A sustained, widespread pandemic would overwhelm many departments that are struggling with cutbacks as well as increased demand from people who have lost jobs and medical insurance.
Stung by the lean economy, 13 states and U.S. territories had smaller health budgets in 2008 than in 2007, and eight more made midyear cuts, according to a survey by an advocacy group, the Association of State and Territorial Health Officials. With local budgets also in trouble, many health officials fear a serious outbreak.
"We would be in a lot of trouble," said Alameda County's director of public health, Anthony Iton in Oakland. "We weren't tested to push the system to see how it responds when you have to make hard decisions. I worry about that because the resources have been cut."
A review by the U.S. Health and Human Services Department in January noted great strides in preparedness but said many shortfalls remain. They include the ability to maintain public health functions such as food safety and daily needs during a pandemic, and the capacity to meet surges in health care demand and to strategically close schools.
State capabilities vary. But some local departments, strapped by layoffs and working overtime on swine flu, say they could not maintain the pace in a major outbreak. An Associated Press review found troubling signs:
"Who will be around to do these things?" she said.
"We have good plans and we're exercising them," said Matthew A. Stefanak, health commissioner of Mahoning County, Ohio, whose work force dropped 20 percent in two years. "But for the nuts and bolts of an outbreak - contact investigations, probable cases of H1N1 flu - we don't have the manpower, the trained disease investigators the public health nurses who would do it. That's where we're weakest right now."
Last year at least 10,000 local and state health department jobs were lost to attrition and layoffs, including at laboratories that identify disease strains, according to surveys by the state and territorial group and the National Association of County and City Health Officials.
An annual flu-shot clinic no longer comes to town hall in Berlin Center, Ohio. "The real danger is how many just won't get shots," said Ivan Hoyle, 78.
Public health nurses such as Erica Horner won't deliver in-home newborn help in Mahoning County. With the program closed, Horner's duties will change.
Ann Cappabianca, one of the remaining nurses, scrambles to track communicable disease and tuberculosis cases. "We just can't get it all done. You try to focus on the most important thing at the moment," she said.
Worst is having to make cuts without "enough ability to assess the needs of my community," said Bob England, the health director of Arizona's sprawling Maricopa County, which closed its family planning clinic.
Public health departments will get some help from this year's stimulus spending of $1 billion for prevention and wellness efforts.
But it will take years to bring local health agencies to the point where they can fight a sustained, widespread pandemic, said Richard Hamburg, a lobbyist at the nonprofit Trust for America's Health, an advocacy group supported by private and government grants.