Winds of Change
SEASON FINALE / Reflecting on transformative change for building the future of the public health workforce
Over the last few weeks, I have examined some recurring themes that keep coming up in The Public Health Workforce is Not OK. You can read the entire archive of articles about working in public health here.
In this final episode of Season 3, I turn my attention to the many ways in which we have witnessed change throughout the 1½ years that I have been publishing this column.
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Lessons learnt
The public health workforce is depleted, traumatised, and still desperately in need of funding. If a global pandemic has not been enough to shake things up, what's it going to take to generate attention to the need for sustained, consistent funding that creates sustained, consistent jobs for the public health workforce?
I’ve seen lots of journalists reporting on lessons learnt from experiences during the COVID-19 pandemic, often based on thoughtful reflection from those who (like me) served on the frontlines. What I haven’t seen is their scientific counterpart: where’s the formal evaluation and learning from the results of policies enacted, based on real world evidence and rigorous methodologies? Efforts to create a credentialled national “911 Commission” for the COVID-19 emergency response stalled in Congress, and formal evaluation also hasn’t consistently taken place at any of the multiple jurisdictional levels of emergency response focussed on public health and infectious disease operations, including local, State, tribal, territorial, and municipal. CDC initiated an internal reorganisation based on experiences during COVID, and NIH has reviewed lessons for research - but my local health department apparently continues to bumble along pretty much as it looked in 2019, just with staff even more exhausted and alienated. Where does this leave us in relation to pandemic preparedness for Disease X?
I’ve described before my unease about the glut of media attention accompanying the fanfare of the “end” of COVID-19, seeking to derive lessons learnt for public health based on anecdata. Most of these lessons share a focus on the need for modernization of the public health system, especially data, logistics, commodities, technologies and other deliverables. Of course I concur that these are important, but my worry is that this focus on sexy technologies comes at the expense of the more mundane staffing questions: who do you think will be delivering the deliverables? Where is the funding for the humans who remain responsible for administering and organising the systems?
We still need to advocate loudly for funding that will create secure, well-resourced jobs in public health that offer career development paths and enable public health professionals at all career stages to feel cherished. Meanwhile, as I read news updates published mere weeks after the declared “end” of the pandemic that describe staffing cuts throughout the public health system, the appointment of public health officials promoting findings unsupported by evidence, and even the unprecedented controversy over reauthorising funding to PEPFAR’s lifesaving support, I wonder exactly which are the public health lessons that have been learnt here?
Outsourcing
A recurring theme coming up throughout this column has been the impact of outsourcing in public health. An increase in the roles of contractors and consultants performing various public health tasks for government agencies at all levels has had an undeniable influence in shaping the current functions of the public health workforce and the opportunities within it.
I have considered these roles from multiple perspectives. I have been an insider, an outsider, and someone who occupies the grey areas in-between. I have variously been an employee, a contractor, a consultant, a freelancer, an entrepreneur, and more. I have seen a lot of advantages from specialisations and a lot of disadvantages from inefficiencies. I have seen positions advertised as consultancies when in a previous era they would have been offered as full-time jobs with security and benefits. I have even applied for them.
Talk of public-private partnerships is cheap and plentiful. There remain many questions about the roles of the private sector working in partnership with government to provide the essential services of public health. Which kinds of expertise should be cultivated in-house within government agencies, and when can outsourcing be advantageous? When is it efficient for government agencies to outsource risk and find someone else to shoulder instability? At what point does outsourcing start to threaten or undermine the growth of internal capacities within government? When is it reasonable to expect individual contractors to shoulder the burden of payroll instability and lack of benefits in return for flexibility and profit? I believe that the answers to these questions lie in the perceived time horizon of our goals: if we are aiming for stable, consistent funding for public health, we need to take a long-term perspective. There are no time limits on the human right to health.
Many different types of partnerships and contracting mechanisms are currently in use within the public health sector, and each has lessons to teach. From the global consulting firms engaging in partnerships with governmental public health actors to conduct the business of public health, we can learn how to offer job security and skills development pathways, how to manage tasks and teams, how to take full advantage of the latest technologies and interface with advanced cross-sectoral skills. From the small-scale (often sole-proprietor) consulting enterprises contracted for specialist public health assignments often at State and local level, we can learn about how to provide in-depth expertise on a particular community or methodological approach. From the contracting firms hiring out labour to health departments on fixed-term contracts, we can learn about nimble and responsive workforce management. Most importantly of all, there are many instructive lessons from all of these types of outsourcing that teach how not to conduct public health tasks. I’d love to create a space to investigate this rarely-explored topic further with others who care and those who have the power to make change. (Perhaps starting with a book group? Contact me directly if you are up for it?!)
The role of the public health workforce in linking public health and healthcare
It has long been acknowledged that the current system of healthcare provision in the United States prioritises resource-intensive clinical treatment to individuals over lower-tech preventive health measures to populations. Far be it for me to treat correlation as causation, but this approach does not appear to be serving the United States well on a global scale, as expressed through health outcomes such as life expectancy and maternal mortality. Even as I advocate for a shift in focus upstream, moving away from discussions about micro-efficiencies and health insurance regulations towards a large-scale transformation of the outdated paradigm, I can’t help but observe the necessity of a robust public health workforce proficiently executing the essential services of public health, led by preventive health policies such as universal access to routine childhood vaccinations and antenatal care, or diabetes screening and referral services.
Population-level public health services and clinical healthcare for individuals are inextricably linked in a fraught and badly misunderstood relationship that is long overdue for a recalibration. When the priorities of public health are proactively addressed by a fully functioning preventive health system, population-level needs for treating sick individuals will decrease, resulting in a lower burden on the healthcare system. Developing a workforce of trained, experienced staff working and growing in their careers as public health professionals will develop and strengthen the system that provides preventive health services and addresses long-term population health outcomes. In order to avoid putting overwhelming strain on the healthcare system from the clinical treatment needs of people who are sick, we must first staff the preventive health system appropriately.
Witnessing positive change
During the year and a half that I have been publishing these three seasons of The Public Health Workforce is Not OK, I have been gratified to see an increasing level of attention devoted to acknowledging the need to reimagine and rehabilitate the public health workforce and planning for its next steps. We’ve witnessed the long-awaited release of federal funding for the CDC Public Health Infrastructure Grant, and we’ve seen organisations starting to work together towards shared goals of research and development for the public health workforce. We’ve seen the birth of a new advocacy organisation, the National Alliance of Public Health Students and Alums, whose efforts are beginning to gain political traction. We’ve seen new data on the public health workforce, and the emergence of efforts to develop evidence-based policy to respond to real workforce needs. In particular, the fabulous report of the President’s Council of Advisors on Science and Technology (PCAST) drew some much needed high-level political attention to the need for support for the public health workforce, but I hope it won’t end up as another report living on a shelf and I wonder how we’re going to leverage political and financial support for implementing its recommendations. We won’t get anywhere new without a high and sustained level of funding to the public health workforce.
It’s great to see resources increasingly directed to a new awareness of pandemic prevention and emergency preparedness, but let’s not forget the ongoing impacts of the unfinished epidemics and pandemics still raging in the US and globally, including HIV and AIDS, the opioid crisis, maternal mortality, vaccine hesitancy, and youth mental health, which all urgently need skilled staff and resources too. In the unequivocal words of the PCAST Report to the President: Supporting the US Public Health Workforce: “a well-defined, well-trained, well-resourced, and well-compensated workforce is the foundation of a truly robust U.S. public health system that can serve the needs of the American people.” Let’s get to work building it.
Join me to continue the conversation in Notes or Chat or Comments or Threads.
Which kinds of public health tasks are suited to outsourcing to consultants or contractors? And which are not?
What are your hopes for the future of the public health workforce?
🕊️I’ll be taking a well-earnt break this week so I’ll close by wishing readers a peaceful season. Please be in touch through LinkedIn if you would like to work together towards future action.