The economic recession, beginning in the fall of 2008, resulted in a sharp reduction in the local public health workforce, threatening the capacity of these agencies to provide vital services to communities throughout the nation. At the same time, these funding shortfalls are causing an examination of the structural and organizational options for local agencies. In this issue of the Journal, Willard and colleagues1 studied the period between 2008 and 2010 by conducting 3 Web-based surveys of a nationally representative sample of local health departments (LHDs). These surveys administered by the National Association of County & City Health Officials revealed that by 2010, 53% of these agencies experienced reduced core funding. In 2009 alone, 23 000 jobs or 15% of the local public health workforce were eliminated. As described by the authors, these cuts have been inflicted on LHDs already weakened in the previous decade by substantial reductions in funding.

Future prospects look grim to reverse this trend of diminishing resources, compromised LHD workforce, and reduced capacity to maintain public health programs. No longer is one-time funding available from the American Recovery and Reinvestment Act or to address the H1N1 flu pandemic. President Barack Obama signed the Patient Protection and Affordable Care Act (PPACA) into law on March 23, 2010. Hailed by its supporters as the most comprehensive public health care reform in US history, this statute has done little to support the local public health infrastructure.2 Jacobson and Gostin3 write that despite its extensive concern for prevention and wellness, "PPACA takes the existing system as a given and does little to change the fundamental dynamic of how public health is organized, financed and delivered." The PPACA has established a "Prevention and Public Health Fund" under the US Department of Health & Human Services to support public health programs. This fund includes grants at the state and community level to promote public health initiatives. But the likelihood of the enactment of plans to reduce the federal deficits imperils these activities. State funding is an important revenue source for LHDs. Reducing the federal deficit by major reduction in discretionary funding will impact the states and lead to a further reduction in this funding stream to local agencies.

Reductions in governmental funding for public health during economic downturns are not unique to this period. Severe retrenchment of public health activities took place during the great depression of the 1930s. Budgets of local and state health departments were slashed at the same time as public health problems in their communities escalated.4 The country experienced tough economic times and high unemployment in 1981, the year after President Ronald Reagan took office. Funds for health programs for the poor were curtailed, and public health funding for states was bundled into block grants. While block grants may have been a simpler system than the previous categorical grants, overall allocations were significantly reduced. Concomitant deterioration in health indices was witnessed, resulting in the reversal of improvements in some diseases such as tuberculosis.

In 1988, the Institute of Medicine5 issued its famous report "The Future of Public Health," which emphasized the responsibility of organized government efforts to protect the health of the public. The conclusion of report, often quoted, was "that this nation has lost sight of its public health goals and has allowed the system of public health activities to fall into disarray" (italics added). The word "disarray" is central to this Editorial. Our pressing problem is not only disarray but also rapidly falling levels of funding to maintain the LHD, the center of the local public health system. Disarray can be defined "to put out of array or order; throw into disorder." Can the disarray be corrected through improved organization and systems in this time of reduced resources? It is questionable whether the public health system did as reported by the Institute of Medicine "fall into" disarray or whether this lack of organization has always been an inherent characteristic of local public health activities. Fee and Brown4 write, "Public health in the United States did not begin as a systematic, rational, centrally directed activity following a coherent plan but rather as a fitful, episodic, and necessity-driven response to immediate local threats." Now with falling funding, addressing the problem of disarray in local health services has grown in importance. There are currently activities at the local level to restructure health departments and organize them into regional systems. Several articles in this issue examine structural changes in individual departments or organizational changes in public health systems at the state level.

Kuehnert and McConnaughay6 of the Kane County Health Department (Illinois) report a case study in which an LHD realigned its structure and human resources in response to severe economic conditions. A significant budget reduction was realized. Despite a significant budget reduction, national accreditation standards were met. Their approach was to transition personal health services previously provided by the LHD to 3 federally qualified health centers in the community. This did result in the layoff of more than one-half of the LHD's workforce. The dynamics of retrenchment, strategic planning, establishing community partnerships, and the need for public health service research are described by the authors.

Richardson and colleagues7 in their article outline how in 1996 the LHD in Amarillo, Texas, divested itself of almost all personal health services and chose to retain only essential health services. This change, again, was in response to dramatic budget changes, but with the change in strategic focus, resources for some core population health functions actually increased.

In their article, Li-Wu Chen and colleagues,8 public health systems researchers, look at organizational changes at the state level. Instability of funding sources was a prominent finding of this qualitative study. A positive finding, however, was that directors of regional health departments play an important role in making resource allocation decisions based on community needs and not on a formula or county population size.

North Carolina and a number of other states are now planning or implementing new types of regional organizations of health departments. Pat Libbey, former executive director of National Association of County & City Health Officials, describes the growing trend for some financially strapped local and state governments to move toward regionalization as a way to contain cost and increase capacity. In his report for the Robert Wood Johnson Foundation, "Cross-Jurisdictional Relationships in Local Public Health," he describes beginning efforts in Colorado, Wyoming, South Carolina, Connecticut, New Hampshire, Nebraska, and Illinois.9 Regional efforts based on mostly informal collaborative efforts have been occurring in New York State for more than a decade.10

Will these organizational efforts resolve the difficulties caused by the funding reductions already taking place and those likely to take place in the future? The need for maintaining local public health funding will continue, but those resources can be used more effectively in a coherent system using sound allocation methods to apply resources, thereby providing capacity across all jurisdictions so that residents will receive a uniform set of core public health services. Public health is vulnerable to funding reductions. Despite the many health gains accomplished by public health activities, the public is accustomed to the accrual of long-standing benefits from these communal efforts. Quentin Young,11 former president of the American Public Health Association, remarked: "Turning on any kitchen faucet for a glass of drinking water without hesitation or peril is silent homage to public health success, which would not have been possible at the start of the twentieth century." The key word here is "silent." Libbey9 writes about the gap between elected officials and public officials in understanding population health. Indeed, in public discussions of our nation's educational problems, problems with mathematics and science skills are related directly to the entities responsible for them-the schools. But in the discourse of national public health, leaders attention is directed, understandably, to our health problems of obesity and tobacco but not to preserving the infrastructure of LHDs, which can provide the services to continue to protect the public from health threats and promote health by through community initiatives that address behaviors and lifestyles. An interesting finding of the Willard article is that funding reductions were less in LHDs with local boards of health. Board members serve as a constituency in their community. For this reason, some public health directors in North Carolina are wary of types of restructuring that would eliminate boards of health.

Efforts by the Public Health Accreditation Board to accredit local and state health departments will be important to promulgating standards of performance and expectation for these agencies. Out of the financial adversity, we are finally beginning to see efforts to tackle the organizational deficits in the array of LHDs and how they work together. Kuehnert and colleagues call for more public health systems and services research to tackle these problems at the local level. Continued investment by the Robert Wood Johnson Foundation in public health systems and services research promises to pay dividends for the development of LHDs anchoring coherent public health systems. The Journal of Public Health Management and Practice is now working with Glen Mays and Doug Scutchfield, of the University of Kentucky, on a special issue looking at public health systems and services research that will be published in October.

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