Colorado public health officials vaulted to prominence three years ago when residents started to sicken and die of COVID-19, kicking off a pandemic that would spark fierce, even violent political debate and offer clear lessons for the future.

At the outset, the outpouring of response was vast and relatively harmonious. Crafters made thousands of masks, local colleges made 3-D printed face shields, pilots flew badly needed personal protective equipment to rural hospitals in dire straits. Residents beat together pots and pans or howled outdoors at 8 p.m. to demonstrate noisy support for health care workers.

Moreover, many agencies and hospitals came together to provide testing. Vaccinations came online with incredible speed.

But as the pandemic wore on, community resolve started to fracture.

For example, the now dissolved Tri-county Health Department became the target of vandalism, death threats and a huge number of angry voicemails, said Dr. John Douglas, the former executive director of the department.

The outrage over mask mandates and social distancing rules was directed to Jefferson County Public Health, as well, said former Executive Director Dr. Mark Johnson, who went from hearing the supportive clamor in the evening to getting threatening emails, voicemails and social media messages.

“We had to have a police car parked in front of our house because of death threats,” said Johnson, who delayed his retirement to help lead his department through the crisis.

In El Paso County, some in the community revolted against steps to slow the spread, protesting masks and social distancing. In 2021, signs at an Academy School District 20 protest read “Masks are theatre” and “Fear is being used to control you.”

Angry residents lined up to speak at El Paso County Board of Health meetings and some insisted to the El Paso County coroner that they did not believe their loved ones had died of COVID.

“There were no perfect solutions — we were doing too much for some and not enough for others and that is the world we lived in at that time,” El Paso County Public Health Director Susan Wheelan said.

Nationwide, 46% of public health employees in state and county agencies left their jobs between 2017 and 2021, demonstrating the impact of the burnout and deep political pressure, according to a study in Health Affairs.

Across Colorado, numerous public health department directors retired, quit or were fired by unhappy county commissioners. Six county health departments are without directors — Jefferson and Gilpin counties share a director — and at least two formerly unified departments have split.

Tri-county Health Department formerly served Arapahoe, Adams and Douglas counties and is now three separate departments. Douglas County pulled out over a mask mandate in schools and Adams County followed, but didn’t give clear reasoning, Douglas, the former director, said. San Juan Basin Health Department, which served La Plata and Archuleta counties in the southwest corner of the state, is also splitting following coronavirus sparked disagreements.

Tri-county officials fended off a split over mask mandates for a year, but when the state phased out requirements and debates over local masking took over, Douglas County decided to leave.

“In the middle of the pandemic was the worst possible time to break up a health department,” Douglas said. But the transition is finalized and it could have gone much worse than it did, he said.

Now, public health is facing a new challenge — pandemic amnesia and a possible failure to act on lessons learned.

Essentially, public health needs rebuilding, said Dr. Jon Samet, dean of the Colorado School of Public Health.

Officials need to rebuild public health staffing, better integrate health care and public health systems, stockpile supplies to provide better respiratory protection to workers in high-risk industries in case of future risk and invest in updating public health databases, among other steps, Samet said.

“Public health was never funded enough, and I think the need to rebuild is pretty well recognized,” he said. “Whether there will be major initiatives to try and promote rebuilding, I think we will have to wait and see.”

However, Samet is concerned needed investments will not happen, now that the immediacy of the pandemic has passed.

“The time to make that investment is now and not to wait to the next pandemic,” he said.

Douglas would like to see investments in public health workers who would build connections with harder to reach communities, such as rural and Hispanic residents. They could work on ongoing health priorities such as mental health and cardiovascular screening and then transition into trusted messengers during a new pandemic. Colorado saw a large gap between the rates of vaccination among Hispanic and white residents for months.

Better coordination between the federal, state and local agencies is also critical in a future pandemic, Johnson said, because the failure to properly distribute medical supplies from the national stockpile turned into a fight among the states for supplies, he said.

“The foundation of emergency response for public health has really been called into question by this pandemic,” he said. He also does not think the public health workforce is as strong as it was before COVID-19.

Despite public health director vacancies, Scott Bookman, the state’s COVID incident commander, said Colorado is “without a doubt” better prepared for the next pandemic in terms of incident response, referring to a state plan for COVID-19 recovery and future preparedness called Colorado’s “Roadmap to Moving Forward.”

The roadmap, announced in February 2022, includes a set of recommendations that could keep the state from being caught flat-footed in the future by a novel coronavirus. Those points include establishing hospital readiness standards, surge planning and normalizing COVID-19 as patient care in regular medical settings, engaging the federal government in pandemic readiness policy and investing in health care workforce stabilization and expansion.

Bookman said those rapid-response strategies have already been implemented in the state, like when monkeypox was first detected in El Paso County in July or when Uganda reported an Ebola outbreak in September.

In November, the state announced a $10 million “recruitment and re-engagement fund” aimed at encouraging registered nurses, respiratory therapists, certified nurse aides and others with active, inactive or expired licenses to return to the health care industry.

Since then, 26 facilities have submitted an Intent to Apply form, which includes proposed spending plans, and one has submitted the Request for Award form as proof of a successful hire, a spokesperson said.

Based on those submissions, the Colorado Department of Public Health and Environment said roughly $5.2 million could be dispersed, and an estimated 258 health care workers could return to the industry.

“Anything we can do to get experience back into the workforce while we’re training up the new workforce concurrently will allow us to stabilize our systems,” Bookman said.

Samet said it is also possible the U.S. is experiencing a “false sense of optimism that we are out of the pandemic.”

The omicron surge in COVID-19 that swept Colorado in January 2022 and the high rates of vaccination have left the population more protected against severe illness and death, but Samet said that it may not last, if the virus mutates and immunity wanes.

In terms of future priorities, public health has lost ground with life expectancy dropping three years in Colorado between 2019 and 2021 because of the coronavirus and illicit drug overdoses.

“We have gone backwards between COVID-19 and opioids and other mental health issues,” Samet said.

The coronavirus also exacerbated mental health challenges for many and brought them to the forefront in a way never seen before.

But Samet noted that “deaths of despair” were up before COVID and the drop in life expectancy was happening in certain segments of the population before the pandemic.

El Paso County officials are shifting to focus on promoting mental wellness and working to prevent substance abuse, suicide and other issues. A full list of updated community priorities is expected in April, Wheelan said.

One of the largest public health challenges is a lack of social connection, which can contribute to depression and mental health challenges, particularly among youth.

“That lack of human connectedness I think is underlying a lot of the challenges that we are seeing,” Coroner Dr. Leon Kelly said.

He is hopeful that a focus on youth wellness will help unite the community.

To tackle the challenges, El Paso County Public Health added staff through the pandemic, funded in part through grants and a five-year plan to boost staff. The department had 148 positions in 2018 and now is funded for 200 people, Wheelan said. But the average size of a public health department for a community like El Paso County is 269 full-time positions, spokeswoman Michelle Beyrle said.

The department has 16 vacancies and struggled the most with recruitment and retention of nurses, Beyrle said. Through the pandemic, turnover rates declined. In 2019 the turnover rate was 14%, in 2020 it was 11% and in 2021 and 2022 it reached about 8%, data provided by the agency showed.

Wheelan said she endeavored to hold the staff together through grueling hours and stay focused on the data and solutions rather than the political aspects of the pandemic. Now, she encourages her staff to take time off to rebuild their resilience.

“It was the most difficult part of my career in public health and I hope it stays that way,” she said.

As the more extreme emotions of the pandemic have passed, some people who disagreed with public health’s approach have come to appreciate the impossible situation officials faced in a scary time with limited information, Kelly said.

“I have been struck by the overwhelming appreciation,” he said.