Who will vaccinate people during the next pandemic? The US public health sector is falling behind

Without a doubt, one bright spot in the overall-checkered US response to COVID-19 was the record-breaking development of effective vaccines coupled with the largest vaccination campaign the country has ever undertaken. Communication around “travel bans” and “lockdowns” or the rollout of tests was all a mess, but getting those shots in people’s arms within a year of the outbreak in Wuhan? That was a shining success.

But since then, the warning signs that the country is ill-prepared for the next big thing are piling up. Among those, one of the most worrisome (and overlooked) is the decay in the very same  public health workforce that comprises many of the individuals who gave those shots.

Public health workers were as important to navigating COVID-19 as the thousands of doctors, nurses, and other hospital staff who saw their work environments turned into infectious warzones overnight. When another disaster inevitably strikes, these workers will again be responsible for monitoring new disease threats, tracking existing ones, applying control measures, and organizing vaccine campaigns. But the pandemic has decimated their ranks. It may be hard to believe, but the public health sector may be even less-prepared for a pandemic than it was in late 2019. Pandemic preparedness efforts appear at risk of stalling in many areas; in the case of building a better public health system, though, they are actively backsliding.

Organizations such as the de Beaumont Foundation and the Association of State and Territorial Health Officials (ASTHO) have conducted nationwide surveys to better understand how public health workers are holding up. The statistics are appalling. About 46 percent of state and local public health employees left their jobs between 2017 and 2021, and this shoots up to over 70 percent for staff under the age of 35 or those with under five years of experience. These numbers mean we are disproportionately losing entry-level, younger staff at the same time as older public health workers continue to retire from the workforce.

If these figures are not bad enough, a survey by deBeaumont and ASTHO in 2022 showed that nearly one-third of current public health workers are considering leaving their jobs in the next year. With public health staff numbers around 200,000 heading into the pandemic, which was already 50,000 less than in 2008, that means we are at risk of losing an additional almost 70,000 workers from an already stretched workforce.

Despite its critical role in responding to biological threats (and more), public health has always faced difficulty with sufficient investment. Each year, or with each crisis, Congress passes funding for the CDC, which then distributes resources to states. Despite arguably greater needs, the CDC has suffered an overall 2 percent budget decrease over the past decade (after adjusting for inflation). And while Congress may point to one-time pandemic-era funding pots like the Infectious Disease Rapid Response Reserve Fund, these are primarily restricted to COVID-19 response activities; they’re the opposite of the sustained, steady funding needed. 

Against this dismal backdrop, the United States is trying to prepare for the next major biological threat. Officials in Washington understand, of course, that another pandemic could happen. They’ve laid out plans to do better next time. For example, in 2022, the Biden administration issued an updated National Biodefense Strategy, a 53-page document detailing how the US government intends to prepare for and deal with natural and intentional biological threats. Laudable in many ways, a major focus of the strategy focuses on continuing the government’s partnerships with the private sector to ensure the capacity to rapidly innovate, research, develop, and mass-produce therapeutics such as vaccines or antivirals. This goal absolutely has its merits. Many leaders and researchers in public health are particularly excited, understandably, about the huge potential held within broad-spectrum antivirals that could more widely target a family of pathogens, instead of a single pathogen or single variant at a time.

At the same time, bluntly put, who is going to make those innovations and wonderful discoveries count? There is a difference between vaccines and vaccinations, as the COVID-19 pandemic made clear. One aspect that the National Biodefense Strategy seems to insufficiently account for is the critical state of our public health workforce.

The words “workforce” or “recruitment” are explicitly mentioned only three times in the entire document. Furthermore, even in those cases, the focus is on staff in laboratories, such as public health laboratorians and technicians as well as “One Health” experts who understand the connection between environmental, animal, and human health. And absolutely, as the strategy does a great job of recognizing the risk of zoonotic spillover of animal pathogens, recruiting these kind of experts will be key moving forward. Yet, even these mentions inherently gloss over the current state of the public health workforce writ large.

There are two implicit assumptions in the strategy about the public health workforce: (1) By not noting any need to rebuild the public health workforce, the strategy implies that the public health workforce remains the same as it was prior to the pandemic; and (2) with no explicit action item to ensure a strong public health workforce, the strategy also assumes that the public health workforce is generally robust, fully resourced, and well-supported. Both of these assumptions are a far cry from the truth.

The reality is that the public health workforce was already strained prior to the pandemic, and then decimated during COVID-19 response both in terms of physical numbers, but also, importantly, in terms of the mental health of practitioners.

Gerrit Bakker, former director of Colorado’s public health agency, told me that public health workers already generally accept that “burnout comes with the territory.” But the pressures of the pandemic proved too much. It was not just the insufficient resources and acutely amplified demands; the workforce faced relentless harassment, especially as public health officials became the object of protests over COVID-19 policies. In contrast to the praises sung for many health care providers, public health workers were not viewed in the same heroic light. Mackenzie Raub, a former county public health agency staffer in Pennsylvania, told me about the harassment that public health workers faced, in the form of phone calls, emails, protests, and direct, public confrontations.

In order to realize the promise in the National Biodefense strategy and other plans for increasing the country’s resilience against pandemics, a strengthened and improved public health sector will be vitally important. Rebuilding this workforce as soon as possible is critical to halt further hemorrhaging of both institutional knowledge and the bodies needed to run a response, because as much as the world may be tired of hearing anything about outbreaks and viruses, the unfortunate reality is that COVID-19 will not be our last pandemic.

With climate change will come more natural disasters such as hurricanes, and with them, loss of housing, displacement, and other crises that create circumstances for disease outbreaks. With increasing globalization will come population growth, overcrowding, and, likely, the rampant spread of illness in areas with poor sanitation. With urbanization will come novel interactions between humans and wild animals that increase the chances of spillover events. But while humans cannot resist all of the forces in these scenarios, we can prepare and react to prevent a singular event from becoming a full-blown pandemic. The public health workforce will and should always be a cornerstone of this larger strategy.

In a future pandemic threat, public health workers will again need to plan vaccination clinics and outreach to communities. Even with efforts by public health departments and federal agencies to improve data collection and upgrade systems, public health workers will still need to be a part of collecting data and analyzing patterns in everything from disease prevalence, based on ethnicity or age, to pathogen presence in a neighborhood’s wastewater. And while the Biden administration’s National Biodefense Strategy discusses the need to counter misinformation and disinformation, outreach efforts and building trust cannot consist of just an AI chatbot or a webpage: it will yet again require personnel—i.e., living, breathing humans on the frontlines who have the time and the resources to take on these roles.

The 2022 National Biodefense Strategy is a wonderful improvement upon the 2018 version, which lacked details such as specific action items about how to enact the ideas in it. While the 2022 iteration is a more concrete roadmap for how to move forward, Congress and public health leaders should dig a little deeper and examine whether, as a country, we are fully accounting for the devastation that COVID-19 has wrought on top of pre-existing vulnerabilities. The public health workforce is just one potential example. One might think that after experiencing COVID-19, that the public health sector is fully prepared for the next big thing, 10 steps ahead of where it was in 2019; the reality is that it has only fallen further behind. Staff remain under-resourced and burnt out; many of Bakker or Raub’s former colleagues are retiring early or continue to leave for other career opportunities. General, long-term investments in pandemic preparedness will most likely require the formal, federal recognition of public health’s cornerstone role in our country’s biodefense capabilities that has so far been lacking.

The Biden administration will lift the COVID-19 public health emergency declaration on May 11, an official end, of sorts, to the pandemic response in the United States. To ensure US biodefense capabilities are robust and ready, whether for the next variant tomorrow or a bioweapon attack in ten years, every single critical component, public health staff included, cannot just exist, hanging by a thread. Rather, they all need to be well-resourced, diverse, and thriving.