Exhausted, frustrated, facing personal threats and political pressure, public health officials nationwide are departing their posts at a rate never seen before, and in the middle of a pandemic.
More than 180 state and local public health leaders -- high level health department staffers in at least 38 states -- have resigned, retired or been fired since April 1, according to an analysis by Kaiser Health News and The Associated Press. It is the largest exodus of public health officials in American history, experts say.
One in eight Americans -- roughly 40 million people -- lives in a community that has lost its local public health department leader during the coronavirus pandemic, the analysis found.
"This has been a major, unprecedented loss in public health leadership across the nation," Dr. Richard Besser, former acting director of the Centers for Disease Control and Prevention and president and CEO of the Robert Wood Johnson Foundation, told ABC News.
While prepared to handle the relentless strain that comes with managing the COVID-19 crisis, officials told ABC they had not anticipated the cross purposes of scientific response and political backlash -- in both red and blue states -- that hamstrung the offices in which they'd been tasked to serve -- and where some said they found little support from their leadership.
"This past year, you saw public health as a science and as a field being berated and belittled," Besser said. We saw it being lifted up as the enemy of economic recovery -- rather than the path to sustained economic recovery."
The contentious atmosphere between political and public health risks eroding trust and morale in the system, experts say; that only gets exacerbated as science becomes the target of public ire -- and physical threats.
In Kansas, Nick Baldetti relied on the local police department to patrol his home to protect his family for about a month. He resigned as director of the Reno County Health Department in July.
"While the vitriol experienced was unnerving, when threats were left on our doorstep it was far more concerning," said Baldetti. "It is one thing to be threatened, but when those threats cross over to your family, it is another stress all together."
In Colorado, at least 20 health officials resigned after facing threats in public, the state health department told ABC News.
In Missouri, a dozen county health department directors have left their jobs since March, according to local reporting. Many of them said they had experienced harassment over the actions they took to curb the spread of the coronavirus.
After seeing sudden resignations within her own board of health officials from across the country, Lori Freeman, CEO of the National Association of County Health Officials, a Washington, D.C.-based organization which includes nearly 3,000 county health departments, decided to investigate why health officials were leaving, at a moment when the premium on clear, consistent public health guidance has never been higher.
"The top reason was politics," Freeman told ABC News. "That constant level of pressure from the public and from elected officials."
For Dr. Gianfranco Pezzino, who had worked as a health officer for the Shawnee County Health Department in Kansas for 14 years, it wasn't the long hours he put in on the job fighting COVID-19 that pushed him to resign in December. It was months of fighting over how to contain the coronavirus -- and feeling that neither safety, nor science, were winning.
"The tension kept growing and we were getting more and more pushback," Pezzino told ABC News. "The moment that this became a political issue instead of a public health issue, that was the beginning of all the major problems."
In Montana, a four-person health department serving 6,000 residents in Pondera County resigned in November, claiming county commissioners undermined their virus prevention advice and criticized what they called a lack of COVID-19 support.
In California, Dr. Aimee Sisson is among several health officers throughout the state who have resigned in the wake of friction with elected officials, departing from her role as Placer County public health director after a unanimous vote by the board of supervisors in September to end the local COVID-19 health emergency declaration, in defiance of her guidance.
"It was the last straw," Sisson told ABC News. "Ultimately, it came down to feeling like I wasn't able to do the job that I was hired to do."
Sisson had expected harassment as part of the job, given the fraught political climate where simple mask-wearing had quickly become a national flashpoint -- but the friction amongst the county leaders paired with physical threats from angry strangers proved a difficult double-whammy.
"No one ever said, 'I want to kill you with a knife on Thursday,'" Sisson said. "They did threaten bodily harm. It was clear, they wanted me gone from my position."
Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials, told ABC News the criticism of public health officials have never been this high.
"You have to be comfortable with controversy and some criticism in this job -- but we've just never seen this level of controversy, and particularly this level of criticism," Plescia said. "And I think that's what's really taking the toll."
Tensions amongst state and local leadership have escalated across the country, particularly in New York, where a string of nine high-level departures in the New York Health Department over the pandemic's many months has inspired scrutiny over esprit de corps in leadership.
New York City Health Commissioner Dr. Oxiris Barbot, who resigned in August, criticized the city's handling of the pandemic.
"I leave my post today with deep disappointment that during the most critical public health crisis in our lifetime, that the Health Department's incomparable disease control expertise was not used to the degree it could have been," Barbot wrote in her resignation letter, obtained by ABC News.
The departures have led to questions over whether brewing discord between executive powers and career public health experts had fomented several staff exits.
The New York Times reported that friction between state health officials and Gov. Andrew Cuomo increased with a unilateral leadership style, announcing policy changes at press conferences and requesting his health team retrofit their guidance accordingly.
Asked by ABC News about his staff's departures, Cuomo pointed to the pandemic's unprecedented stresses, and the "incredibly challenging" response.
"It's highly stressful, highly challenging, highly exhausting, highly fatiguing," Cuomo said Tuesday. "It's not what a lot of people signed up for. It's not what a lot of people want to do, it's not what a lot of people can do."
Sisson said she doesn't see a need to be vested with sole authority -- but emphasized -- collaborative effort is crucial.
"Where I get concerned is when public health is not one of the key voices -- or doesn't get a set of keys at all to what's driving our response, and they're left in the backseat," Sisson said.
"I hope what comes out of all this is increased understanding and investment in what public health does. We always say -- when we're doing our job well, nobody knows that we exist -- because we're preventing outbreaks before they happen," Sisson said. "This is bigger than the pandemic."
ABC News' Aaron Katersky contributed to this report.