In rural Alabama, the COVID-19 pandemic has thrown a harsh light on the crumbling foundations of the state’s public health system. Alabama was recently ranked 46th in the nation for overall COVID-19 safety by Wallethub.com; the same study ranked it 50th for COVID-19 death rate and 50th for vaccination rate. This is the direct result of decades of criminal cuts to the public health budget.

Alabama has delegated the distribution of COVID-19 vaccines to the county health departments—a scheme bound to result in failure. Many of the county health departments have no full-time nurse on staff. Nurse practitioners are often shared between several different counties, and some departments only operate a few days a week.

Rural Coosa County, which has one of the highest rates of COVID-19 in Alabama, has no county health department at all. The Alabama State Department of Public Health (ASDPH) made no arrangements for alternate vaccination sites in the county; instead, it gave 500 vaccines slated for Coosa County to neighboring Tallapoosa County. The distance needed to travel to get vaccinated will cause added hardship and financial burden for the poor in this heavily rural state.

The problems are not new. They have developed over the years under successive budget cuts, as well as the state’s refusal to expand Medicaid coverage. Alabama has some of the nation’s most stringent Medicaid eligibility requirements; childless adults without a disability are denied coverage. The impact of this decision has not only been borne by the numerous impoverished, uninsured Alabamians, but by the state’s rural hospitals as well. Coosa County, for example, is one of eight counties without a hospital. There is a lot of slack for an underfunded, understaffed public health system to take up.

Jim Carnes, Policy Director of the Montgomery-based advocacy group Alabama Arise, wrote in the Montgomery Advertiser in February: “Fulfilling Alabama’s vaccination target goals will require levels of personnel, data management, communications and community engagement that ASDPH alone simply does not have.”

The chaos wrought in Alabama by the COVID-19 pandemic was not inevitable, but it was predictable. Alabama Public Health Officer Scott Harris told the Montgomery Advertiser on February 21: “It’s not any one person’s fault… there’s a lot of competing needs out there and there’s never enough resources to go around. But it’s become really difficult to try to keep up with all the things that we’re statutorily required to do. Things like inspecting restaurants, taking care of septic tanks and following up on animal bites.”

Alabama Department of Public Health has hemorrhaged staff for years. The agency has seen a 65 percent reduction in staffing over the past 12 years; it was stretched to its maximum capabilities well before COVID-19 hit the United States.

Lowndes County is located within the Black Belt, a region notable for the richness of its soil and the poverty of its residents. The county is infamous as the birthplace of disgraced Trump-era Attorney General Jeff Sessions and as “Bloody Lowndes,” the epicenter of some of Alabama’s most violent crackdowns on the civil rights struggle. Now, the sparsely populated county is notable for having the highest rate of COVID-19 deaths in Alabama. The county is home to fewer than 10,000 people, but over 50 residents have died of COVID-19-related causes.

In 2017, UN Special Rapporteur Phil Alston brought international attention to the deplorable state of Lowndes County’s sanitation, where raw sewage frequently runs directly out of homes into the surrounding soil and creeks.

“I think it’s very uncommon in the First World,” Alston remarked incredulously to a reporter at the time. “This is not a sight that one normally sees. I’d have to say that I haven’t seen this.”

The state of the county’s sewage systems had been well-known to public health experts in Alabama for at least a decade before Alston visited. Conditions resulted in a 2017 hookworm outbreak that garnered international attention. Hookworm is well-documented in impoverished, so-called “third world” countries in Southeast Asia and Sub-Saharan Africa. The backwoods of Lowndes County became infamous as the seamy underside of the richest country in the world.

The spotlight of international infamy did not lead to an amelioration of Lowndes County’s substandard sanitation. With a skeleton staff and a derisory budget, Alabama’s Department of Public Health is not equipped to offer resources or oversight.

In 2016, an unprecedented tuberculosis (TB) outbreak brought national attention to another Alabama Black Belt county. The tiny town of Marion, in Perry County, became the epicenter of a TB outbreak on a scale unseen in the industrialized world for over 100 years. With an incidence rate of 253 cases per 100,000 people, Marion’s tuberculosis infection rate was 100 times higher than the state’s rate.

Perry County is Alabama’s poorest county and is one of the most impoverished counties in the United States. As the Harvard School of Public Health noted, Marion’s TB infection rate was “also worse than many developing countries, including Afghanistan, India, and South Sudan.”

Phyllis Kanki, professor of immunology and infectious diseases at Harvard’s T.H. Chan School of Public Health, said in 2016 that Marion’s TB outbreak “illustrates the impact of poverty on healthcare delivery and epidemic control.”

Marion’s 2016 TB outbreak sounded a clear and insistent warning about the dangers of epidemics in Alabama’s rural communities. Alabama’s government responded by plugging its ears. Like Lowndes County, Perry County has fewer than 10,000 residents. It has reported 1,071 cases of COVID-19 at the time of this writing, with 27 deaths.

Alabama has long functioned as an illustration of the poverty, ignorance, and violence which accompanies the piling up of wealth by America’s capitalist elite. The state government’s wretched dereliction of duty regarding public health was well-documented before the pandemic, and the coronavirus has served to give clearer focus to that dereliction.

There was nothing inevitable about the alarming rates of COVID-19 transmission or death in rural Alabama; had the state acted when Lowndes’ sewage crisis became evident, or when Marion’s TB outbreak startled epidemiologists, the public health system would not be so woefully unprepared for COVID-19 testing, treatment, and immunization.

The reason for this crisis is the same as it is across the US. Throughout the pandemic, the stock market has enjoyed historical gains. The wealthy have become wealthier. The cost is borne, as always, by the working class, who must contend with sluggish vaccine rollouts and overburdened healthcare systems. Alabama’s pattern of public health crises and governmental disinterest will not change.

Workers throughout Alabama must recognize that the solution for these unconscionable conditions lies with them and within themselves and the working class internationally. They must act to halt capitalism’s assault upon their well-being and reorganize society to meet human need, not profit. In short, they must take up the fight for socialism.