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Building Back a Stronger Public Health Workforce Post-Pandemic

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Robert Johnson:
This is Public Health Review. I'm Robert Johnson. On this episode, the pandemic makes the case for a more robust public health workforce, leaving little doubt about staffing needs and opportunities.

Dr. Joneigh Khaldun:
I really think that our response would likely have been more robust and quicker if we'd had more staffing. So when you have a health department that does not have an epidemiologist, or you only have a couple of epidemiologists, or case investigators, or contact tracers, that are already spread thin working on other infectious communicable diseases, and then you throw a pandemic on top of it, it makes it very challenging to have as robust of a response, whether that is the case investigation or the contact tracing.

Dr. Lauren Powell:
What are the credentials that are actually needed to do public health work? Does it require a master's degree? Does it really require a bachelor's degree? Or does it really require knowing your community well and having the passion and will to want to see people well around you? So I think we could get creative in this moment. This is the opportunity to try new things.

Johnson:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories. Today, an examination of the public health workforce, how it's doing more than a year into the COVID-19 pandemic, and a discussion about the opportunities to do more, to help exhausted workers and improve the response while prepping for the next crisis.

Our guests on this episode have given a lot of thought to the future of the workforce. Dr. Lauren Powell is vice president of US health equity and community wellness for Takeda Pharmaceutical. She's along later to share her ideas for a stronger public health workforce post-pandemic. But first we visited with Dr. Joneigh Khaldun, a practicing emergency medicine physician in Detroit, the Chief Medical Executive for the state of Michigan, and a member of President Joe Biden's COVID-19 health equity task force. She's talking about the state of the workforce even before the pandemic and her vision for moving forward.

Khaldun:
Absolutely. And those days sound so long ago, right? Pre-pandemic. And again, I worked as the chief medical officer of the Baltimore City Health Department, I was the director of the Detroit Health Department, and it also is in my current role for the state of Michigan. There is no question that the public health workforce has been shortchanged, under-staffed, for decades really.

Over the past decade, we know that the public health workforce has shrunk by approximately 56,000 positions, primarily due to funding. And that's at the federal state and local levels. And before the pandemic, before 2020, state officials estimated that up to a quarter of their workforce would actually be eligible for retirement in 2020. And we are well aware of what's happened over the past year with this pandemic and how that potentially accelerated some of our health officials and staff, their retirements, and leaving the workforce. So it's absolutely a challenge before the pandemic. It is even more so a challenge now.

Johnson:
So we started this one's in a lifetime situation, this crisis with a deficit already, how has that affected the response over the last year?

Khaldun:
I really think that our response would likely have been more robust and quicker if we had more staffing. And so what do I mean by that? Oftentimes many health departments, especially at the local level, they may not actually have an epidemiologist. And I think everyone in society now knows the importance of an epidemiologist.

When you have a health department that does not have an epidemiologist, or you only have a couple of epidemiologists, or case investigators, or contact tracers, that are already spread thin working on other infectious communicable diseases, and then you throw a pandemic on top of it, it makes it very challenging to have as robust of a response, whether that is the case investigation, or the contact tracing, or the data analysis so you can understand how the virus is spreading and you can also make sure the public understands.

So all of those things, I think, have been all of the more challenging given where we started before the pandemic even hit.

Johnson:
How about diversity? How diverse was the workforce before March of 2020?

Khaldun:
That's an excellent point. I think that it really depends health department to health department, but there's no question that there has been a challenge when it comes to diversity of the workforce in general, but also I'd say diversity of the leadership in public health department who is actually leading those charges. So I think there is absolutely more work that needs to be done when it comes to diversity of staff, making sure staff reflect the communities that they are serving, and also the fact that leadership diversity also being present in our health departments across the country.

Johnson:
I suppose all of these challenges make the response that was mustered even more amazing.

Khaldun:
Absolutely. And that's an important point. I think it's always easy to look back and do that Monday morning quarterbacking. I'm quite proud of what the public health system has done in this country. Here in the state of Michigan, we were one of the first states actually to release our cases and deaths by race and ethnicity.

When it comes to data reporting, we had a very robust response brought down on our curve in the spring last spring, pretty quickly by most accounts, we were quite successful in saving lives, tens of thousands of lives. So, very proud of what we've done in public health and sometimes feeling like we have one hand tied behind our backs.

Johnson:
So thinking about the state of the workforce and the pandemic's impact on the people working in this field the last year, what have we learned?

Khaldun:
I think we've learned how important it is for public health staff, frontline workers, but also leaders, to have various skillsets. I think when it comes to our pipeline of people who will be the next people leading the next pandemic, I think it's really important that when we were teaching our public health students, that we teach them not just the epidemiology but also leadership, management, managing budgets, public speaking.

I think those things are really, really important when it comes to our workforce. But I also think that it's really important that we continue to inspire the next generation of public health leaders.

Public health is an amazing field. Obviously, everyone now sees how important public health is and they understand what public health even is. Because quite frankly, before the pandemic, I don't think that a lot of people understood that, but I think it's important that we think about our pipeline in the next generation of public health leaders coming through.

Johnson:
That takes a while to build up. Are there steps that can be taken in the interim to fill positions and address immediate needs?

Khaldun:
Absolutely. I have been pleased by, obviously, the amount of money that's coming in from the federal level to be able to support our vaccination efforts, but also our ongoing just general pandemic response, incredibly important.

I also think it's important to think about the employee wellness and, quite frankly, a lot of our staff are burned out. I mean, there were several months, more than six months at least, in Michigan where several people did not have a single day off and we're working on this well before the first cases were identified which, for most places and including Michigan, was March. So I think it's important that we think about employee wellness, make sure that we're giving our public health teams days off, and that we're also making their work easier.

I know we're talking about workforce right now, but we also have to talk about data systems and technology. And when you don't have a robust data infrastructure to be able to run analyses, to be able to make sure that your public health system is speaking to your hospital system, and you can analyze data easily, it really burns staff out. So I think it's about the workforce, but also just everything that it takes to really run a smooth public health response. It really needs to be in place.

Johnson:
Do you see progress these days on those issues? Is anyone doing it right, even though we're trying to get people vaccinated at the same time?

Khaldun:
That's right. We were flying the plane and building it at the same time. There have been investments made over the past year. We have gotten additional staff here in the state of Michigan. We've been able to get a staff hired on a local level as well. And, of course, President Biden has put in a lot of money into states and local governments to be able to really support COVID response.

So we absolutely have made progress. My fear, however, is that, once this pandemic goes away, it is not the top news story. Will we continue to fund and prioritize public health? Because they will be more pandemics, and we have to make sure that we are ready for the next one and we don't get complacent with public health funding for both the workforce and just general public health infrastructure.

Johnson:
Congress passed a bunch of COVID bills and included in those bills was flexibility in programs. Does that have any effect on the ability to build and maintain a good workforce?

Khaldun:
Absolutely it does. And this is something that we in public health have been advocating for years. People in public health often work on different topics. Some of the same people who are working on land are working on immunizations, working on clean water. So it's really important that when you're trying to hire staff that you have flexibility in the funding sources because, quite frankly, public health is not siloed. Public health is about communities, it's about protecting the health of families. And if you have more flexibility with those dollars, you are able to respond to more efficiently and effectively.

Johnson:
We've talked about educational partnerships to build the pipeline, we've talked about funding, we've talked about policy flexibility. Is there anything else that you need to accomplish, that public health needs to accomplish, in order to build a better, stronger, more effective workforce going forward?

Khaldun:
I think those are the key items. You know, if we make sure we are taking care of the experts, the dedicated servants who are currently working in public health, making sure, quite frankly, they don't quit—making sure that they know that they're valued, making sure that they get days off, making sure we understand what they need to do their jobs, I think we will be in a good place.

Of course, I'm concerned about all of the retirements that have happened over the past year, many of which we expected. I do believe many were accelerated by the pandemic.

We have to make sure that we have that pipeline, not just people coming out of public health school, but people who are already working in departments, making sure that they actually want to step into those leadership roles in a public health department and they see the value of that work, and also feel like they will be supported and respected if they step into those leadership roles, which I know has been somewhat of a concern over the past year with the pandemic.

Johnson:
How do you frame public health and the need to continue those investments when things are better?

Khaldun:
I think anyone who is gone through the past year understands how important public health is and how it is that investments in public health and partnerships are so important, whether it's businesses being open, having enough PPE, data systems that speak to each other so we can understand outbreaks and respond quickly.

I hope that people don't forget what we've been through and lessons learned drive us into the future. And I do think we have created wonderful partnerships here across the state. I know other states are doing similar things. Everyone has a role to play in public health. Public health is not just about the work of the state or local health departments. And I think that that is something that will be forward beyond this vaccination effort and beyond the time where this pandemic is declared over.

Johnson:
You mentioned everybody now knows what public health is or are somehow familiar with it, some more than others. How does that help in this effort to continue the work toward growing the workforce, getting it where it should be making the investments necessary in people and technology?

Khaldun:
Well, people now understand how what's going on in their community and how someone who could make it infected with a virus or disease that may not be in their immediate circle of influence if you will, how that still could have an impact on them.

And when you look at things like states putting in place policies based on how cases are increasing or decreasing in their general community, I think every business understand how they have a role to play in preventing outbreaks, but also how, if those outbreaks continue, how it can have an impact on everyone, by seeing the policies put in place that temporarily limit their ability to conduct business the way they would wish to.

I do think that this concept of everyone has a role to play in this public health ecosystem. That's something that public health leaders have been talking about for years, but I truly think that—literally we have tables in the state of Michigan, tables where we bring together businesses and colleges, and we have the local health department and others, all at the same literal table talking about how we can collectively, in our community, address the pandemic.

And I think that's a really important thing that, again, public health officials have been trying to do for some time, is that chief health strategies. But COVID-19 has really forced those tables to come together in a really, really powerful and positive way. And I do hope that that type of collaborative work continues after the pandemic is over.

Johnson:
Finally, tell us why this is important to start thinking about now, even with everything still going on.

Khaldun:
Absolutely. Well, yeah, I mean, I know everyone's very focused on vaccinations right now, as are we in a state of Michigan, but we have to also be looking to the future. If people have been looking to the future for a few years ago when there were many experts, quite frankly, who were warning that a pandemic was going to be right around the corner, we would have been more prepared.

So I think it's important that we focus on what's here and now in front of us, but we have to think about prevention and how we can be prepared for the next public health crisis.

Johnson:
Dr. Lauren Powell has held several positions focused on health equity during her career, among them senior advisor to Virginia state health commissioner, and strategist consultant to the Cambridge public health department. Since December, she has been vice-president of US health equity and community wellness for Takeda Pharmaceutical. When it comes to the future of the workforce, Powell's ready to explore every option.

Powell:
Well, I think the workforce is absolutely critical to bouncing forward. And I really like this phrase that we're using, because it has so much momentum behind it. And you think about bouncing forward, you think about a lot of energy behind that. And our workforce is critical to doing that.

I think COVID-19 has clearly unearthed lots of inequities, racial equities, health inequities, but also inequities in our industries across healthcare and funding in workforce development opportunities and all of that. So I think the workforce is absolutely critical, that we see this pandemic has shown us just how severely underfunded public health infrastructure has been for so many years, and now to the point of an emergency, right? Many of our agencies were behind on technology, had many openings on their staff and were not fully staffed in order to adequately respond to the emergencies right in front of us.

And so I think in order for us to move forward in a productive way as an industry and as a part of this important healthcare ecosystem, we have to have a workforce that's ready, able, and willing to respond to emergencies. And there are a couple of entities who are working on this. I actually serve as a co-chair for the de Beaumont Foundation's Consortium on the Public Health Workforce.

And we're actively thinking about what needs to happen, what needs to transform, and how the workforce needs to transform, what types of training needs to happen, and what are the new types of positions and new types of skills that we need to be uplifting for the future of the public health workforce.

Johnson:
Can you give us a little more detail about that work? What kinds of topics or discussions are you having as part of that group?

Powell:
We're really thinking about, you know, the core of health equity and where our health equity belongs in the prioritization of who we hire, how we hire them, and ultimately what the roles of the public health workforce will be in the future. We really see the workforce being more community-facing in the future, more community-integrated in the future.

And we're thinking about, as we know, you know, the Biden administration, and so many other legislators, their eyes have truly been open to the need for a strong public health workforce. And there have been legislation and money put behind that.

And there are projections to hire, you know, hundreds of thousands of public health positions in the future. And we're really thinking about how best to leverage those positions and how to ensure that we're keeping equity and keeping health equity at the core of all of that.

Johnson:
Well, let's connect the two. When we talk about health equity in the workforce context, what are we talking about?

Powell:
I think we're talking about a couple of things. I think we're talking about prioritizing and ensuring that our public health workforce is as diverse as the populations that we're serving and not only the workforce, but ultimately that our leadership is reflective of that.

I think public health as an entity is very diverse, but COVID has further underscored that when we look at the leadership across our states and the leadership across our public health departments, they're often not people of color, they're often not women necessarily, and we really want to see, I think, that embracing health equity is ensuring that we see that diversity from the top all the way down to the bottom.

I think in addition to that, ensuring that we are hiring individuals who have an appreciation for and an understanding of health equity, not just how to use the phrase, not just how to say the word, but how to actually operationalize it. One of the biggest challenges in the midst of COVID is that we've had a movement of folks within public health who are very comfortable using phrases like the social determinants of health, health equity, racial equity, anti-racism. But as we see when the rubber hit the road, there are a lot of folks who don't know how to put that into practice. And so prioritizing a workforce that prioritizes health equity, I think, is how we bring the two together.

Johnson:
So many health departments around the country are rushing to fill positions. They need the help. People are tired, it's been a long year. What can you tell them now that could help them do a better job of hiring the right people? Is there any advice that we can share today?

Powell:
I don't know that I'm best suited necessarily to speak on hiring practices. But, one, I think first and foremost our public health departments deserve a shout out. They deserve an award, they deserve our extended grace and gratitude, and thanks for all the work that they are doing. I was formerly the director of health equity for the Commonwealth of Virginia, and I'm still very connected to the public health workforce here.

And I see just how hard people have been working and are continuing to work. And I'm grateful for that, but I think you're right. I mean, we are sort of in a deficit mode right now, and it's very challenging. People are very tired. We've got folks who are set for retirement and are ready to move through that phase of their lives. And that's leaving a lot of space in a time where we don't have a lot of time to fill those spaces.

So I think that number one, there are tons of college students who have just graduated who are desperately looking for work. And I think that's a place where we should start really thinking about it and looking. And that's actually, by the way, something we're talking about in the Workforce Consortium, the Public Health Workforce Consortium, is what are the credentials that are actually needed to do public health work? Does it require a master's degree? Does it really require a bachelor's degree? Or does it really require knowing your community well and having the passion and will to want to see people well around you? So I think we could get creative in this moment. This is the opportunity to try new things. And so perhaps building up more of a workforce and filling those positions with folks who are from the community, people maybe who are coming from other industries who have been laid off from other sectors who could bring something new to the public health workforce.

And so I think diversifying our requirements, our work requirements perhaps, and thinking outside of the box as to what are the credentials and what are the qualities and skills that are really needed to do public health work. And perhaps it's not necessarily always formal education.

Johnson:
It sounds like more people are responding to this pandemic with the registrations going up in public health schools around the country, the Fauci effect they call it. Are you happy to see that?

Powell:
Oh, I'm always happy to see an increase in, I think, interest in public health. And I hope that this is permeating diverse communities, right? That we have more people from Native American communities who were a part of our public health workforce, from our Latinx and Asian communities, and from our Black and Brown communities, from the LGBTQ+ community, and from the disability community.

I'm hoping that we see an influx from a diverse group of folks, and I think that's excellent. And that's only going to serve to make our public health workforce stronger and our ability to respond in moments like this that much stronger as well.

Johnson:
You've talked to a lot about the de Beaumont task force that you're a part of—is the goal there to offer public health some recommendations for how to fill this need, how to address health equity in the workforce going forward?

Powell:
Absolutely. I think that there are plans to ensure that there are some recommendations that will come out and that will also engage the larger workforce. And some of those recommendations, by the way, will also be to the private sector. And I'm so excited to be a part of Takeda who is already recognizing that we have a role to play in helping to build up the public health workforce as well.

Johnson:
Speaking of that, I think the entire country, if not the world, got a crash course in how the drug trials work because of the spotlight on COVID-19 vaccines. We've learned so much about how many people are in them, what people are in them.

And one of those issues had to do with diversifying the folks who were volunteering, making sure that communities of color were represented because sometimes their physiology is different and reacts in other ways to drugs and vaccines and that sort of thing. Is that the only way that the private sector is responding, or can you tell us about other ways that they're working to sort of address these health equity concerns that we have?

Powell:
Oh, I really appreciate that question. And I think it's a great one. I think you're absolutely right. I mean, COVID has just really opened our eyes to so much. And among that are health inequities that perhaps other pieces of the healthcare ecosystem may not have necessarily recognized.

And Takeda, I think, is a leader in this area, really not only recognizing the need and responsibility to contribute to building community wellness and health equity but then creating a position that is solely focused on that, which is really unheard of and really, really new.

I'm excited to be here because I really think that there is a major opportunity for Takeda to be a leader in this area and really creating the blueprint on how best to engage with communities and how best to contribute to generational impacts, positive generational impacts on communities.

And while a lot of companies are focused on the need to diversify clinical trial representation, that's not the only way I think that we can contribute. We're certainly actively thinking about, and I'm thinking about, our framework of contributing to health equity.

How do we move sort of be on a corporate level of giving or a corporate level of involvement in communities to a really grassroots level of involvement in communities and thinking about ways that we could support perhaps rural communities that don't have access to the internet or create, you know, jobs in communities that are more community-rooted and community-facing? If there are ways that we can help folks better understand the research process and understand the pharmaceutical industry, towards, perhaps, increasing the participation of minorities in clinical research.

But ultimately, I see our job as building trust and recognizing that that's going to take some time and then sort of leveraging our power and privilege as a major global company to have a positive impact on some of the social determinants of health that we know are making life really difficult for certain populations among us.

Johnson:
Is industry doing anything to directly support the government side of public health? Or is it just running alongside that, supporting the same issues?

Powell:
Well, I think this is an opportunity for the industry to step in and to be of direct support to our public health departments. I'm certainly thinking about ways to do that. I'm certainly looking forward to the opportunity for Takeda to perhaps work with ASTHO and work with others who we know are major stakeholders in the public health community and the public health workforce.

And I think at this point, you know, it, it's important to realize there were so many different pieces of the healthcare industry, and the pharmaceutical industry is a big anchor to that. And so I'm just excited that we had the opportunity to really create a path forward.

Since we're talking about bouncing forward, this is another part of bouncing forward is recognizing that there is a lot of momentum, not only in pharma, but even in tech. There are folks in Google and lots of other industries, private industries, that all want to see us all live a healthy and well life because it ultimately, you know, it impacts all of us.

Like COVID has shown us exactly what population health is in that is that my health is connected to the health of my neighbor. And so as long as I'm trying to help my neighbor be healthy, I'm going to be healthy as well.

Johnson:
I suppose it doesn't hurt to have public health alums like yourself now in the private sector, beating that drum every day.

Powell:
I suppose it doesn't hurt either. I didn't really know that this was going to be the next step I would take, but I couldn't be more thrilled about it. I think we need folks who understand health equity and who understand equity everywhere. This is not something that the public health sector and public health departments can carry on their own. They don't have the workforce, they don't have the money for it. And this is a heavyweight that we all have to carry, we all have to lift together.

Johnson:
How long does it take to get the kind of equity were looking for out of the public health workforce, is there a year or a deadline put on this process? How long?

Powell:
Well, I'm not sure if that's something we can put a timeline on. I think if anything, I would say it's of urgent need is we see where, you know, currently still in the midst of an emergency and who knows what else could be to come.

So I think it is an urgent imperative, but I think it's ultimately when we think about equity and health equity, those are ultimately things that we are constantly striving for. So there is not necessarily like a finish line in sight, it's that we have to constantly be evolving constantly, be ready to meet the next challenge, and ensure that our workforce is ready for it.

Johnson:
Someday soon, we hope—we all hope very soon—this pandemic will be behind us and we can put our masks in our back pockets. Does interest in all of these issues that we've discussed here, that are being discussed across the country and the world, does it fade when the pandemic ends?

Powell:
Well, I certainly hope not. I think, you know, we can have a short attention span as Americans sometimes, we can quickly move on to the next thing. But I certainly hope that this experience, this collective experience that we've all had, is not something that will fade quickly.

I think we'll have reminders even after COVID of how important it is that we ensure that we are ready for the next emergency that comes. And so I certainly won't let this charge fade and I think there are several other leaders in public health who won't let up either.

Johnson:
Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues. And if you have comments or questions, we'd like to hear from you. Email us pr@astho.org. That's PR at ASTHO dot org. This show is a production of the Association of State and Territorial Health Officials. For Public Health Review, I'm Robert Johnson. Be well.


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