be in to deal with the pandemic,” Heigel said.
But now DHEC will have to do it on a much larger scale to prevent a second surge of coronavirus infections once the first wave crests. Federal guidelines released Thursday say that states need to be able to find and investigate cases before they start getting back to normal.
When DHEC stopped investigating every infection, the state was reporting an average of about 50 new cases a day. Now, it's seeing three times as many, with the peak yet to come.
"Obviously, looking forward, we now understand the importance of being prepared for pandemics like this," said state Rep. Murrell Smith, the chair of the House Ways and Means Committee. "This is going to change our priorities as it relates to funding, especially with DHEC. I presume that there would be an emphasis to ensure there's appropriate funding in the infectious disease area."
Public health experts have estimated that the U.S. would need to assemble 100,000 people to do enough contact tracing to stop the virus’s spread. South Carolina would likely need a couple thousand, said Dr. David Cole, president of the Medical University of South Carolina, which is consulting with DHEC on a contact tracing plan.
DHEC has not said how it plans to ramp up its ability to investigate cases. The agency says it is dispatching epidemiologists and nurses around the state and more than 1,000 employees have played a role in its response to the pandemic.
The nation’s immediate need comes against a backdrop of health departments that have been weakened around the country since the last recession, according to the Trust for America’s Health, a non-partisan health policy group.
Local health departments lost more than 55,500 staff in the decade after 2008. The group ranked South Carolina as among the least prepared states to protect the public in an emergency.
“Persistent underfunding of the country’s public health system has left the nation vulnerable,” John Auerbach, the group’s president, said in 2018.
South Carolina and the rest of the country are likely to face difficult financial decisions again soon. The pandemic has brought the state’s economy to a halt for weeks and caused tens of thousands of layoffs here. No one knows how much the economic damage will cost state coffers.
Gov. Henry McMaster's office defended the state's response to the pandemic, saying the problems South Carolina has encountered have been seen nationwide. But Brian Symmes, a spokesman for the governor, acknowledged a need for more preparation.
“While the state regularly plans and prepares for these situations, there’s no denying the fact that the pandemic has highlighted a need for the entire world to more heavily focus on the possibility of another," Symmes said in a statement. "Part of the 'new normal' will almost certainly include strategic investment in the plans and resources that will help combat it.”
As the virus spread across the state last month, South Carolina health officials scrambled to manage a surge of illness its experts had predicted long before. Its labs faced a crush of samples to test. State lawmakers quickly handed DHEC $45 million to address the crisis, a sum that could have funded its requests for pandemic planning money for more than four decades.
The agency used it, in part, to hire about 90 temporary employees, including 12 that had once worked on its staff. Yet even amid this rush, the agency lacked a permanent public health director. That position wasn’t filled until Friday.
Seanna Adcox and Andy Shain contributed to this report.