Local and state health departments across the U.S. monitor communities for infectious disease outbreaks, ensure that restaurant food is safe, and provide walk-in immunization and clinics for sexually transmitted diseases. Yet since the financial crisis began in 2007, 40 percent of the nation's health departments have suffered serious budget cuts that have forced them to shed a quarter of their workforce. Many experts fear that these cutbacks are putting the country at risk for epidemics.

Consider Duval County, Florida: it is in the midst of the worst tuberculosis outbreak in the U.S. in 20 years, yet in March, Florida governor Rick Scott signed a bill downsizing the state health department and closing A. G. Holley State Hospital, which specialized in treating tuberculosis patients who were not taking their medications, a practice that spurs drug resistance. (Mike Haridopolos, president of the Florida Senate, has said that the budget helped make the state “more attractive to business owners and entrepreneurs,” in part because it did not raise taxes.) “The outbreak is among the very people who were typically candidates for A. G. Holley,” says Marc Yacht, former president of the Florida Public Health Association. Some patients were transferred to other hospitals, and the four who were discharged are considered noninfectious, and health workers are checking on them daily, reports the Florida Department of Public Health.

In California, which has more than one fifth of the country's TB cases, recent budget cuts have forced more than a quarter of local health departments to cut basic clinical services and surveillance for the disease. “We're setting ourselves up for a resurgence,” says Robert Benjamin, former tuberculosis controller for the Alameda County Public Health Department. The Centers for Disease Control and Prevention estimates that more than 11 million Americans—among them 2.5 million Californians—have latent TB infections that can become active.

Immunization services have also been hit hard. Snohomish County, Washington, is the epicenter of an ongoing pertussis (whooping cough) outbreak that started in March 2011. To curb its spread—pertussis can kill young infants—the county health department recommends vaccinations for kids and adults. Yet in 2009 budget cuts forced the department to halve its immunization clinic hours and to eliminate 30 percent of its full-time staff. Montgomery County, Texas, recently canceled an annual event that provided kids with free or low-cost vaccines—which is a problem, considering that one third of young children in Texas have not received all their recommended vaccinations. The crisis has prompted the Institute of Medicine to hold a meeting in Washington, D.C., to discuss how health departments can continue to provide essential services in the face of dwindling resources.

A lack of awareness about what health departments do contributes to the funding woes. “When departments are doing their jobs well, nothing happens,” says Robert Pestronk, executive director of the National Association of County and City Health Officials. Yet, he argues, health departments are as important as police and fire departments. “We may not wear uniforms,” says Gary Goldbaum, director of the Snohomish Health District, “but we're also doing lifesaving work.”