The current economic recession is the deepest recession that the United States has experienced in more than 70 years. The convergence of severe economic conditions with the multiple population health and organizational challenges facing public health presents unprecedented demands on public health policymakers and executive leaders. This article reports a case study in which a Midwestern local health department intentionally realigned its structure and human resources to meet national public health accreditation standards while significantly reducing its budget in November 2010. The department transferred personal health care services that it previously provided to 3 federally qualified health centers in the community and reduced its workforce by 50%. The interrelated public policy and organizational management issues raised by the case study are reviewed, and questions and implications of the case for public health executive leaders, managers, policymakers, and researchers are identified.