Public health workforce in dire need of long-term investment: Biden proposes Public Health Job Corps
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* Kim Krisberg

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/51/2/1.2/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/51/2/1.2/F1)

Marijorie Tabago, RN, LVN, a San Bernardino County Public Health Department nurse, conducts COVID-19 testing in Ont-ario, Calfornia, in December. The U.S. public health workforce needs long-term funding and training to meet the nation’s needs.

Photo by Irfan Khan, courtesy Los Angeles Times/Getty Images

A day after his inauguration, President Joe Biden proposed hiring 100,000 new public health workers to help fight COVID-19. Health departments certainly need the help, but experts caution longer-term, structural changes are needed to rebuild a public health workforce that is still digging out from the last major recession.

“Public health work is incredibly person-intensive,” said Adriane Casalotti, MPH, MSW, chief of government and public affairs at the National Association of County and City Health Officials. “So people really, really matter in this profession.”

When the pandemic began last year, the public health workforce was already facing a deficit. According to NACCHO, state and local health departments have lost 23% of their workers since 2008, shedding more than 50,000 jobs across the country.

Some projections suggest half of local and state health department workers could leave in the coming years. One survey conducted in 2017 — the first nationally representative survey of the local governmental public health workforce, known as PH WINS — found more than a fifth of respondents intended to leave in the next year for reasons other than retirement, with pay often cited as a top reason.

The pressures of COVID-19, including the extreme politicization of pandemic response measures and sometimes-violent backlash against public health officials, could make the situation even worse. An investigation by the Associated Press and *Kaiser Health News* published in December found at least 181 state and local public health leaders in 38 states had resigned, retired or been fired since last April.

At the same time, threats to public health keep accumulating. In 2008, the Association of Schools and Programs of Public Health released a first-of-its-kind assessment calling for an additional 250,000 public health workers by 2020, warning the nation “will soon be ill-equipped to identify looming public health crises and respond decisively.” As of 2019, the local public health workforce stood at 136,000.

In one of his very first executive orders, Biden focused on the public health workforce, directing federal agencies to provide technical support to state, local, tribal and territorial agencies on COVID-19 testing and contact tracing efforts. He also called on them to help train new public health workers and produce five-year targets and budget requirements for “achieving a sustainable public health workforce.”

Biden’s order additionally called for establishing a U.S. Public Health Job Corps, which would ideally mobilize 100,000 workers to help with COVID-19 response. Funding for the new corps was included in Biden’s $1.9 trillion proposed relief package that was making its way through Congress as of mid-February.

John Auerbach, MBA, president and CEO of Trust for America’s Health, said health departments undoubtedly need help with COVID-19 response, but it is unclear how permanent the new corps jobs will be. It is also unknown what will happen after the pandemic recedes and whether agencies can eventually pivot those workers to nonemergency public health work, which has suffered greatly in the pandemic and during years of funding-driven service cuts.

![Figure2](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/51/2/1.2/F2.medium.gif)

[Figure2](http://www.thenationshealth.org/content/51/2/1.2/F2)

As part of a campaign to reach people who are homeless, a Los Angeles Department of Health worker administers a COVID-19 vaccine to Hector Ortiz at the Los Angeles Mission in February.

Photo by Mario Tama, courtesy Getty Images

Auerbach, an APHA member, said the field needs more future-looking, longer-term funding commitments that focus on building public health infrastructure, which might also help the field attract and offer competitive-paying jobs in areas of high need, such as data systems.

“Truthfully, I think what (the public health workforce) will look like after this is very uncertain,” he told *The Nation’s Health* in February. “The focus right now among policymakers is getting through the pandemic, not necessarily on what we can learn from the pandemic going forward.”

But he said there are reasons to be optimistic. For example, in 2018, the Public Health Leadership Forum released a paper estimating an annual $4.5 billion gap between current public health spending and what is needed to fully implement core public health functions across the nation. It called for new infrastructure funding in that same amount. At the time, pre-COVID-19, Auerbach noted, “people thought it was too much money; today, of course, $4.5 billion seems like a good deal.”

He said the Biden administration is taking such proposals and concerns seriously and has been open to meaningful talks on the issue. But he worries that without quick action on longer-term public health workforce commitments, momentum could fade, as it has after other health emergencies.

Chrissie Juliano, MPP, executive director of the Big Cities Health Coalition, said a relatively quick infusion of 100,000 corps workers would boost pandemic response and provide relief to an exhausted workforce. But she said any new job corps should be scaled up in collaboration and coordination with public health authorities at all levels. It also needs to be more than a one-off, with a mechanism for integrating emergency workers into the general public health workforce.

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[Figure3](http://www.thenationshealth.org/content/51/2/1.2/F3)

A community health worker provides a rapid COVID-19 test in Immokalee, Florida, in February. While public health workers have been on the front lines of the pandemic, inadequate funding and a workforce shortage has made their work harder.

Photo by Spencer Platt, courtesy Getty Images

“Ramping up and then down is one of the problems we had in the past,” Juliano, an APHA member, told *The Nation’s Health*. “In public health, we boom and bust. This is an opportunity to hold on to the boom.”

Another key to rebuilding the workforce, she said, is making sure funding dollars reach local public health agencies. Tracking the flow of funding to local agencies is difficult. For example, even groups such as NACCHO had trouble determining how much of the first round of federal COVID-19 emergency money made it to local health departments last year.

But that data is set to improve, thanks to a tracking measure passed in December’s COVID-19 relief bill, said NACCHO’s Casalotti. While public health advocates were unsuccessful in securing designated funds for local health departments in the relief package, they were able to secure a new rule that requires states to report on how dollars are distributed locally. For now, Casalotti said, the measure only applies to the public health funding authorized in the December bill, but it still represents a “big step forward.”

> “In public health, we boom and bust. This is an opportunity to hold on to the boom.”
> 
> — Chrissie Juliano

Like her colleagues, Casalotti said Biden’s public health job corps proposal is welcome support, but it needs to go beyond the pandemic. She also noted there are existing ways to build up volunteer health reserves rather than starting from scratch, such as by increasing funds for the chronically underfunded Medical Reserve Corps, which already has volunteers around the country embedded in pandemic response.

In the long-term, she said, efforts to rebuild the public health workforce need to focus on recruiting, retaining and job availability, all of which are tied to public health funding, which had also been struggling for years before COVID-19. In a 2019 NACCHO survey of nearly 1,500 local health departments, 67% reported stagnant budgets and 15% reported reduced ones.

There is hope for legislative movement on those fronts. For example, as of February, Casalotti said she expected members of Congress to reintroduce bills that would offer student loan assistance for serving in governmental public health, as well as create mandatory, predictable funding to build public health infrastructure. The latter would be a major shift from typical public health funding mechanisms, which tend to be highly disease- and program-specific with little flexibility.

“What we’ve seen in COVID-19 and in previous recessions is the jobs that get lost first are the ones not attached to specific diseases or grants,” Casalotti said. “But in many ways, they’re the most important — the public health generalists, the jobs that don’t fit nicely in a box...We have to start valuing the people already doing this work and the work itself or we’ll continue to have this churn.”

In Canton, Connecticut, APHA member Jennifer Kertanis, MPH, director of health at the Farmington Valley Health District, which serves 110,000 people, said keeping up with pre-pandemic routine duties was hard enough for the full-time staff of 15. As of February, the medium-sized health department had not lost any staff during the pandemic. But Kertanis said she is worried that the long hours of COVID-19 response, coupled with a growing backlog of nonemergency work, is taking a serious toll on her staff.

She said she fears that history will repeat itself, with attention to public health disappearing after the pandemic.

“In public health, our greatest asset is our human resources,” Kertanis told *The Nation’s Health*. “We need people — well-paid people.”

For more information on PH WINS, visit [www.debeaumont.org/ph-wins](http://www.debeaumont.org/ph-wins). For more on Biden’s executive order, visit [www.whitehouse.gov](http://www.whitehouse.gov).

*   Copyright The Nation’s Health, American Public Health Association