Wave of Departing Public Health Workers Puts America at Risk

If 80 percent of young police officers, teachers and firefighters were expected to leave their jobs by 2025, would that seem like a problem? “That’s what’s at risk with public health,” says J.P. Leider, a senior fellow at the University of Minnesota School of Public Health.

Leider is one of the authors of a paper analyzing the large decline in the public health workforce. It draws on data from the Public Health Workforce Interests and Needs Survey, the largest national poll of the sector.

The findings heighten worries about the relationship between decades of underfunding and the faltering health of Americans. The U.S. spends more per capita on health care than do other large, wealthy countries — almost twice as much as most — yet has the lowest life expectancy of all of them. Last October, the CDC revealed that American life expectancy declined between 2019 and 2021, erasing more than a quarter century of progress.

COVID-19 and opioid overdoses were factors, but they came on top of a longstanding crisis of preventable conditions such as heart and lung disease, obesity and diabetes, says Howard Koh, a professor at the Harvard School of Public Health. A co-author of the study, he served as public health commissioner for the commonwealth of Massachusetts and assistant secretary for health for the U.S. Department of Health and Human Services during the Obama administration.

The Biden administration has set May 11 as the official end date of the COVID-19 public health emergency. With it comes an impulse to move past the devastation and public health issues that have dominated recent years.

Instead, this is a time to reaffirm a national commitment to public health, says Koh.

“It's critical to emphasize that when public health works, it keeps people out of hospitals; prevents doctors, nurses and other health-care professionals from being overwhelmed; and helps businesses, schools and society at large to function.”

Crisis Upon Crisis

The public health workforce was shrinking before the pandemic, declining 16-17 percent from 2018-2019. Nearly half of all state and local public health employees left their jobs between 2017 and 2021. A 2021 research brief from the de Beaumont Foundation estimated that the state and local health departments needed 80,000 more workers, an increase of 80 percent, to be able to provide “a minimum set of public health services” to citizens.

The new analysis found that 75 percent of workers 35 and younger left state and local public health agencies in the 2017-2021 period. If current trends continue, a similar percentage of this age group could leave by 2025, as would 80 percent of those on their jobs three years or less.

The collision of these trends with a much dreaded but unmitigated “silver tsunami” of retirements in public health could be catastrophic, says Brian Castrucci, de Beaumont’s president and chief executive officer, another co-author. “We've always known that this was happening, but now we've proven it.”

Most departures from leadership positions are the result of political pressures and the inability to give sound public health advice without being questioned by elected officials, says Lori Tremmel Freeman, chief executive officer for the National Association of County and City Health Officials (NACCHO). Those who have stayed on the job are managing workers burned out by overwork, harassment and threats.
“None of what we are seeing is necessarily surprising,” Freeman says. She’s especially concerned about small health departments that serve populations of 50,000 or less. They make up two-thirds of the sector and have unique resource problems.

In some cases, pushback against public health is being further fueled by laws limiting public health authority, or candidates seeking city council or county executive positions to act on their perceptions of public health “overreach” during the pandemic.

“This is the first time where the public health power and authority, the exercise of the public health sciences and the validity of those has really been challenged at scale,” says Leider. “It’s a different world.”

More Than Mask Mandates

Public health professionals admit they have not done a good job of marketing the sector. “It's a very misunderstood field,” says Freeman. “A lot of people think public health means government-funded entitlement programs to help vulnerable people.”

Public health was center stage during the pandemic, but mostly operates in the background. Its efforts encompass such things as water systems, air quality, disaster response, food safety, health education and keeping mosquitoes and ticks at bay as well as detection and treatment of disease.

“When prevention works, absolutely nothing happens, and all you have is the miracle of a perfectly normal day,” says Koh. “When prevention works over years, you have the gift of a lifetime of precious moments with your family, friends and people you love.”

In many ways, Koh is echoing the observation of Dr. Leana Wen, emergency physician, professor of health policy and management at George Washington University and former Baltimore health commissioner, who famously said, “Public health saved your life today. You just didn’t know it.”

Preventing problems brings economic benefits as well, and Leider believes these have not been communicated adequately. A study of California county public health departments found that every dollar invested yielded an average return of $67-$88 in societal benefits.

Averted costs are another matter. The annual cost of treating preventable diseases has been estimated to account for 25 percent of health-care spending, equal to more than 4 percent of America’s gross domestic product. Despite this, less than three percent of health spending is projected to go to public health in 2023.

Momentum to change the public health narrative is gathering. Castrucci is one of the authors of a book published in 2022 intended to help the public sector improve its communications “through framing, messaging and storytelling.”

In April, Koh will chair a public workshop for the National Academies of Sciences, Engineering and Medicine that will take on “diseases” that have afflicted public health itself — that is, mis- or disinformation. He expects strategies that can better address future infodemics to come out of the meeting.

Leadership Gap

Leider and his colleagues underscore well-recognized strategies for recruitment and retention, from simplifying hiring to leadership training and loan forgiveness for public health workers. (The last was included in the omnibus spending bill passed at the end of 2022.)

The missing ingredient is support and leadership from outside the public health field. As has been the case with embattled election officials, few in elected office have come forward to support the public health mission or recognize its workers and their service.

“Until mayors and county executives and governors see the consequences of empty health departments and see the backups that come from the lack of public health protections, things might not change,” says Leider. “But we don't want it to get there.”

Applications for Harvard’s public health school have increased significantly through the pandemic, says Koh, a trend that is reflected nationwide. It would mark a turning point if state and local leaders sent a common message that public health is critical to the functioning of society and let students know that if they commit to the field, they will be supported, encouraged and rewarded.

During his student days at Yale, Koh was glee club president. If you’re fortunate enough to be a member of a chorus, he says, you experience the glory and harmony of a collective effort for a common purpose.

“Currently, we have cacophony and discord, and the challenge is to transform that back into harmony.”