Baltimore is struggling with its public health. Sexually transmitted infections are rising, and infant and maternal health disparities continue. Opioid overdoses have dropped but remain substantial.

The city could stand to see a doctor.

For the better part of the past two years, Baltimore has been without a permanent health commissioner. On Friday, the city announced that Dr. Michelle Taylor, currently head of the Shelby County, Tennessee, health department, had been hired for that role.

She steps into one of the city’s largest departments, one that is facing growing issues, say inside and outside observers. Long-running problems, such as proper staffing and building maintenance, have festered during the agency’s lack of a permanent leader. Lost funding means costs have trickled down to clients — potentially affecting their care — without anyone to seek out other solutions.

The challenges are only likely to grow with Republicans in control of the White House and Congress pushing a tax cut that’s partially funded by cuts to health programs.

Taylor already has missed a big opportunity to influence how money is spent from millions the city has been awarded through lawsuits against manufacturers and distributors of opioids. The department will get 25 new positions under the city’s proposed budget, a spending decision that could commit future years’ opioid settlement funds.

Baltimore Councilwoman Phylicia Porter, chairwoman of the council’s Public Health and Environment Committee, said the lack of permanent leadership has made it more challenging to coordinate with the department. It’s of the “most importance” to get stable management in place as federal cuts loom, Porter said.

“Approximately 30% of the Health Department is managed and programmed with federal grants,” she said. “We’re going to need to have a leader that is not only a visionary, but is able to leverage the assets we have at the state level and also the existing assets we have here in the city.”

Porter said Friday she believed Taylor was up to the task.

“I’m truly grateful that Dr. Taylor has not only the experience but also the cultural competency to serve in this role,” Porter said.

Mayor Brandon Scott’s administration terminated the previous commissioner, Dr. Ihuoma Emenuga, in July after she had just seven months on the job amid an investigation into her secondary employment at a health clinic. She was cleared of wrongdoing by state prosecutors and spoke out in an interview.

The agency had no leader for the eight months before Emenuga’s tenure and, in the 10 months since her departure, has been led by interim commissioner Mary Beth Haller.

Baltimore had long been known for commissioners who take big swings, from launching a needle exchange before most other cities to removing barriers for residents to access the opioid overdose remedy naloxone.

Amid the recent leadership vacuum, however, the department has had issues with the basics: billing, building upkeep and staffing.

“Baltimore City has, over the years, benefited from strong consistent leadership — most of the time,” said Dr. Georges Benjamin, a former state health secretary and executive director of the American Public Health Association.

Benjamin counts himself as an admirer of the department, which he said never had adequate resources but maintained a sense of mission.

The department, he said, is certain to face more funding cuts as public health funding and priorities undergo a major overhaul under the Trump administration.

In addition to grant funding, at stake is Medicaid, the federal-state health program for low-income residents. Scott said recently that the cuts to that program would be “devastating” for Baltimore.

“This is going to be the challenge a new commissioner comes into,” Benjamin said.

City officials acknowledged the challenges but say they’ve made progress while searching for Taylor.

Among the department’s core services are running health clinics for some of the city’s poorest residents and most marginalized. With a shrinking budget, clinics began charging for services, some for the first time.

Several people who have worked in the clinics expressed concerns to The Baltimore Banner.

The workers, who request anonymity out of employment concerns, said that charging for services has left some patients with large lab fees they couldn‘t pay that could interfere with their care. Workers described one patient who had outstanding bills totaling hundreds of dollars for HIV testing and the lab, left unpaid, wouldn’t continue monitoring him.

They’ve also been frustrated by long-running problems with buildings, specifically the Druid Sexual Health and Wellness Clinic, where a leak and rodent infestation forced a closure last year. The clinic reopened but splits hours for some 15,000 patients with another clinic.

It’s not what they said they signed up for.

“People had been doing wonderful things on a programmatic level with low resources,” providing “white glove care” for all comers, said one former worker, but “failures in leadership have destroyed that space.”

In a statement, city officials acknowledged issues but said they’ve been addressing them during the commissioner search.

“The Baltimore City Health Department is working with city agencies to upgrade infrastructure and ensure safe, welcoming spaces for patients and staff,” said Blair Adams, spokeswoman for the department.

Plans to replace the Druid clinic, one of the department’s most troubled facilities, have moved slowly. Baltimore’s spending board recently approved a loose agreement with Baltimore City Community College to explore moving the clinic to the school’s West Baltimore campus. The agreement, which does not obligate the city to lease the property, was necessary to avoid losing a 2023 state grant for the move, city officials explained.

Negotiations with the college for the space are underway, City Administrator Faith Leach said.

For the nearly year-old billing system, officials have added training to ensure staff understands how to bill patients properly and begun reviewing older charges. In some cases, the city is temporarily covering patients’ lab fees.

An audit of the Health Department’s contracting process and grant recipients is due to be presented soon to the city’s spending board.

The city also faced criticism for its seeming silence as the city’s opioid overdose rate skyrocketed.

Funding is an issue. Budget documents show the department absorbed cuts to special grant funding and lost more than 90 positions, about a 10% cut, in the latest fiscal year that ends next month. That’s on top of a sharp drop last year in funding for HIV programs, which have also become a particular federal target this year.

Lynda Dee, co-founder of the advocacy group AIDS Action Baltimore, said Baltimore’s and Maryland’s top leadership fail to prioritize public health.

“We could make HIV go away. We have the tools to do it,” she said. “They’re going to have to take some responsibility, and not just in who they hire. They can hire the best person in the world, but if there is no money, what are they supposed to do?”

Porter, the City Council member, said she most fears additional cuts could be coming to school health, nutrition and environmental justice programs in the department.

Money problems aren‘t new, though, according to Dr. Leana Wen, a former city health commissioner.

The foremost thought for the department, however, ought to be with city residents it serves — some of the city’s “most vulnerable,” Wen said.

“The department needs far more resources, not less,” Wen said. “I hope that the city will think through creative uses of the funding it received from the opioid lawsuit settlements to bolster core infrastructure that helps BCHD safeguard health.”

Antoinette Ryan-Johnson, president of the City Union of Baltimore, which represents some department workers, had other advice: “When things consistently change and it’s unstable, that trickles down,” she said. “There has to be steps where new leadership hears from workers, hears their very valid concerns and works in collaboration with them so we can ensure a healthy environment for the public.”