Iowa's public health workforce is burned out. Can it recover?

Sep. 20—The pandemic public health emergency placed an overwhelming burden on an already underfunded and understaffed public health workforce.

For at least 15 months, staff at public health agencies have worked seven days a week, sometimes unable to take more than two hours away at a time from their email and phones, administrators told The Gazette. They tried to soothe terrified residents and were battered with abuse from those who disagreed with pandemic mitigation strategies, all while feeling the impact of the pandemic on their personal lives.

The response to COVID-19 took a mental and physical toll on public health professionals across the nation.

"It has been hell. It has been absolute hell," Jefferson County Public Health Administrator Chris Estle said.

Burnout from the pandemic has left many health care professionals questioning their ability to continue their work. As a result, a large number of workers is contemplating an exit from the field, which has experts worried about the future of Iowa's public health workforce.

"I can't even imagine doing this again. I would leave," said Danielle Pettit-Majewski, Washington County Public Health administrator who became the director of Johnson County Public Health in August.

"I am surrounded by smart, hardworking, gritty people who are thinking of leaving the profession, who are thinking of leaving the state or retiring early, and I don't blame them a bit," she said.

"This has been hard on our health, and this has been hard on our mental health."

Role of public health

Local health departments play an essential role in ensuring the overall well-being of a community. Without staff to provide services and offer safety nets and monitor potential hazards, counties, cities and people suffer, Iowa Public Health Association Executive Director Lina Tucker Reinders said.

And if they lack the institutional knowledge those professionals present, local public health departments may not be equipped to cope with the next emergency.

"Public health is more than COVID-19," Tucker Reinders said.

The phenomenal workload faced by state and local public health departments has been unlike anything seen before, Iowa Department of Public Health Director Kelly Garcia said, "and we're no strangers to working hard in our system."

In fact, the workload during the first six months of COVID-19 vaccine distribution equates to four-and-a-half years in the state's Vaccines for Children program, she told The Gazette.

"It's not just the number of hours," said Garcia, who holds a dual role as the director of the Iowa Department of Human Services. "The stakes are so high, the decisions are so big, the frequency by which we're moving is so fast."

The impact of the prolonged emergency response is something researchers are only beginning to understand.

In a survey conducted in August and September 2020, more than 66 percent of public health workers nationwide reported burnout, according to a study published in the International Journal of Environmental Research and Public Health.

The national survey reported a nearly 24 percent drop in professionals who planned to remain in the workforce longer than three years when compared to responses before the pandemic.

Tucker Reinders, of the Iowa Public Health Association, pointed out that professionals were not being compensated fairly for the work they did throughout 2020 and into 2021.

For the most part, public health staff are salaried, meaning they don't receive overtime pay for extra hours. Many workers, she said, did not receive hazard pay, or additional compensation given for performing hazardous duty.

Not only are staff early in their careers looking at other opportunities in more low-stress environments, but older professionals reaching that retirement milestone are considering an early exit from their current positions, Tucker Reinders said. Thirty-four percent of Iowa's county public health administrators are between the ages of 55 and 64, according to a statewide survey in September 2020.

Policies, 'finger-waggers'

That desire could be driven by any number of factors, including the constantly changing policies and recommendations.

In some cases, Estle, of Jefferson County, said local officials were recommending policies without fully understanding the reasons behind them because guidance from both the federal and state government was changing so quickly. Local public health administrators — including from Linn County — criticized the state for some of its decisions throughout the pandemic.

They also were the face of pandemic restrictions.

"We were the finger-waggers," Tucker Reinders said. "We were telling people 'you don't get to go to the movies or your kid's soccer game. You have to wear a mask over your face.'"

Perhaps because of that, public health has not received the same accolades as other front-line workers during the pandemic. But they're used to that, Tucker Reinders said. When public health is working — whether that's ensuring clean water and clean restaurants or addressing health equity — it's often invisible to the general public.

Dealing with anger

However, COVID-19 brought with it an intense polarization, mostly driven by partisan differences in American's response to the crisis. Being the finger-waggers suddenly made public health workers a target.

Administrators said they received dozens of angry phone calls and emails because of recommendations around masking and social distancing. Any and all social media posts triggered a torrent of online abuse.

"I've been called all kinds of names," Pettit-Majewski said. "Some days I was worried for my safety. It's a small town, people know where you live, people know your face and obviously know where you work. It enters your mind.

"Nobody signs up for that," she said.

The onslaught of misinformation was unprecedented, and very few local agencies were equipped to deal with it in a meaningful way, Tucker Reinders said.

And in small communities, workers can be bombarded from both sides. Even at home, they couldn't leave work behind as they fielded questions from family and friends and neighbors about the virus, and then the vaccine.

The demand to continuously respond to the novel coronavirus has been "like being in flight-or-fight mode constantly," Washington County's Pettit-Majewski said.

Mental health impact

All that accumulated stress carried increased risk for developing mental health conditions, including depression, anxiety and even post-traumatic stress disorder.

Garcia said Iowa's public health department deployed mental health resources to local teams throughout the pandemic, and the state is seeking to expand services and establish resiliency programs for professionals coping with the lingering effects the pandemic has had on their well-being.

As more vaccines make their way into the community and life begins to return to normal, Garcia said her department also will have more debriefing conversations with local public health departments about lessons learned since March 2020. In doing so, both parties can determine next steps to refine public health work to be better equipped for the future, she said.

"I hope to continue to lead a team that feels inspired to get up and do this work every day," Garcia said. "What I hope to do is create a space where they feel really safe to do it, where they can feel like they can tell me when there's a problem; when they can raise their arm and ask for help; and feel inspired to get up and do the work that they have been trained to do."

Understaffed, underfunded

Even as the stress on public health workforce has declined since the COVID-19 vaccine has become more widely available, concerns about the underfunded and understaffed public health system linger.

In a statewide survey of local public health offices in September 2020, administrators identified lack of sustainable funding and a reduced public health workforce as the top barriers to their ability to provide services in their communities.

According to the American Public Health Association, the shortage of public health professionals has been a growing issue in the United States. The number of public health workers declined to 158 workers per 100,000 Americans in 2000, compared to 220 workers per 100,000 in 1980.

Years of budget cuts led to the elimination of more than 55,000 positions in local public health departments between 2008 and 2017, according to a report from the Trust for America's Health. The health policy advocacy organization further stated public health efforts were $4.5 billion underfunded in fiscal year 2017, with public health funding representing about 2.5 percent of the roughly $3.5 trillion spent on health care that year.

An analysis by Kaiser Health News and the Associated Press found spending for state public health departments has dropped 16 percent since 2010. Spending for local departments has declined by 18 percent.

Federal rescue funds

The only way to supplement those lost dollars is through federal and state grants available to agencies for specific purposes.

More help is arriving in the form of federal pandemic relief dollars aimed at aiding the public health workforce as it recovers from its COVID-19 response.

In May, the Biden administration announced it was directing $7.4 billion from the American Rescue Plan to support local public health. That includes $4.4 billion to increase staffing at public health departments as well as a $3 billion grant program to "expand, train and modernize the public health workforce for the future."

While the relief is welcomed, state officials worry how Iowa can spend those big dollars without creating something that falls onto future Legislatures to sustain or eventually ends due to lack of support.

Garcia said her department is developing a budget that lays the groundwork for strong foundations at the local level and closes gaps in service deliveries.

"We're being very strategic in the way that we're putting those plans into action," she said.

For the American Rescue Plan to work, officials need to ensure that "proper funding has been allocated to support public health infrastructure at a local level," said Nafissa Cisse Egbuonye, administrator for Black Hawk County Public Health.

To Iowa's local public health administrators, supporting infrastructure on a local level would include allowing those agencies to make expenditures for long-term needs, including investments in new IT services and upgrading viral surveillance systems used to track disease in the community.

For much of 2020, local public agencies used what Egbuonye described as an "antiquated" virus surveillance system to track COVID-19 in their county. Iowa did update its contact tracing software — but in the midst of a surge of new cases in November, slowing down local health departments' efforts.

"It shouldn't be a pandemic that highlights how antiquated our system is. If you wait for that to happen, we can lose lives," Egbuonye said. "So I think it's very important for us to have something that prepares us for future pandemics. That structure is critical."

Recruiting new workers

A key piece of that effort includes robust recruitment at the local and state level.

Officials at the University of Iowa'sCollege of Public Health say there's strong interest in its students to join the government-run public health sector. In fact, the university — as with many higher education institutions nationwide — are seeing increased enrollment numbers as a result of the pandemic.

From fall 2019 to fall 2020, the UI College of Public Health grew 13 percent, said Scot Reisinger, assistant dean for student services. Both undergraduate and graduate applicant numbers increased more than 15 percent for fall 2021 compared to the previous year, and school officials anticipate enrollment will grow between 10 percent to 15 percent for the fall, he said.

State public health officials are working with Iowa's universities to broaden the pipeline of graduates into the state's workforce by creating more internship opportunities and similar programs to entice more future workers to the government-run public health sector, Garcia said.

The workforce learned a great deal throughout the pandemic. Even as they face recovery from burnout and stresses from the response, Garcia said she is confident that public health professionals who stay on the job will be a key asset to Iowa.

"What I've seen is this team rise to the occasion," Garcia said. "So we're going to have spaces where folks decide to go, but what we have underneath is a bench who have really risen to the occasion."

Comments: (319) 398-8469; michaela.ramm@thegazette.com

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