April 7, 2021

         

I write to you on behalf of the Big Cities Health Coalition (BCHC), a forum for leaders of America’s
largest metropolitan health departments to exchange strategies and collaboratively address issues to
promote and protect the health and safety of the nearly 62 million people they serve. Our members
have not only been on the frontlines of the pandemic response for the past year but have also
experienced firsthand the field’s workforce challenges for many years. We very much appreciate the
increasing focus on the public health workforce and this opportunity to provide input for forthcoming
bipartisan legislation. Having both of you leading the HELP Committee at this moment is so critically
important. We thank you for your foresight in promoting and protecting the public’s health.
Our comments will speak to the Committee’s question on ways to address workforce and training
needs of the public health sector to address COVID-19, economic recovery and beyond.
Looking ahead, it is clear that long-term, sustainable, and predictable investments in the
governmental public health workforce, and the system as a whole, are needed to ensure that our big
city health departments (like Public Health Seattle-King County in WA and Mecklenburg County Public
Health in NC) are able to support those communities that have been hardest hit as they work to
recover from the pandemic, as well as the decades of inequity that predated and exacerbated it. It is,
therefore, critically important to consider the challenges that the governmental public health
workforce faces and how we can best build the infrastructure we need to prevent and respond to
future emergencies.

In order to do so, a strong emphasis on strengthening health department capacity at all levels of
government is necessary. Unfortunately, the local and state public health workforce was in a crisis
before the COVID-19 pandemic. Local health departments entered the pandemic down over 20
percent of their workforce capacity compared to before the 2008 recession – and we do not yet know
what the longer-term workforce implications of the pandemic will be.1 Over the same period, the
nation’s population increased by 8 percent,2 with the number of fulltime equivalent employees
dropping from 5.2 per 10,000 people to 4.1 per 10,000 people in 2019.1 As you both well know, public
health challenges over the past decade have only increased. Impending retirements, staff that do not
reflect the demographics of their communities, and positions tied only to specific ailments/funding
streams have led to both a shortage in people power and a lack of flexibility to meet new challenges.

As we think about how best to rebuild our nation’s public health system, we need a modern, wellresourced, and sustainable workforce that has the right mix of skills and training, and one that is made
to last. This will take sustained and predictable federal funding to create and maintain jobs that can
support core public health functions, work across health department programs, and support the
foundational capabilities of health departments so that all Americans can benefit from these efforts
no matter where they live.

A key component to achieving a robust public health workforce to address COVID-19, economic
recovery, the next pandemic, and every day public health work is adoption and funding of the Chair’s
Public Health Infrastructure Saves Live Act. The legislation supports core public health infrastructure
and cross-cutting capabilities that are chronically underfunded due to the categorical nature of federal
funding.

Importantly, federal funding and workforce support must be designated to communities across the
country and not stop at the state level to distribute. Health departments working in the nation’s
largest metropolitan areas must have rapid access to sustained and long-term funding to build their
workforce, which includes not just public health generalists or specialists, but also all the skill sets that
it takes to run a well-functioning organization: human resources, grants and contracts specialists,
policy advisors, and communications experts, to name just a few. These latter types of positions are
often not covered by disease specific grants from the federal government, which is a challenge then to
building up the workforce. In most cases, it takes an incredibly long time for dollars to get to our
member health departments when they are passed through the state. While it is not realistic to think
about the federal government directly allocating funds to 3,000 local health departments, it is possible
– and moreover likely more efficient – to reach the nation’s largest ones directly. With COVID-19 relief
funding, CDC has begun to directly fund jurisdictions of 400,000 or more in population in some
instances. We strongly support this and would like to see CDC do this regularly.

As we think about increases in public health funding, we cannot continue the “boom and bust” cycles
that have resulted in chronically underfunding the system. This has hampered our pandemic response
and will hamper future ones as well. We must look for mechanisms to improve recruitment and
retention in the governmental public health workforce, whose skillsets are in even higher demand
since the beginning of the pandemic. The growth and retention of the public health workforce should
specifically focus on racial and ethnic diversity to address issues of trust, confidence, and
representation of the diversity of the residents served by the health department, a concern which
certain workforce programs may exacerbate. One policy intervention is the establishment of a public
health loan repayment program, as introduced in the 116th Congress by Representatives Jason Crow
(D-CO) and Michael Burgess (R-TX) and Senator Tina Smith (D-MN) and is likely to be reintroduced in
the 117th Congress. Modeled after the National Health Service Corps, this program is one way to
improve recruitment and retention in governmental public health and bring needed skillsets to health
departments across the country.

In terms of workforce training for governmental public health, we must invest in building new skills for
new challenges. The public health workforce includes many highly specialized and knowledgeable
experts in distinct scientific disciplines (such as, epidemiology, laboratory sciences, chronic disease
prevention, maternal and child health, environmental health, and injury and violence prevention)
serving as the foundation for many disease response efforts. However, while continued excellence in
core scientific disciplines is a priority, the governmental public health workforce increasingly requires
strategic skills that allow them to transcend traditional public health disciplines to meet the evolving
needs of the public.

Recently, we developed recommendations in coordination with the National Association of County
and City Health Officials (NACCHO) in response to EO 13996 and the American Rescue Plan (ARP); that
document is attached. Below we share some key, relevant highlights from that document and/or drive
home points unique to our members in the nation’s largest, most urban health departments.
Federal Funding Must be Sustained and Predictable
Funds must be predictable and sustained so that health departments can plan for and hire the
staffing they need on a “permanent” basis, not based on the lifetime of a grant, which could be
a year, for example. In these instances, staff are hired and trained by local health departments,
but not retained for the long term. We also must ensure that these funds get to the core needs
of health departments. The pandemic has also highlighted the need to support local health
department staff, and the community as a whole, to address health disparities and build a more
equitable health system for all.

Transitioning to a Sustainable Public Health Workforce

While we appreciate the interest in creative approaches to address governmental public health
workforce challenges, we caution that while a U.S. Public Health Jobs Corps could contribute to
some surge staffing capacity, it is not a substitute for building a sustainable, diverse public
health workforce. Any increases in the workforce aimed at the COVID-19 response, including a
Public Health Corps program, should operate within the existing public health response and
structure. For long term sustainability, strengthening and growing existing entities, such as the
Medical Reserve Corps, along with investments in the formal, fulltime workforce, is critical.
Finally, we must also think about how to repurpose the tens of thousands of contact tracers,
and others, who have entered various parts of the health department structure and response.
For those individuals with training, skills, and experience, we must keep them in the field, both
for the immediate vaccine work, perhaps as navigators, or as much needed disease intervention
specialists, or other identified local needs for which their skill sets match.

Mechanisms for Local Support

Creative funding mechanisms that have invested both dollars and people in the community
largely on behalf of local health departments who do not receive resources directly have proved
an amazing tool in supporting on-the-ground needs. Non-governmental partners are able to
purchase resources and hire and onboard qualified applicants much faster than government,
and these partners can also serve as “fiscal agents” to support rapid intake and output of
resources. We also need to have flexible approaches to help local health departments hire
directly. A variety of options should be employed depending on what works for the individual
health department in order to increase staff capacity.

Diversify the Workforce to Reflect the Community

While not a substitute for permanent workforce employed at the local level, workforce
programs based at the CDC, such as the Public Health Associate Program (PHAP) and the
Epidemic Intelligence Service (EIS), as well as other detailed federal employees, have been used
for years to extend the capacity of health departments and key partners at all levels of
government. This should continue, and the PHAP and EIS programs should be expanded. They
provide critical capacity and public health training provided by the CDC to supplement the
current workforce, and many “graduates” of these programs continue their careers in
governmental public health. Unfortunately, low pay often makes it difficult for these trainees to
join their health department after their traineeship has ended. Additional consideration should
be given to efforts to help them continue their career in local public health departments.


All public health workforce programs should consider how to best support efforts to increase
diversity, open doors of opportunity for all, and make every effort to ensure that staff reflect the
community. The growth and retention of the public health workforce should contain a specific
focus on racial and ethnic diversity to address issues of trust, confidence, and representation of
the diversity of the residents served by the health department. This should include diversity and
inclusion resources, as well as implicit bias training for the current workforce.

Priority Governmental Public Health Workforce Positions and Functions

Key workforce positions most in need by local health departments essential for COVID response
(and beyond) include informaticians, molecular lab specialists, public health nurses, and
epidemiologists, as well as policy, outreach, communications, and administrative support.
We again thank you for your leadership and the HELP Committee’s focus on, and dedication to, the
critical issue of the public health workforce. A robust and trained governmental public health workforce
is essential to the challenges that lie ahead. We appreciate the opportunity to share these
recommendations and would be happy to discuss them with you further. Please do not hesitate to
contact me at juliano@bigcitieshealth.org.

Regards,

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The Big Cities Health Coalition (BCHC) is a forum for the leaders of America’s largest metropolitan health departments to exchange strategies and jointly address issues to promote and protect the health and safety of their residents. Collectively, BCHC member jurisdictions directly impact nearly 62 million people, or one in five Americans. For more information, visit https://www.bigcitieshealth.org.