CHARLOTTE, N.C. – Americans are losing a vast array of people and programs dedicated to keeping them healthy. State and local health departments responsible for invisible but critical work including inspecting restaurants, monitoring wastewater for harmful germs, responding to outbreaks and other tasks to protect both individuals and communities are being hollowed out.

The Trump administration is cutting health spending on an unprecedented scale, experts say. It’s pulled $11 billion of direct federal support and eliminated 20,000 jobs at national health agencies that in part support local public health work. It’s proposing billions more be slashed.

Public health leaders said the cuts are reducing the entire system to a shadow of what it once was and threatening to undermine even routine work – even as the nation faces threats from diseases like measles, whooping cough and bird flu.

The moves reflect a shift away from the very idea of public health: doing the work that no individual can do alone to safeguard the population as a whole.

Here are some takeaways from The Associated Press examination of how federal cuts to public health are affecting communities and people across the United States.

Disease prevention is unseen — and ignored

Prevention work is low key. It’s impossible to identify who was saved because, if it goes well, the person never knows when they’ve fended off a mortal threat with the invisible shield of public health.

The health department in Mecklenburg County, North Carolina, for example, has run a mobile clinic that it brings to high schools to ensure students are up-to-date on shots for diseases like measles and polio. Those shots help both the student and the wider community stay healthy — if enough people are vaccinated.

U.S. health departments run programs to reduce suicides and drug overdoses, improve prenatal health and help people stop smoking. They educate people about health and test for and treat diseases such as HIV and tuberculosis. Some, including Mecklenburg, operate medical and dental clinics too.

The work departments do is also cost effective, experts have found. For every dollar spent on childhood immunizations, the country is estimated to save $11; on tobacco cessation, $2-$3; on asthma control, $70.

Chaos in Washington puts ‘lives at risk’

State and local health departments depend on federal money and support. The U.S. Centers for Disease Control and Prevention sends about 80 percent of its budget to states and local communities and helps those departments with its expertise and other resources.

When the Trump administration pulled $11 billion from state and local health departments without warning in March, then laid off thousands of people at CDC a week later, public health leaders said the cuts delivered a serious blow to communities across the country.

All eight employees dedicated to the mobile vaccine program in Mecklenburg were laid off. Nine disease intervention specialists in Columbus, Ohio, were let go as the department prepared to address a measles outbreak. Nashville had to end a program offering free flu and COVID tests.

Meanwhile, tobacco hotlines, early intervention programs for children who are deaf or hard of hearing, and programs to prevent drowning are all being affected in states and communities because CDC teams were laid off.

A spokesman for the U.S. Department of Health and Human Services said HHS is reorganizing what he said were “broken systems” and rejected “the implication that HHS has turned its back on urgent health threats.”

HHS justified the grant cancellations by saying the money was for COVID and the pandemic is over. But most of the cuts were in areas that are especially important given today’s health threats, including epidemiology and laboratory capacity as well as immunizations.

Connecticut’s state health commissioner told a Democratic congressional hearing the current uncertainty “puts lives at risk.”

Public health funding is going bust — and about to get worse

The new cuts are especially damaging because health departments are funded differently than other government agencies meant to protect the public: Funding pours in during emergencies and slows to a relative trickle when they subside. Public health leaders often cite the contrast with fire departments, which are kept ready at all times, not scrambling to find firefighters and fire trucks when houses are already burning.

A temporary surge of money during the pandemic allowed some health departments to expand and strengthen programs. But by early this year, most of that money had disappeared, along with other COVID-era grants across the nation — some because they ended and some because the government rescinded them. Departments were again left brittle and vulnerable.

In Chicago, one-time COVID grants made up 51% of the health department budget, and their ending will push staff numbers below pre-pandemic levels — slowing responses to outbreaks and forcing officials to scale back food safety, violence prevention and other programs.

In Mecklenburg, the department lost 180 employees as COVID funds dried up. It also lost a wastewater monitoring partnership with the University of North Carolina at Charlotte that helped the county react quickly to changing COVID variants and could have also been used to detect new threats like bird flu.

The cuts are not over.

The Trump administration has proposed cutting billions more from CDC’s budget, enough to cut the agency’s spending in half. CDC sends about 80 percent of its budget to states and local communities

Public health leaders warn the the relentless cuts to the system leave departments unable to respond to new pandemics and old diseases returning across the United States.

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Ungar reported from Charlotte and Louisville, Kentucky, and Smith reported from Providence, Rhode Island. Associated Press reporters Mary Conlon in Washington and Kenya Hunter in Atlanta contributed to this report.