Public Health Workforce Struggles to Keep Up With Evolving Responsibilities


Michelle Gourdine

Dr. Michelle Gourdine, former chief public health physician and deputy secretary for public health services for Maryland, on a time bomb in the making.

The events of September 11, 2001, affected every American, but the day was a landmark for public health.

“It was a turning point because on October 4, 2001, we received the first report of a suspected case of anthrax in Florida,” says Dr. Michelle Gourdine, a public health consultant who at the time was health officer and director of the Baltimore County Department of Health. “Public health was the lead agency in Florida and across the country in investigating those types of suspected attacks. At that point, our responsibilities began to increase.”

Suddenly, in addition to their traditional core responsibilities – mental health, alcohol, and drug abuse services, immunizations, AIDS and other communicable diseases, maternal and child heath — public health practitioners found themselves in entirely new roles: first responder to emergencies; defender against bioterrorism and new diseases like SARS, West Nile virus, and pandemic flu; and relief coordinator for those displaced by disasters like Hurricane Katrina.

“We hadn’t had training in it,” Gourdine says. “It was the ultimate challenge to make sure our staff were properly trained to take on the additional roles while also performing our core functions. In many local public health departments funding and resources often fell short and so we saw dual, triple and quadruple use of an individual’s expertise to cover not only core public health functions, but new responsibilities.”

Fewer staff, bigger workload

Unfortunately, the expansion in responsibilities coincided with a serious shortage of skilled public health personnel.

Like every other government agency, public health stands to lose years of experience with the imminent retirement of the baby boomers. Forty-five to 50 percent of public health employees will become eligible to retire in the next five years, and many governments are facing vacancy rates of up to 20 percent due to retirement, attrition, and expanded responsibilities.

Gourdine points to three chief causes for the public health workforce crisis: non-competitive salaries; the competition among federal, state, and local governments for talent; and a shortage of crucial specialists, including doctors, nurses, environmental health workers, and epidemiologists.

This is not a new situation. When Gourdine was chief public health physician and deputy secretary for public health services for Maryland from 2005 to 2008, 56 percent of the unit’s directors and 79 percent of the deputies were eligible to retire by the year 2009, taking years of knowledge and history with them. Luckily for the state, many of these seasoned veterans are still on the job.

Five workers, 1,000 required inspections

Public health departments have always had to make the most of limited resources. Earlier in her career, Michelle Gourdine served as health officer and director of the Baltimore County Health Department.

The county, Maryland’s third largest jurisdiction, has a large and growing number of adults over the age of 65. To support that aging population, more assisted living facilities and nursing homes have been built, along with hospitals and other health care facilities. Every facility must be inspected by county environmental health workers, some annually.

Although the workload increased, staffing stayed level. The department currently has seven positions for inspectors; with two vacancies, five workers are responsible for 500 facilities and more than 1,000 required annual inspections, which vary in complexity depending on the size and conditions of the facility.

“We got it done,” she says, “I don’t know how but we got it done. But do the math. It’s a very precarious situation to have to rely on so few individuals to ensure those annual inspections are done.”

Vulnerable populations count on public health workers to protect them. In one case, an adult day care center had a history of violations. Over the course of a year the county tried to get the facility to improve conditions but when management proved uncooperative, the county ordered it shut down. That took yet another year, requiring the public health department to divert attention and resources from other core functions.

Attracting new talent

Gourdine puts forth several solutions she thinks could help bring new talent into the public health pipeline. One is to enhance collaborative efforts between local and state public health agencies and schools of public health, to encourage graduates of public health programs to enter public health practice as a career, even offering incentives, such as student loan forgiveness. And, of course, another is to raise salaries so they are at least competitive with the private sector.

“Most of public health occurs under the radar screen and goes largely unnoticed when we’re working effectively,” she says. “When we do things right you don’t hear about it. We only draw attention when something goes wrong. The increasing workload of public health workers, the loss of knowledge, and the leadership gap all conspire to increase the likelihood that something might go wrong.”

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