It's been a tough year for public health workers. The recession led states such as Maine to cut spending on public health. And then workers had to contend with the H1N1 flu pandemic.  A new report from the Robert Wood Johnson Foundation and Trust for America's Health shows that the combination of factors forced Maine and other states to make tough choices.

"What happened in Maine was that, in order to ramp up staff to respond to the pandemic situation, public health nurses were diverted from other activities, like addressing child abuse cases or tuberculosis cases," says Jeffrey Levi, executive director of the non-profit Trust for America's Health.

"While some diversion is inevitable in a situation like this, all three -- pandemic flu, child abuse and tuberculosis -- are all issues that require constant vigilance," Levi says. "And when states are short funded, either by the federal government or by the state legislatures, it becomes very hard to maintain that type of capacity."

But Dr. Dora Anne Mills, the state's director of public health, does not think services suffered in Maine. "Our public health nurses did a phenomenal job this last few months," she says. "They vaccinated well over 10,000 people, and they also were able to maintain the most critical services, such as tuberculosis control and child abuse issues."

She says nurses were able to do this by working extra hours. "They were able to earn some comp time that they can take at a later time and that enabled us to allow people to work a lot of extra hours and not stretch the budget too much as well."

At the local level, public health workers in Bangor also worked extra hours. Their director, Shawn Yardley, says he redirected staff from the maternal and child health program to dealing with the pandemic.

The department has a lot of experience putting on seasonal flu clinics, but an unpredictable supply of H1N1 vaccine created special challenges. "Because of the delays in the vaccine and the manner in which we received it just made planning more difficult and more time-consuming," Yardley says.

Yardley predicts his staff will be able to deal with the next surge in H1N1 more efficiently. But he's expecting his staff will take a hit from another area: funding cuts. "We're saying good bye to someone today because she's choosing to retire knowing that her position isn't in the budget come July 1st."

The equivalent of four full-time jobs out of 33 are being left vacant or are going away because of funding issues. Yardley isn't counting on more money coming from the state. According to the report, Maine cut public health spending by $1.4 million -- or 4 percent -- in 2009.

Dr. Dora Anne Mills questions whether the report's numbers account for funding that came later in the budget cycle. What she and the report's authors can agree on is that Maine does well when it comes to getting federal dollars because of aggressive grant-writing -- 15th best in fact.

"The vast majority of the Maine CDC's funding comes from about seven different federal agencies," Mills says. "I'm very proud of the fact that our Maine CDC staff do go after federal grants quite aggressively."

The federal government spends about $23 per average Mainer compared to the national average of about $19. The vast majority of it goes to pay for childhood vaccinations.