Karen Koenemann wakes up at dawn, rubs the sleep out of her eyes and immediately starts tapping away on her iPhone from her bed. The anxious emails that began to sprinkle in a few weeks ago are now a daily deluge for the public health director for Pitkin County, Colo.

Since the coronavirus reached U.S. soil, thousands of local health officials across the country have been working nonstop and scrambling to prepare. Pitkin County has not had a case, at least not yet, but Koenemann has helped businesses decide whether to cancel conferences, walked leaders through potential school closures, pored over response plans with the local hospital in the county seat of Aspen. And it is exhausting.

When an outbreak hits, public health departments are America’s front line of defense. They investigate the infected and trace their contacts with other people, take passengers’ temperatures at the airport, harangue the public to wash their hands. They advise local leaders on whether to cancel school, and they find facilities to isolate the sick from the healthy.

In the unfolding war against the coronavirus, they are already hamstrung — decades of budget cuts have left many local departments without the staff, equipment or plans to mount an adequate response. Local health departments say they’re already pulling employees from critical efforts such as opioid abuse prevention. A sudden burst of new cases could force them to choose where to divert resources and possibly endanger the public, experts said.

“They have to de-prioritize other things. Maybe they can’t adequately follow up on an HIV/STI outbreak in their community, or they can’t inspect a restaurant or a pool. It boils down to a diminished capacity to protect the community,” said Lori Freeman, chief executive of the National Association of County and City Health Officials. “Something is going to be put on the back burner, and we have to hope and pray that it’s not a critical function of the health department.”

In San Bernardino County, ­Calif., the staff is spread so thin that three paid interns from the health department have been handling most of the coronavirus groundwork, according to assistant health officer Erin Gustafson. Their main responsibility is to monitor about 390 recent travelers returning from China and other countries severely affected by the outbreak who have been asked to self-quarantine.

Other health workers in the county of more than 2 million are tied up with a hepatitis A outbreak that officials disclosed in early February, right around the time that the U.S. government started evacuating Americans from the coronavirus hot zone in Wuhan. The health department is also busy tracking residents who are being treated for syphilis and tuberculosis, largely among the county’s homeless population.

“We’re doing the best we can,” Gustafson said. “Following up on all those cases is challenging under normal circumstances.”

Local public health agencies have lost almost a quarter of their overall workforce since 2008 — a cut of almost 60,000 workers, according to national associations of health officials. The agencies’ main source for federal funding — the Centers for Disease Control and Prevention’s emergency preparedness budget — has been cut 30 percent since 2003. And the Trump administration has proposed cutting even deeper.

“The biggest cuts came during the last recession, and while other parts of government were restored over time, public health never was,” said John Auerbach, who worked on health policy for Boston, the state of Massachusetts and the CDC. Instead, over the past decade, local health departments have seen annual rounds of cuts, punctuated with one-time splurges in the wake of crises like outbreaks of Zika, Ebola, measles and hepatitis. That short-term funding quickly dries up and does nothing to address the long-term problems of preparedness.

“One-time, emergency money is great, but it’s not how you hire the right people or get the right supplies for future crises,” said Auerbach, who now leads the nonprofit Trust for America’s Health. “A forest fire is not the right time to start hiring firemen and buying firetrucks and equipment. It’s too late.”

One reason health departments are so often neglected and taken for granted is that their work focuses on prevention — of outbreaks, sexually transmitted diseases, smoking-related illnesses. “When you’re preventing something, it’s invisible,” Auerbach said. “The more successful you are, the less of that bad thing or crisis people see.”

King County, Wash. — which has the most coronavirus deaths in the United States so far — is an example of good funding and planning, experts say.

Within days of the first community cases emerging, the wealthy county, which includes the city of Seattle, had announced plans to buy an entire motel to house and isolate the infected, with three other lots being outfitted with self-contained trailers that have beds and water/sewer hookups.

Following a plan developed years in advance, other county work ground to a halt to divert extra staffers toward emergency response. The county launched a phone bank to take calls from residents and check on those quarantined. It began tracking public transportation ridership to gauge how many residents were abiding by its advice to telecommute. It established lines of succession for county positions six people deep in case county government workers started falling ill themselves.

What made almost all of it possible was a $24 million “rainy day fund” the county set aside for emergencies. “I’m not quite ready to declare it’s a monsoon, but it’s getting close to that,” the county’s budget director, Dwight Dively, said at a county council meeting last week.

The motel and the other three temporary housing locations alone will cost $14 million, Dively said in an interview. Then there’s the avalanche of overtime and medical costs, which he said will depend on how severe the outbreak becomes. “The total cost is beyond my ability to predict,” Dively said. “My best guess is many, many, many millions of dollars.”

The county plans to spend whatever is needed now to save lives and wait to see how much federal and state officials are willing to reimburse. But most counties don’t have that luxury.

“If this spreads beyond King County, we have smaller counties in Washington who are not going to have money to throw at the problem like we have,” he said.

Crucial support came Wednesday when Congress passed an $8.3 billion emergency spending bill to combat the coronavirus. Roughly $950 million will help pay for an array of local response activities, including lab testing and infection control, and will reimburse state and local agencies for some of the work they’ve already done. But it could take months for that money to filter from the Department of Health and Human Services to CDC to states and finally to counties. In the wake of national disasters, some counties pointed out, federal reimbursement sometimes takes as long as three years to reach them.

In rural Pitkin County, the threat of coronavirus looms especially large. The population is small, about 18,000, but the county seat of Aspen is a year-round tourist destination and host to international events such as the winter X Games — bringing new travelers and potential vectors for transmission every month.

For days, Koenemann and her skeleton crew of eight staffers have fielded a growing list of community concerns. Hotel workers want instructions on how to clean rooms if a guest is infected. A skiing company wants feedback on its pandemic plan. Organizers want to know if they should cancel upcoming conventions.

Koenemann said her workdays have become a blitz of conference calls and group huddles. A recent day started with an early meeting about how to cover the work of the department’s only epidemiologist when she goes on maternity leave. Then there was a communications meeting and a check-in with the county emergency manager. After that, a meeting with health directors in neighboring counties, followed by a meeting with a local hospital team.

In between, in a phone call with a reporter, she wondered aloud how her team will fare once the outbreak reaches Aspen. “For a tiny little team,” she said, “it’s pretty inundating right now.”

By the end of the day, Koenemann realized she hadn’t even had lunch, and there was already another pile of urgent emails waiting in her inbox.

Maria Sacchetti and Jay Greene in Seattle contributed to this report.

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