WORKFORCE EXODUS — We might be even less prepared for the next public health emergency than we were for the last one. After all the billions of dollars on pandemic era upgrades to labs and data and surveillance, after all the studies and convenings and white papers about emergency preparedness, the U.S. still lacks two crucial things in the public health arsenal. People. And trust. Without an adequate public health workforce, and without trust in those people and the work they do, the U.S. could get caught flat-footed once again. Two research papers published this week in the journal Health Affairs quantify what we more or less already knew. America’s public health workforce is depleted. And Americans are a skeptical bunch; they don’t have a huge amount of trust in public health nor its messengers, although the trust deficit may not be quite as deep as you’ve heard. Unless something changes and fast, “our health departments will be empty and no one will be paying attention until it is way too late,” said Brian Castrucci, a lead author of the workforce study and the president and CEO of the de Beaumont Foundation, which focuses on public health. Amid low pay, long hours, cumbersome bureaucracy and, nowadays, abuse and threats so severe that researchers found huge numbers of public health workers had at least some symptoms of PTSD, public health workers are quitting in droves — and the exodus began even before Covid-19 made everything harder. Nearly half quit between 2017 and the end of 2021, and it’s not just pandemic-exhausted older workers choosing early retirement. The under 35s are also fleeing. That means not just a loss of workers for now, but no pipeline for leaders of the future, pointed out a worried Georges Benjamin, executive director of the American Public Health Association. “That knowledge base is going out the door,” he said. The shortages in the public health sector aren’t getting anywhere near as much attention as labor challenges in the health care system. Doctors and nurses and others who take care of patients are of course important, said Castrucci. But letting public health erode leaves us vulnerable in different ways. “It’s like opening the gates that protect the army,” he said. “If we don’t have a strong public health system, there’s no way we can have enough hospital beds to make up for the problems.” Fixes can’t be piecemeal. Diseases cross state lines — as do toxic fumes from train wrecks, or the fallout from natural disasters. If even one state is unprepared, people in other states can be harmed. A big reason people don’t stay in public health is money. Salaries are small. Bureaucracies are large. Since the pandemic, abuse has also been on the rise. And in more than half the states, lawmakers have curtailed public health experts’ ability to make and carry out policies. Castrucci said that’s like using a jackhammer to shatter our own collective safety. The labor shortage is not because we aren’t training people. To the contrary, we’re turning out people with both undergraduate and graduate public health degrees in droves. Enrollment in these programs surged after 9/11 and didn’t abate. According to the Association of Schools and Programs of Public Health, enrollment grew steadily over the last decade, with another bump up in 2021, after the pandemic hit. There was a small dip in undergraduate enrollment last fall, but graduate schools kept growing. But people with public health degrees are not all going into public health, at least not in federal, state and local agencies. They go to digital health and tech firms. They go to businesses and consulting firms. Many go into the health sector as managers or administrators of hospitals and clinics. They may be physicians or nurses, who want the extra public health knowledge or credential to enhance their practices. Emily Burke, who tracks workforce development for the public health school association, said there was an uptick in new graduates going into traditional public health jobs last year. Whether that’s the beginning of a trend, or a one-off, remains to be seen. Whether they stay in public health, or do a year or so and move on, is also an open question. The distrust in public health has also made it a harder world to work in. Still, the degree of outright, hostile distrust might be overstated, said Gillian SteelFisher, a Harvard T.H. Chan School of Public Health researcher who led the trust study. Not many of the 4,200 people surveyed had really high trust. Only four-in-10 adults reported a great deal of trust in the CDC. For state and local public health departments, it dropped to one-in-three. But not many reported zero trust either. The haters on the fringe make a lot of noise and get a lot of attention, from the media and elsewhere. But the focus should be on reaching the tens of millions of Americans with some, but not a ton of trust, said SteelFisher. “You have to bring those people to the table,” she said. This low trust, interestingly, didn’t correspond with how well people thought the public health officials controlled the pandemic. It centered on the belief that federal public health decisions are politicized, not based purely on science, and that state and local officials do a poor job of communicating how people can protect themselves, with recommendations constantly changing in bewildering ways. Consistent, and frequent communication — including about uncertainty — can rebuild trust. “Here’s what we know today and we’ll be back here tomorrow,” she said. “Inviting people into the process is the critical piece… We have to be trustworthy if we’re going to be trusted.” Welcome to POLITICO Nightly. Reach out with news, tips and ideas at nightly@politico.com. Or contact tonight’s author on Twitter at @JoanneKenen.
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