"Underresourced, understaffed, and overburdened"-that's how the Trust for America's Health described the nation's public health agencies in its May report, The Impact of Chronic Underfunding on America's Public Health System. The nonprofit, nonpartisan public health policy, research, and advocacy organization examines federal, state, and local public health funding trends annually. A key finding of this year's report? "Years of eroding resources for public health emergency preparedness contributed to the country's flat-footed response to the COVID-19 pandemic."
The report also revealed troubling long-term trends. The Centers for Disease Control and Prevention received an infusion of Public Health Emergency Preparedness funding during the pandemic, but the dollars were not enough to offset a 25% decrease (50% when adjusting for inflation) in this funding stream since 2003. Hospital preparedness funding totaled $280 million in 2021, down by almost half (66% when adjusting for inflation) from $515 million in 2003. Between 2012 and 2019, state public health agencies saw their combined workforce shrink by 10%, and local departments lost 16% of their workforce between 2008 and 2019.
"Public health is a bridge in need of major repair, major strengthening," says Lisa Campbell, DNP, RN, PHNA-BC, FAAN, chairperson of the Council of Public Health Nursing Organizations and professor at Texas Tech University Health Sciences Center in Lubbock. "You just have to see the response to the pandemic, and you can see that it's weak."
According to the National Association of County and City Health Officials (NACCHO), in the four years following the 2008 recession, more than 40% of local health departments reported smaller budgets compared with the previous fiscal year. When times are tough, says Campbell, public health is one of the first items states and localities cut. The reason, in her view, is that "people don't see us doing our job. We are essentially invisible." Unless, of course, a public health emergency occurs, she points out.
"COVID sort of pulled the covers back and revealed to all of us what dire circumstances we have been operating in," says Zenobia Harris, DNP, MPH, CPH, vice chair of the Council of Public Health Nursing Organizations and executive director of the Arkansas Birthing Project, based in Little Rock, a nonprofit working to improve birth outcomes for women of color. "Probably the most critical part has been not having the opportunity to develop our workforce-to properly staff and then to properly train people and support them in their work," she says.
THE PUBLIC HEALTH NURSING WORKFORCE
The rate of workforce attrition at the local health department level is especially troubling among RNs. According to the NACCHO, staff totals for RNs declined by 36% from 2008 to 2019, an estimated 33,200 to 21,200, respectively.
"Here's the thing," Campbell says. "In public health, public health nurses have the highest salaries. They're your most expensive employee. So, when there's cuts, they are the first to go." Campbell served as public health department director in Victoria, Texas, and says building back the department's nursing workforce following recession-era cuts was a long haul. "I got us our first additional public health nurse since 2008 right at the beginning of 2016. So, it took eight years to get one public health nurse. One. Eight years."
Recruiting RNs to public health has always been challenging given that acute care settings offer much more lucrative pay. A 2017 Public Health Workforce Interests and Needs Survey found 80% of public health workers earned annual salaries of less than $75,000.
The politicization of public health during the pandemic is likely to exacerbate the recruitment challenge. Many public health employees have endured threats to themselves and their families. A June 12, 2020, article by Kaiser Health News and the Associated Press found that at least 27 state and local health leaders resigned, retired, or were fired between April and June 2020.
One public health department director Campbell knows received death threats and had police security at her home for months. Campbell also knows another director, a former military nurse, who, she says, went toe to toe with elected officials who opposed public health measures. "He had to fall back on statute and say, 'No, I'm sorry. You cannot tell me what to do.'" Not surprisingly, survey results published in the July 2 Morbidity and Mortality Weekly Report reveal that more than half of public health workers had symptoms of depression, anxiety, posttraumatic stress disorder, or suicidal ideation last spring.
RENEWED FEDERAL SUPPORT
Money may not be able to solve these problems, but it can mitigate other challenges. "After 9/11, a great infusion of funding came in for emergency response," Harris recalls. "We actually built up our emergency response like we've never done before."
In response to the current crisis, this past March Congress passed, and President Biden signed into law, the American Rescue Plan Act of 2021. The $1.9 trillion spending package contained more than $84 billion for COVID-19 response and other public health priorities.
The Trust for America's Health applauded the legislation, noting in its report that "the investments in public health data modernization and workforce beginning under the American Rescue Plan Act should lay the foundation for enduring change in the system: real-time public health surveillance; a well-trained, expert workforce; and the capacity to promote health equity in every community." But the organization also pointedly called the plan a "down payment" primarily aimed at "controlling the pandemic."
"What the system urgently needs is sustained, predictable funding that allows it to grow and maintain its workforce and invest in modern data systems and all-hazards preparedness planning on a year-in, year-out basis," said John Auerbach, the president and chief executive officer of the Trust for America's Health at the time it published the report. The report recommends substantially increasing federal funding to strengthen the core public health infrastructure and workforce, which the organization estimates will cost $4.5 billion per year.
LOOKING AHEAD
Harris has a vision for a future public health nursing workforce that is not only better resourced but also better prepared to practice. The Association of Public Health Nurses and others, she says, are developing formal residency-style programs for this purpose. In addition, the Tri-Council for Nursing called for "core public health education across all health care professions" in a January report of a virtual meeting to discuss the implications of the COVID-19 pandemic.
Harris also wants to see the public health workforce respond to community needs in a much more collaborative and fluid fashion. "A nurse working in a clinical setting providing immunizations feels like she's expected to have tunnel vision in her work," says Harris. "Public health nurses have the ability to assess needs, address needs, and plan effectively. So I think it's important to allow them to utilize all those skill sets."
Campbell also takes a broad view of the profession's capabilities. "As public health nurses, I've always believed we are the essential bridge between acute care, primary care, and public health," she says. While primary and acute care nurses see health conditions in their patients, public health nurses understand how to collaborate with communities to address the socioeconomic drivers of those conditions, she explains.
Budgetary constraints can make it difficult for nurses to practice as Campbell and Harris envision. "Funding for public health typically comes in the form of legislatively determined program budgets, which create silos and restrict limited funding to a specific condition, disease, or purpose," according to the Trust for America's Health report. "Yet individuals and communities are at risk of multiple interconnected health problems that often do not align neatly with budgetary line items."
As a result, the report calls not only for more public health dollars but also for more flexibility in how those federal funds may be spent. Greater latitude could also help public health departments plan their programs "with local communities, rather than for them," as the report notes.
This distinction is critical, says Harris, a proponent of involving program recipients in the design of efforts to improve their health. "I think our health system made a critical error when we started promoting [COVID] vaccinations without doing the background work," she notes. "In my community, there were so many people who were distrustful of the quick response. If we had used more representatives from our community to inform and educate, we may have had a better uptake."
Campbell is also keenly aware of past missteps and lost opportunities. "I don't have an easy fix," she says. "The only thing I know is to get out in front of the public and to have those strong trusting relationships."
Harris also takes the long view. "As a community, as a country, as a nation, we've got to come together and decide these are important things for our overall health," she says. "Not just for now, but for future generations."-Nicole Fauteux