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What Will It Take to Recruit and Retain Public Health Workers?

State spending on key public health activities has been flat or in decline since 2008 and salaries lag behind the private sector. Stakeholders are exploring strategies to meet the need for these essential workers.

Mask protestors outside City Hall in Columbia, Mo.
(Don Shrubshell/Tribune/TNS)
Just weeks after states began to lift COVID-19 restrictions, a fourth wave of infections has brought new cases back to levels seen last fall. At the same time, the beleaguered army of public health workers working to turn the tide is often being met with resistance, if not outright hostility.

It’s unknown how badly, or how long, the delta variant — or variants that will follow it — will thwart a return to “normal.” What’s certain is that progress depends on the efforts of public health workers, and that effective strategies to recruit and retain them are more important than ever.

Unlike other government sectors, public health never fully recovered from cuts made in the wake of the Great Recession, says JP Leider, director of the Center for Public Health Workforce Development and Applied Practice at the University of Minnesota. Leider examined state spending in key public health activities between 2008 and 2018, finding that per capita spending was flat, or decreased, in every category other than injury prevention, which saw a modest increase.
Following the Great Recession, per capita public health spending by states decreased, and never recovered, in every category except injury prevention.
Over that same period, Leider and his fellow researchers found that rates of preventable deaths rose and life span decreased, concluding that “funding is not being calibrated to need.” As a result, the workforce was already strained and stressed when COVID-19 hit.

A survey of public health interests and needs published before the pandemic found that roughly half the workforce planned to leave their jobs by 2022. Events since then have brought an unexpected dynamic to the field.

“In the middle of the most significant public health event in the last hundred years, we saw hundreds of health officials fired, resigning or retiring because the agenda of elected officials did not align with science,” says Brian Castrucci, president and chief executive officer of the de Beaumont Foundation. “This is like driving out the firefighters as the fire rages.”

The Shrinking Public Health Workforce
DBF Workforce Infographic
A decade before COVID-19, H1N1 showed the potential for a novel virus to emerge and overwhelm public health systems, yet states allowed the workforce to continue shrinking.

A Unique Workforce

Federal response to the pandemic has remained a subject of debate, scrutiny and controversy, but the primary responsibility for public health lies with state and local health departments, says Joshua Franzel. Franzel, managing director of MissionSquare Research Institute (formerly SLGE), authored a 2020 report examining the characteristics of workers in this sector.

“It’s important to understand that the public health workforce differs from the overall state and local government workforce,” he says. “It tends to skew a bit older, more female, more educated and more diverse.”

Franzel found that more than two-thirds of public health workers were in the 35-65 age bracket, with higher numbers in the 46-65 bracket than the overall government workforce. “That should be a clarion call for some aggressive recruitment,” says Castrucci. “Between retirement and burnout, we just might not have a public workforce there to protect the nation.”

As is the case in other government sectors, public health jobs pay less than private-sector jobs requiring similar skills. The fact that the great majority of these jobs require post-secondary education, or even advanced degrees, means that college loans factor heavily in the decisions of candidates.

Adriane Casalotti, chief of government and public affairs for the National Association of County and City Health Officials (NACCHO), recalled a recent conversation with a health official in Nassau County, N.Y. “He explained that a brand-new nurse out of nursing school can make in the $30,000 range to come to the public health department, or in the $90,000 range at a local hospital.”

Casalotti and her colleagues agree that this gap could be bridged in part by enabling public health employers to assist workers in repaying student loans. H.R.6578, which would provide more than $500 million for this purpose over a period of six years, has bipartisan support. The bill does not limit funding to specific degrees, or specific job titles, but is intended to help departments hire workers that fill their unique needs.

In May, the White House announced that $400 million in American Rescue Plan funds would go to Public Health AmeriCorps, a joint effort between the CDC and AmeriCorps that would be modeled on an established program that provides a living allowance and education awards to participants. The goal is to fund up to 5,000 positions over the next five years, to develop “a new generation of public health leaders.”

While efforts such as these can help offset lower salaries, it’s also important to pay public health workers more, says Michael Fraser, chief executive officer of the Association of State and Territorial Health Officials (ASTHO). “The public health workforce is incredibly committed to the job, to the mission of public health, and we want to keep them engaged. We hear from current workers that they are looking at the salaries that contract physicians are getting to do the same work, and there’s big inequity.”

When nurses in one Atlanta county health department found out that contract nurses were earning more than they were, they quit, joined the contract nursing firm and came back to do the same job with better compensation, says Casalotti. “Local health departments have been under-resourced to compete.”
Dr. David Haim Bolour, health-care worker Monica Botello and public health nurse Cynthia Key standing outside talking.
Dr. David Haim Bolour, left, health-care worker Monica Botello and public health nurse Cynthia Key visit a Los Angeles housing project to educate residents about the importance of COVID-19 vaccination.
(Irfan Khan/Los Angeles Times/TNS)

A Better Pipeline

Public health has also fallen behind the private sector in making it easy for job seekers to find jobs and apply for them, says Brian Castrucci. “Google has hiring down to a science, it’s quick, it’s fluid. Government is none of those things — schools are graduating more and more MPH candidates, but they aren’t finding their way to government or public health.”

At present, there is no national database of public health jobs, forcing job seekers to search from jurisdiction to jurisdiction. There are job sites, but they require someone in government to be proactive and post listings on them, says Castrucci. Moreover, “all the jobs have some weird title, so I can’t just search ‘public health jobs’ and find them.”

ASTHO is working on funding to create a web resource that would remedy this, says Fraser, in part to capture job seekers among those who have become more aware of the public health field due to the pandemic. “Should they have to go to 59 different state territorial websites, and 3,000 different county governmental websites to find a job, or is there a way we can make that easier?”

Some academic institutions are connecting with public health departments and partnering to help students get real-world familiarity with their work. In March 2020, the Florida Department of Health hired 100 professors and students from universities in the state in one weekend to serve as part-time epidemiologists and conduct phone interviews with coronavirus patients.

Workforce development efforts such as the Centers for Disease Control and Prevention’s Epidemic Intelligence Service and Public Health Associate Program are also helping fill the pipeline. Some public health departments have had success sharing staff, a strategy that can help small or rural jurisdictions meet needs for specialized care or vacation relief.

Stimulus funds have provided more than $7 billion for the public health workforce, says JP Leider, perhaps as much as $12 billion. “It’s allowed agencies to staff up contact tracers and temporary positions, but you can’t hire people on one-time money.”

ASTHO’s Fraser is aware that many are reluctant to bring on new state employees if funding will run out in a few years. “I understand that, but I think we need to get them into public health — when these folks are demonstrating results it will be obvious that we need to keep them.”

“I don’t know any other way to do it,” he says. “Unless we want to continue on the basis of ‘let’s not invest now, but let’s spend $16 trillion in the next pandemic.’”
A nurse preparing COVID-19 vaccinations at a drive-through clinic.
A public health nurse in Summit County, Ohio, readies supplies to administer shots at a COVID-19 mass vaccination site.
(Mike Cardew, Akron Beacon Journal/TNS)

Connecting the Dots

When public health does its job, nothing happens, says Georges C. Benjamin, executive director of the American Public Health Association (APHA). That may be one reason why decision-makers don’t fully appreciate the return from investing in it.

“When nothing happens, people don’t realize they were saved,” he says. One way to make this point is to walk someone through their day: the water they brush their teeth with doesn’t make them sick, their breakfast is safe to eat, the air is safe to breathe, they drive to work in a car with a seat belt.

Public health needs to do a better job communicating its value to policymakers, says JP Leider. “A lot of our interventions take years to show a return, but there’s good literature that shows investment in prevention saves dollars in addition to improving health and extending life; in some ways, it’s not fair to ask public health to do both of those things, but there’s good evidence that it does.”

A panel convened by the Public Health Leadership Forum determined that a $4.5 billion fund of new, permanent resources is needed to provide public health infrastructure that could protect all Americans. A Senate bill, the Public Health Infrastructure Saves Lives Act, would establish this fund.

“Compared to the trillions we are spending to deal with the COVID pandemic, $4.5 billion is a rounding error,” says Benjamin.

State investment is also essential. It’s equally the responsibility of state and local governments to find ways to invest in and develop their workforce, says Castrucci. “Federal funding typically comes as disease-siloed funding and that doesn’t give us an opportunity to develop our workforce.”

One important target for this investment is updating public health data systems. “One of my favorite things about public health is how we get excited about two-year-old data,” says NACCHO’s Adriane Casalotti. “COVID has highlighted how challenging our data systems are, and that communicating what the picture is on any given day is critical to creating a feedback loop from the health department to the community and back again.”

Governmental public health is the only entity with legal responsibility for ensuring the health and well-being of the community, says Benjamin. “We have to make sure that elected officials, the community, and the people who take these jobs understand that role and we need a societal agreement to stand behind them and support them when they have to make tough decisions.”

Such support is needed now to retain valued members of the public health workforce who have suffered from both long hours and attacks on their fundamental beliefs, what ASTHO’s Mike Fraser and others see as a “moral injury.” A survey of more than 26,000 public health workers conducted during March and April 2021 found more than half of reported symptoms including depression, anxiety, and post-traumatic stress disorder (PTSD), and urged more attention to employee assistance programs and workplace culture.

Public health events have cost more lives than all the wars of the 20th century, including an estimated 250,000 preventable premature deaths each year.

Teachable Moment

The threat of the pandemic was always a “when,” not an “if,” says Brian Castrucci. The consequences of being unprepared for it — lost lives, homes, businesses, careers, educations and more — should resolve any doubts about the need to invest heavily in public health infrastructure.

“We’ve lost three years of life expectancy in some communities, a year of life expectancy overall, because of COVID,” says Georges Benjamin. “That’s not going to just come back after a year of things being better.”

“We have been preparing for a war for a long time, but we were preparing for other nations, not viruses, despite the warnings, despite the data, despite hantavirus and Ebola and chikungunya and Zika, all the other warnings that we had,” he says.

Elected officials need to understand that public health isn’t an issue for one side of the aisle or the other, but “the dirt on which those aisles are built,” essential to the human experience, let alone the American experience.

“We put $7 billion every year into defense,” says Castrucci. “There is not a single foreign nation that has taken 600,000 American lives on American soil.”
Carl Smith is a senior staff writer for Governing and covers a broad range of issues affecting states and localities. He can be reached at or on Twitter at @governingwriter.
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