Tisha Coleman has lived in close-knit Linn County, Kansas, for 42 years and never felt so alone.
As the public health administrator, she's struggled every day of the coronavirus pandemic to keep her rural county along the Missouri border safe. In this community with no hospital, she's failed to persuade her neighbors to wear masks and take precautions against COVID-19, even as cases rise. In return, she's been harassed, sued, vilified and called a Democrat, an insult in her circles.
Even her husband hasn't listened to her, refusing to require customers to wear masks at the family's hardware store in Mound City.
"People have shown their true colors," Coleman said. "I'm sure that I've lost some friends over this situation."
By November, the months of fighting over masks and quarantines were already wearing her down. Then she got COVID-19, likely from her husband, who she thinks picked it up at the hardware store.
Her mother got it, too, and died Sunday, 11 days after she was put on a ventilator.
Across the United States, state and local public health officials such as Coleman have found themselves at the center of a political storm as they combat the worst pandemic in a century. Amid a fractured federal response, the usually invisible army of workers charged with preventing the spread of infectious diseases has become a public punching bag. Their expertise on how to fight the coronavirus is often disregarded.
Some have become the target of far-right activists, conservative groups and anti-vaccination extremists who have coalesced around common goals: fighting mask orders, quarantines and contact tracing with protests, threats and personal attacks.
The backlash has moved beyond the angry fringe. In the courts, public health powers are being undermined. Lawmakers in at least 24 states have crafted legislation to weaken public health powers, which could make it more difficult for communities to respond to other health emergencies in the future.
"What we've taken for granted for 100 years in public health is now very much in doubt," said Lawrence Gostin, an expert in public health law at Georgetown University in Washington, D.C.
It is a further erosion of the nation's already fragile public health infrastructure. At least 181 state and local public health leaders in 38 states have resigned, retired or been fired since April 1, according to an ongoing investigation by The Associated Press and KHN. According to experts, this is the largest exodus of public health leaders in American history. An untold number of lower-level staffers have also left.
"I've never seen or studied a pandemic that has been as politicized, as vitriolic and as challenged as this one, and I've studied a lot of epidemics," said Dr. Howard Markel, a medical historian at the University of Michigan. "All of that has been very demoralizing for the men and women who don't make a great deal of money, don't get a lot of fame, but work 24/7."
One in 8 Americans — 40 million people — lives in a community that has lost its local public health department leader during the pandemic. Top public health officials in 20 states have left state-level departments, including in North Dakota, which has lost three state health officers since May, one after another.
Many of the state and local officials left due to political blowback or pandemic pressure. Some departed to take higher-profile positions or due to health concerns. Others were fired for poor performance. Dozens retired.
KHN and AP reached out to public health workers and experts in every state and the National Association of County and City Health Officials; examined public records and news reports; and interviewed hundreds to gather the list.
Collectively, the loss of expertise and experience has created a leadership vacuum in the profession, public health experts say. Many health departments are in flux as the nation rolls out the largest vaccination campaign in its history and faces what are expected to be the worst months of the pandemic.
"We don't have a long line of people outside of the door who want those jobs," said Dr. Gianfranco Pezzino, health officer in Shawnee County, Kansas, who is retiring from his job earlier than planned because, he said, he's burned out. "It's a huge loss that will be felt probably for generations to come."