A Health Podyssey

Learn more about academic opportunities in Health Policy and Law at UCSF and UC Law San Francisco.

Health Affairs Editor-in-Chief Alan Weil interviews Brian Castrucci, president and CEO of the de Beaumont Foundation on his paper in the March 2023 issue examining the state and local public health workforce between 2017 and 2021, before and during the COVID-19 pandemic.

They found during this period, about half the workforce left their jobs with higher rates for younger and less experienced workers.

Order the March 2023 issue of Health Affairs.

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What is A Health Podyssey?

Each week, Health Affairs Editor-in-Chief Alan Weil brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.

A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.

00;00;00;00 - 00;00;05;16
Alan Weil
Hello and welcome to “A Health Podyssey”. I'm your host, Alan Weil.

00;00;08;03 - 00;00;39;04
Alan Weil
State and local public health leaders have faced tremendous pressure during the COVID-19 pandemic. Thrust into the spotlight, they were often the target of animosity regarding business and school closures, mask mandates and other sometimes controversial public health measures designed to reduce the harms of the emerging pandemic. Now, behind these leaders are many tens of thousands of epidemiologists, health educators, program administrators and others who make up the state and local public health workforce.

00;00;39;19 - 00;01;11;28
Alan Weil
While they're less visible, their work is no less important, and in many instances, the stresses they experience are just as great. What is the health of the public health workforce? That is the topic of today's episode of “A Health Podyssey”. I'm here with Brian Castrucci, president and CEO of the de Beaumont Foundation. Dr. Castrucci and coauthors published a paper in the March 2023 issue of Health Affairs, examining the state and local public health workforce between 2017 and 2021,

00;01;11;29 - 00;01;36;20
Alan Weil
before and during the COVID-19 pandemic. They found that during this period, about half the workforce left their jobs with higher rates for younger and less experienced workers. These data raise serious concerns about our ability to retain the workforce needed to meet our public health needs into the future. We’ll discuss these challenges in today's episode. Dr. Castrucci, welcome to the program.

00;01;36;29 - 00;01;38;12
Dr. Brian Castrucci
Thank you so much for having me.

00;01;38;22 - 00;01;57;20
Alan Weil
It's a really important topic. And before we get into sort of the numbers and who's coming, who's going, I just want to make sure that our listeners have a good understanding when we talk about the state and local public health workforce. What are these folks do? Tell us a little bit about what it means to be a state or local public health worker.

00;01;58;13 - 00;02;20;09
Dr. Brian Castrucci
Well, you would think that after three years of a public health pandemic that everyone would know what public health is. But that's tragically not the case. For some, public health is a group that closed their businesses or kept their children from school. For others, public health was on the front line fighting every day to keep people out of the hospital and providing prevention information.

00;02;21;10 - 00;02;44;25
Dr. Brian Castrucci
For me, I like to describe public health like the foundation of your house. It's not something you think about a whole lot, but it's essential for everything else to function. If you want your children to read on grade level or graduate on time, or if you want to worship on Sunday, or have your employees show up to work as their complete selves, they all have to be healthy.

00;02;45;25 - 00;03;06;13
Dr. Brian Castrucci
So public health to me is economic development. It's our safety. Our security. What COVID taught us is that decades of underinvestment in public health has weakened our foundation, which is now being exacerbated by a new breed of conservative politician determined to take a jackhammer to the foundation of our own house.

00;03;07;04 - 00;03;30;01
Alan Weil
So before we get into some of the threats to this workforce, and you mentioned the critical role they play, I still think even if we can get people to understand what public health is or why it's important, it's hard to visualize what the day in the life of a public health worker is. And I realize that they do lots of different things.

00;03;30;13 - 00;03;39;07
Alan Weil
But if we're trying to convince people of the importance of this workforce, could we describe like, okay, what does it mean? How do you protect my foundation of health?

00;03;39;25 - 00;04;06;06
Dr. Brian Castrucci
Well, I think this is part of our challenge is when you think about how we're acculturated in our society, we understand what doctors and nurses are. We've all had that experience of going to the doctor, of being unhealthy and then having ourselves kind of returned to health. But what we don't understand and we're not even taught that there's this indelible link between community health and individual health.

00;04;06;27 - 00;04;40;08
Dr. Brian Castrucci
And so public health is there to ensure that each of us have an opportunity to live our most healthy lives. And that's through policy change, understanding disease dynamics, changing traffic patterns to know that there's a stop sign where a lot of people are getting to a car accident, so that should be a stop light. Those changes to our environment, to where we live, to where we work, to where we play, making those places supportive of health.

00;04;40;29 - 00;04;42;15
Dr. Brian Castrucci
That's what public health does.

00;04;42;16 - 00;04;43;19
Alan Weil
Okay, so we

00;04;43;19 - 00;04;44;06
Alan Weil
need

00;04;44;22 - 00;05;11;23
Alan Weil
a strong workforce if we're going to go about the business every day. And I like your contrast with the clinicians, doctors and nurses that we kind of know why we go and we know what we think they're supposed to do when we get there. A lot of what keeps us healthy is invisible on a day to day basis, and so we don't have sort of a mental map of what these folks are doing to help us.

00;05;11;23 - 00;05;35;13
Alan Weil
And until, as you noted, they seem like the face of people trying to shut down our schools or business, which is not what they do most days. Now you focus on the workforce. And this is an area I know of great interest and concern to you, not just in this paper. Recruiting and retaining the public health workforce has been a challenge, you know, predating the COVID-19 pandemic.

00;05;35;14 - 00;05;58;18
Alan Weil
So give us a little of the context, if you would. We can't just sort of look at departures during COVID and say it was bad. If it was bad before then, then clearly the problems are more systemic. So what can you tell me about challenges having a solid and retaining a solid workforce in state and local public health?

00;05;58;28 - 00;06;26;23
Dr. Brian Castrucci
There are many structural reasons why recruitment and retention has lagged in the public health workforce. Salary is the most commonly cited reason, but also limited opportunities for growth and often an inability to move vertically within governmental organizations. Like so many industries, we have a multigenerational workforce and older Americans are staying in jobs longer, and that limits promotional opportunities for earlier career professionals.

00;06;27;12 - 00;06;59;16
Dr. Brian Castrucci
Generally, I don't think the state of state and local governmental human resource departments has made the evolution to think of themselves as talent acquisition or talent recruitment. Often they find themselves beholden to archaic and outdated processes and the competition has increased. Google, Disney and the Federal Reserve were not destination employers for public health practitioners when I first attended a school of public health way back in 1997.

00;07;00;08 - 00;07;24;07
Dr. Brian Castrucci
But that's all changed today. So governmental public health is often having to compete for staff with fewer resources and less flexibility than its competitors. We also have to look at just the structure of the workforce. We are often contracted workers. Transitional. We're only there for as long as the funding pays us, and that's typically funding from a philanthropy or from federal government.

00;07;24;20 - 00;07;39;24
Dr. Brian Castrucci
And so permanency of the workforce is always being threatened. And you saw that through COVID. All of the public health staff who were hired for the pandemic response when the pandemic had waned, then they were gone.

00;07;40;23 - 00;08;12;20
Alan Weil
So you describe a really tough work environment, which I can really understand this sort of project to project hiring and firing archaic systems, maybe not a very good career trajectory. This notion of competition with the private sector, we could have a whole podcast about this. We don't have time to go deep into it, but I think that's a really interesting point, is that even as it's devalued in the public sector, the private sector's had a realization of how important public health is.

00;08;12;20 - 00;08;40;00
Alan Weil
And so people who have that expertise are very valuable in the private sector, even as we devalue them in the public sector. Let's look at your study and the survey data you analyzed. I'm just going to sort of ask you to give the top line here. You're looking at departures from state and local public health jobs. What did you find in terms of departures and maybe a little bit about who stayed and who was more likely to go?

00;08;40;18 - 00;09;17;03
Dr. Brian Castrucci
So we've conducted the Public Health Workforce Interest and Need Survey, which is PH WINS for short, three times: in 2014, 2017 and 2021. And the workforce has always expressed high levels of intent to lead. This study is the first that we know of that could actually examine real departures and the findings are super concerning. We found that between 2017 and 2021, 46% of the staff in state and local health departments left their organizations.

00;09;17;22 - 00;09;40;29
Dr. Brian Castrucci
That's half, half of the people who are there to ensure our food and water are safe, inspect our restaurants, work to prevent injuries, help to ensure gun safety, reduce opioid deaths, and protect us from emerging infectious diseases. They're gone. Imagine if you were getting on a plane and you heard that we lost half of all of our air traffic controllers.

00;09;41;20 - 00;10;06;27
Dr. Brian Castrucci
Would you fly? Or if we lost half of all our teachers, how would we educate our children? You know, Senator Bernie Sanders and Surgeon General Vivek Murthy have brought attention to the needs of a diminishing health care workforce, and that's a significant need. But if we don't address the public health workforce, you won't be able to hire enough doctors and nurses to meet the need.

00;10;07;16 - 00;10;17;07
Dr. Brian Castrucci
Public health is that first line of defense. And if it's gone, the consequences for every aspect of our lives will be disastrous.

00;10;17;22 - 00;10;30;03
Alan Weil
Wow, you know, I am trying to imagine losing half the workforce in just a handful of years. And as you note in the survey, there’s certain younger and shorter tenure where the rate’s even higher. Can you say a little bit about that?

00;10;30;03 - 00;10;54;20
Dr. Brian Castrucci
The 50% number is bad enough, but among the youngest and newest public health practitioners, they were the most likely to leave. 74% of workers, 35 years of age or younger, and 77% of those with five years of experience or less in 2017 were gone. Again, it's three quarters, it's three out of every four under 35 year olds are gone.

00;10;55;13 - 00;11;20;22
Dr. Brian Castrucci
And we know that since 2008, there have been a wave of delayed retirements that can only be delayed for so long. Now we find that there is this early exodus among younger people in the workforce. When these trends collide, when we lose young people, at the same time, more senior leaders begin to leave in droves, it could be a disaster of epic proportions.

00;11;21;04 - 00;11;39;26
Dr. Brian Castrucci
It would be a perfect storm taking direct aim at our nation's continued safety, security and prosperity. Those are the stakes we’re gambling with. And we need to wake up as a nation and figure out how we fix this problem and not just solely focus on health care, but health workers generally.

00;11;40;10 - 00;12;17;05
Alan Weil
Okay. Well, we have to turn to how do we fix this problem? Given these data, that's got to be where our focus is. I'll talk to you some more about some of the potential solutions and some of the implications of these findings after we take a short break. And we're back. I'm speaking with Dr. Brian Castrucci about departures from the state and local public health workforce.

00;12;17;06 - 00;12;38;20
Alan Weil
Before the break, we got the bombshell results of almost half of the staff leaving and almost three quarters when you look at younger, shorter tenured workers. Before we talk about what to do about this, there is a dimension of the work that may seem a little technical, but I found it particularly interesting and I want to make sure I understand it and that our listeners can understand it.

00;12;39;08 - 00;13;00;09
Alan Weil
You mentioned that we've in the past known about intention to leave, but now we have data on actual departures. And you know what I'm thinking about forecasting and how you plan for what your workforce is going to be, what information do you have? Presumably knowing that people plan to leave is helpful, but it's, but plans don't always play out.

00;13;00;09 - 00;13;10;21
Alan Weil
So I wonder if you can tell me a little bit from the work you did about whether people saying they're going to leave turns out to be a very good predictor of whether they will leave or not.

00;13;11;03 - 00;13;44;13
Dr. Brian Castrucci
Intend to leave throughout the business literature is generally a good indicator of actual turnover. However, unpredictable events like the COVID-19 pandemic can cause unusual patterns. In our most recent survey, we found extraordinarily high levels of stress and burnout. The impact of this is that the rate of departure for people who did not report and intend to leave in 2017 was much higher than the rate of departure

00;13;44;13 - 00;14;18;06
Dr. Brian Castrucci
among those who didn't report an intent to leave in 2014. So what we're seeing in these data for 2021 is that those folks who intended to leave, left, and those folks who didn't intend to leave, they left too. That's what's making this a real critical time, because we're seeing that confluence of leaving throughout the entire workforce, and one of those situations where intent to leave was a good predictor, but not intending to leave was actually not a good predictor because those folks still left, too.

00;14;18;20 - 00;14;39;05
Alan Weil
Yeah, that's a scary situation to be in. So if we're going to talk about solutions, I think one of the things we need to understand is what makes people want to stay. So your study asks people about job satisfaction and what is it? What are the ingredients of someone who's satisfied enough to want to stay in these jobs?

00;14;39;24 - 00;15;09;08
Dr. Brian Castrucci
For workers who said they weren't considering leaving their organizations, there were two common reasons for staying: the benefits and job stability. Of course, supervisory satisfaction and organizational satisfaction were critical to people staying and feeling good about their job. We also have to recognize that the governmental public health workforce is an extremely mission driven workforce and so part of retaining these employees is ensuring that they can achieve that mission.

00;15;09;28 - 00;15;40;23
Dr. Brian Castrucci
And that became much harder throughout the pandemic and even now, I worry about our governmental public health workforce in places where the governor and the health official have turned their back on science and facts or turned down needed federal funds for disease prevention or introduced legislation that weakened, if not crippled, future public health response. And of course, just because public health is strong in one place, that doesn't really matter.

00;15;41;04 - 00;15;46;16
Dr. Brian Castrucci
Public health is like a chain only as strong as the state with the weakest public health system.

00;15;47;10 - 00;16;24;25
Alan Weil
There's a lot there that I want to follow up with you on. So first of all, there are ingredients of jobs that make people want to stay. And that's good to know because if we're going to address this, we've got to be able to look at those strengths. But then you also mentioned sort of the political dynamics that if you're mission driven and you don't feel supported, if you don't feel like the mission of your daily work is being supported by your departmental leaders or your political leaders, then even if you have good benefits, even if you have a good job, it's hard to feel motivated to come in every day. In the

00;16;24;25 - 00;16;50;01
Alan Weil
wake of those stresses, I'm not sure I know what to ask you about the leadership issue. If public health is under strain because of politics, I don't know that we have a natural fix for that. Although maybe you have an idea that I'd like to hear. But I'm also thinking about this issue of sort of the links in the chain.

00;16;50;10 - 00;17;06;09
Alan Weil
How do we think about assuring not just a sufficient workforce where we are because we have some control over that, but assuring that there's a sufficient workforce everywhere because we're all affected by wherever is the weakest link.

00;17;07;01 - 00;17;39;26
Dr. Brian Castrucci
This is the major challenge coming out of the pandemic. We all understand federalism a whole lot better and that public health is the responsibility of the state. But I don't know that we ever imagined a time where we would treat pandemic response like some “choose your own adventure” book. You had governors opening up restaurants, bowling alleys and movie theaters at the same time that their health department was trying to hire contact tracers.

00;17;40;21 - 00;18;20;00
Dr. Brian Castrucci
So we need a reckoning. We need a reckoning in this nation that we cannot protect ourselves from emerging infectious disease, each working individually. This is not an ideological debate. This needs to be a practical conversation. We need to find those things that we can agree on and move from there. But what we're witnessing in a state like Florida, where the health department is putting out analyses that you wouldn't publish in Health Affairs on your worst day and using that in that state to make policy about who should get vaccination,

00;18;20;08 - 00;18;44;08
Dr. Brian Castrucci
this is something I never thought I would see in my public health career. And so we have to call out misinformation. We have to rebuild trust. We have to be present in the lives of our community members. They have to know us. That's how we're going to rebuild trust. And we need people, we need elected leaders, community leaders, faith leaders to support their public health practitioners.

00;18;44;16 - 00;18;52;12
Dr. Brian Castrucci
But you can't support someone if you don't know them. And so that's the job for the public health practitioner going forward. Be out there, be known and be engaged.

00;18;52;28 - 00;19;19;10
Alan Weil
Well, that seems like a good starting point when we're worried so much about trust. I am curious, we have heard for decades about the underfunding of public health in general. And you mentioned that as a relevant factor around employment. In the paper you do say that we need new funding to support the public health workforce. I doubt anyone who's looked at this issue would disagree.

00;19;19;19 - 00;19;32;02
Alan Weil
But you also say, and here's just a short quote, “Funding alone will not adequately address the current workforce challenges.” Now, I suppose we've discussed that some, but I'd like to give you the opportunity to say a little bit more about that topic.

00;19;32;13 - 00;20;11;01
Dr. Brian Castrucci
Yeah, I think the Beatles taught us that money can't buy you love and it certainly can't rebuild our nation's public health system. The 3.2 billion invested by the CDC (Centers for Disease Control and Prevention) is a great start, but it needs to be sustainable. Also, these funds are going to be filtered through governors offices. Governors who, like I said, open bars and restaurants during COVID while their public health departments were trying to hire contact tracers. Governors who opposed basic public health prevention efforts, who fought mask mandates, who openly railed against the vaccine.

00;20;11;26 - 00;20;50;14
Dr. Brian Castrucci
So we have to confront this misinformation and politicization, or it's going to erode not only our health, but also our economy and our military preparedness. Now, for those who are actually interested in building a strong and vibrant public health infrastructure, in addition to the funding, we need to seriously reform and streamline our governmental hiring systems, we absolutely have to reduce the burden of student debt by extending loan forgiveness and service scholarships for public health practitioners and make it easy and accessible.

00;20;50;14 - 00;21;19;24
Dr. Brian Castrucci
We need to offer supervisory training tailored for government practice. We are far too often hiring people for technical expertise in our leadership roles rather than their ability to work with and lead people. So we need to train those skills into our supervisory workforce. We have to create recruitment pathways for people with bachelor's degrees, create mentorship programs to prepare early career professionals for eventual leadership roles.

00;21;19;24 - 00;21;56;19
Dr. Brian Castrucci
We have to actually improve the systems that monitor and track our workforce trends so that we can anticipate and address challenges. And lastly, we have to find ways to pay for public health services and infrastructure at the state and local levels and not simply rely on federal funding. That's the recipe to rebuild public health in this nation. It's now a question of will we have the political will to do these things, or will the politicization that is infiltrating public health derail our ability to rebuild and essentially threaten the future of our country?

00;21;57;16 - 00;22;15;23
Alan Weil
Well, I sure am glad I asked that last question, because listening to the first 10 minutes of our conversation, it was pretty easy to get depressed and there's a lot to worry about. But it's quite clear from your answer to the last question that there are some great ideas and great models out there for how to address these barriers.

00;22;15;26 - 00;22;39;15
Alan Weil
There's a lot of work to be done. There's the need for political will and commitment, all of those things. But it's not that we don't know what we need to do. In some instances, we really don't know how to get from here to there. It sounds to me like you have, and the evidence shows, that there is a way from here that gets us to a stronger public health infrastructure and a stronger public health platform and a stronger public health workforce.

00;22;40;24 - 00;22;57;18
Alan Weil
So, Dr. Castrucci, I appreciate the work you've done in this area. I know it goes far beyond this paper and your commitment to making sure we have a healthy community and states and country and world to live in. Thank you for being my guest today on “A Health Podyssey”.

00;22;57;18 - 00;23;02;04
Dr. Brian Castrucci
Thank you. I appreciate it.