Growing threats of a mass exodus in governmental public health

The backbone of the nation’s public health workforce is buckling.

A recent study has raised alarms with its dire prediction of a mass exodus of governmental public health workers—considered the “backbone” of public health efforts in the United States—if current trends hold.¹ “In our analytic sample, nearly half of all employees in state and local public health agencies left between 2017 and 2021, a proportion that rose to three-quarters for those ages 35 and younger or with shorter tenures,” the study’s authors wrote. “If separation trends continue, by 2025 this would represent more than 100,000 staff leaving their organizations, or as much as half of the governmental public health workforce in total.”

Based on data from the Public Health Workforce Interests and Needs Surveys in 2017 and 2021, the study has raised troubling questions about the country’s health priorities and the ability of local and state governments to recruit and retain new talent to help fill a yawning gap. “If you saw half or three quarters of firefighters or police indicating that they were planning to quit, much less retire, I think that would be pretty concerning. That’s kind of where we are right now in public health,” says lead author Jonathon Leider, PhD, an associate professor of public health and the director of the Center for Public Health Systems at the University of Minnesota in Minneapolis.

Many of the public health jobs lost during the Great Recession of 2008–2009 never returned and left governments with a workforce deficit, Dr Leider says. Then, older employees who had delayed retirement during the recession started to leave during the economic recovery. Their departure was compounded by what some demographers have dubbed the “silver tsunami,” or the wave of baby boomers reaching retirement age.

“We’ve been investing in this short-age for a long time,” adds study coauthor Brian Castrucci, DrPH, MA, president and chief executive officer of the de Beaumont Foundation in Bethesda, Maryland, which focuses on improving community health and public health systems. By the start of the COVID-19 pandemic, he notes, a lack of attention to filling the available positions and increasing low pay rates had already contributed to a shortage of 80,000 full-time equivalents.

The pandemic then led to “unprecedented levels of bullying, politicization, and political attacks on the public health workforce,” he charges. Amid that hostile environment, employees were pulled from other health department divisions to bolster short-staffed pandemic response teams, which added to the stress. “This is just a recipe for burnout,” he says. “The pandemic was an accelerant, but the fire was already burning.”

Emily Burke, EdD, MPH, senior director of workforce development and applied practice at the Association of Schools and Programs of Public Health in Washington, DC, says that a continuation of the alarming exodus could have major consequences for health initiatives such as cancer prevention. “I see public health practitioners as the first line of defense when it comes to cancer,” Dr Burke says. “I think we understand that environmental exposures can cause cancer. We understand that smoking causes cancer. We know that HPV [human papillomavirus] causes cancer. But some of the first lines of defense there are the environmental sciences folks in health departments, the smoking cessation folks in health departments, and those vaccine campaigns in health departments.”

Governmental public health agencies can struggle to compete with the private sector on salaries, but Dr Burke and other experts have suggested multiple ways to better compensate workers in public health departments. Among them, the Association of Schools and Programs of Public Health is pushing for student loan forgiveness for those who enter the governmental public health workforce. “These students are purpose driven, they want to help, they want to do good work,” Dr Burke says. “I think it’s important for them to see themselves in civil service and to understand how to get there.”

Georges C. Benjamin, MD, executive director of the American Public Health Association in Washington, DC, agrees that more loan repayment programs and scholarships should be explicitly linked to public service to encourage more students to enter the governmental public health workforce, particularly in historically underserved urban and rural communities.

Agencies can also invest in improving their workplace environments to boost job satisfaction and reduce turnover, Dr Leider points out. “Research has shown for a long time that whether you’re in a clinic or a health department, people quit their supervisors, they quit their organizations much more than they quit that low-paying gig,” he says. In addition, cutting more red tape could speed up recruitment decisions. “There is no question that bureaucracy in hiring is one of the biggest problems that we face in public health,” he asserts.

Perhaps the biggest overarching problem, however, is what Dr Leider and other public health experts call the “panic, neglect, repeat” cycle of funding in the United States. “We’re in this situation right now in the US where we’re basically firefighters who get funded when the house is already on fire, and then get asked to go buy fire trucks, go create an infrastructure, and buy and hook up the pumps to put the fire out.”

In 2023, the federal government began distributing $3.2 billion through the Centers for Disease Control and Prevention—an infusion called the Public Health Infrastructure Grant—to help shore up depleted public health workforces across the country. Dr Castrucci, however, notes that the grant carries few guardrails about how the money is spent; funding decisions are made largely by each state’s elected leaders and health officials. In some cases, those leaders have actively blocked the implementation of public health authorities and mandates.

In Florida, which received the most federal grant money in workforce support, the state’s surgeon general, Joseph A. Ladapo, MD, has repeatedly railed against vaccines and recently called for a halt to the use of messenger RNA vaccines against the SARS-CoV2 virus because of what he alleged was dangerous DNA contamination. Public health experts have widely debunked the claim as “scientific nonsense.”²

Dr Leider bemoans the growing partisan and ideological split over public health policies that has contributed to backlash over decisions and ordinances once seen as relatively uncontroversial. Rampant misinformation and disinformation about vaccines and COVID-19 have only fueled public mistrust and perceptions of governmental overreach. Rebuilding that trust, he says, may require convincing more elected officials to tout the value of public health in protecting communities. Public health officials themselves, he and other experts agree, could also do a better job of communicating more directly with their constituencies.

“Far too often, public health is pretty silent,” Dr Benjamin says, citing the common joke that when health officials do their best work, nothing happens. “And yet, every day, the water is safe to drink, the air is safe to breathe, the food is safe to eat, and my colleagues don’t get credit for the work that they did to make sure all that happened,” he says. The same goes for cancer prevention. More proactive visibility, he says, could allow public health officials to rebuild trust with the communities they serve while pushing back against misinformation and disinformation being spread by both domestic and foreign sources for political gain.

Dr Castrucci suggests that a major redesign of public health strategies may be necessary. “Every person in every county in every corner of this country benefits from public health, but we’ve never sold it that way,” he says. “We’ve never sold public health as an economic indicator.” To change the current trajectory, he agrees that the federal government should fund loan repayment for students entering the public health workforce. In addition, he says, health departments need to engage youth and youth activists to get their message out and form business councils to talk directly to the business community about their value.

Without a course correction, Dr Castrucci warns, the United States could face even more self-inflicted pain in everything from preventable cancers to future pandemics. “We are weaker today than we were at the start of COVID-19,” he asserts. “We went through the worst pandemic in a hundred years, and we came out of it weaker: fewer public health workers, less public respect, more misinformation. That is a deadly combination for the next round.”