Death Threats, Stress and Signs of Crisis in the Public Health Workforce

The nation's public health workforce is in the grips of a mental health crisis, according to a new survey.

Two years into the pandemic, long hours, mounting stress and harassment from people critical of government guidance regarding masks and vaccines have led to high rates of post-traumatic stress disorder among state and local public health workers.

More than half of the government public health employees who responded to the Public Health Workforce Interests and Needs Survey reported at least one symptom of PTSD and one in five rated their mental health as "fair" or "poor.”

The survey by the de Beaumont Foundation, a Maryland-based charity, and the Association of State and Territorial Health Officials, was completed by more than 40,000 government public health workers. 

It also documented the toll threats and abuse have taken on public health workers, especially those at the executive level. Forty-one percent of public health executives say they have been bullied, threatened or harassed, while 14% of nonsupervisors say they have been targeted.

“This pandemic has been tragic and hard and sad and you see people taking out their anger and their frustration in a whole series of different ways,’’ said Dr. Anne Zink, Alaska’s chief medical officer and incoming president of the association. “Public health has been at the center of a lot of the response.’’

Zink, an emergency medicine doctor who became Alaska’s top public health official six months before the Covid-19 pandemic took hold, says she’s received death threats and been attacked on social media. She’s also become a target for politicians, several of whom support legislation eliminating her position.

Her experience is not unique: Zink said many high-profile public health officials, such as state-level commissioners or big-city directors, have faced death threats. “Most of us have had to have security at some point or another during this pandemic,’’ she said. “I don’t know another person in my role who either didn’t have death threats or security or had to change their behavior or where they were going because of concerns about their personal safety while they’re trying to serve the public.’’

In New York City, police are providing security for Health Commissioner Dr. Ashwin Vasan after critics of a school mask mandate for children under 5 showed up at his house and threatened him.

Zink said the trauma of the pandemic has unleashed strong emotions.

“I can understand why people are angry,’’ she said. “But directing that anger at our frontline public health workers have been working 60, 80 or 100 hours a week and have really been the backbone of this response, giving up family time, vacations and working day and night around the clock to keep their communities safe and healthy is misdirected.’’

The anger is driven by multiple grievances, including disagreement with mask mandates, vaccine rules and other Covid-containment measures, and the same type of anti-government activism that’s led state and local voting officials to become targets of those who question election results. In some instances, people blame local health officials for decisions made by the federal government.

“We see it from people who lost their loved ones and are angry that more wasn’t done to protect them,” Zink said. “We see it from people who have lost their business because of requirements or mandates to shut down that were required.”

Nearly 60% of public health executives—and a quarter of all public health workers—said in the survey their expertise has been questioned or challenged. 

To measure the prevalence of probable PTSD, the survey incorporated a checklist developed by the U.S. Department of Veterans Affairs. It asked respondents if the Covid-19 outbreak was so frightening or upsetting that it prompted nightmares or unwanted thoughts and feelings of numbness or detachment.

The questionnaire also asked public health workers if they went out of their way to avoid situations that reminded them of the pandemic or if they felt constantly on guard or easily startled.

Probable cases of PTSD were more common among officials at big city health departments than for those working at state health agencies or smaller local departments, the survey found.

The levels of trauma and stress facing public health workers is causing burnout: Nearly one in three public health workers said they are considering leaving their job within the next year and 44% said they plan to leave or retire within the next five years.

“The negative effects of responding to the pandemic and outside stressors could have long-lasting effects on public health workers’ desire to remain in governmental public health,’’ the survey states. 

This is the third time since 2014 that the association has looked at the public health workforce. A preliminary analysis found that the rate of employee turnover from 2017 to 2021 was two to three times higher than it was from 2014 to 2017.

The survey was distributed between September and January to 137,447 state and local governmental public health workers from 47 state health agencies, 29 big-city health departments and a variety of medium and small departments. The questionnaire was returned by 44,732 workers. 

For more information from the study click here.