Public Health Departments Need 80,000 New Employees. But That's Not Enough for Another Pandemic.

State and local health departments need an influx of 80,000 full-time employees—an increase of roughly 80%—to adequately deliver basic public health services to their communities, according to a research brief released this month.

Adding those employees would allow health departments nationwide to better deliver services like immunizations and preventive health measures—but not to prepare for or respond to emergencies, including outbreaks and pandemics, according to “Staffing Up,” an analysis conducted by the nonprofit de Beaumont Foundation and the Public Health National Center for Innovations.

“The estimates presented in the brief encompass only the minimum number of [full-time employees] needed for the development of infrastructure and provision of minimum services,” the organizations said in a news release. “They do not account for additional [employees] that may be temporarily required to respond to the extensive needs of pandemics or other new challenges.”

To gauge staffing levels and vacancies at public health agencies, researchers collected employment and cost data from 173 health departments in four states (Colorado, Ohio, Oregon and Washington), then extrapolated those numbers to create models for “the key activities that all health departments should be able to implement, based primarily on population size.” Employment estimates also relied on data from state and local health departments collected prior to the Covid-19 pandemic.

The analysis does not recommend hiring specific types of employees, nor does it estimate the cost of adding 80,000 positions—a scope that’s narrow by design, said Brian Castrucci, president and CEO of the de Beaumont Foundation, which advocates for public health. It’s meant simply to provide a snapshot of staffing levels at state and local health departments, similar to the health professional shortage areas identified by the federal Health Resources and Services Administration.

“We wanted to go with a simple and straightforward message, based on the data we have, which says that for us just to meet these basic services, we need 80,000 people,” he said. “We also need to realize that throughout this entire pandemic, we’ve been surging on a broken foundation.”

Long-standing Staffing ShortagesStaffing shortages in public health departments began long before the pandemic, with years of budget cuts that began during the Great Recession and never really stopped, Castrucci said. The number of full-time local public health employees decreased by 16% from 2008 to 2019, while state health agencies lost nearly 10% of their workforce from 2012 to 2019, according to the nonprofit Trust for America's Health. Federal funding for public health preparedness and response programs decreased by nearly $40 million between the 2019 to 2020 fiscal years, and overall funding for those programs has been cut in half over the past decade, according to data from the organization. 

Those cuts became particularly noticeable in the early months of 2020, following a year of continuous public health issues—including outbreaks of measles and hepatitis A, a mysterious vaping-related illness, prolonged debates about the effectiveness of vaccines and historically high levels of sexually transmitted infections—that were then overshadowed by an emerging pandemic of a then-unknown virus.

“Despite the critical role that state and local governmental public health departments play in ensuring the safety, security, and prosperity of local communities, they have been consistently underfunded,” the analysis said. “Budget and staffing cuts have weakened the nation’s collective health and increased its vulnerability to emerging infectious disease and unchecked chronic disease … These cuts have limited the ability of health departments to plan for and respond to emergencies like the Covid-19 pandemic and to meet the daily needs of their communities.”

Legislators and members of the public have become more attuned to that reality in the past two years, Castrucci said.

“Throughout the pandemic, we’ve heard people say, ‘We agree with you that public health is underfunded and understaffed. How many do you need?’” he said. “This is saying, ‘This is the gap. It’s 80,000.’ Who fills that gap, and with what money, are questions that still need to be answered.”

Creating and funding an additional 80,000 full-time positions would increase the public health workforce by nearly 80%, from an estimated 103,500 workers to 183,500, according to the analysis. Based on the existing shortages, researchers recommended that about 54,000 of those positions should go to local health departments (an increase of 70%), with the remaining 26,000 deployed to state agencies (an increase of 80%).

“While all state and local health departments need additional full-time employees,” it says, “the most acute needs are in those local health departments that serve fewer than 100,000 people.”

Variety of Specialties Needed

To ensure the delivery of comprehensive health services, the positions would need to encompass a variety of specialties and levels of expertise, including 13,000 employees who focus on chronic disease and injury prevention and 9,000 to focus on assessment and surveillance activities. Because those duties could be carried out by a number of different professionals—nurses, epidemiologists, disease experts—pinpointing a dollar figure is difficult, though it’s likely at least several billion dollars, Castrucci said.

In the immediate future, federal Covid-19 relief money could be used to pay for some new positions, along with other initiatives from the Biden administration. But the longevity of public health departments will ultimately require some type of permanent funding, likely at the state level—which is almost certain to result in disparities from place to place, Castrucci said.

“We’ve already seen 26 states pass legislation to limit public health authority, so we’re losing the next pandemic before the current one is even over,” he said. “There are some initiatives in place to put people in health departments and that’s great, but what we need is the states as well to step up and invest in public health.”