Finally, New Federal Cash Will Bolster Public Health Ranks

Daniel Daltry, Vermont’s chief of disease investigation, knows exactly what his department is going to do with the extra $1 million it’s slated to receive from the federal government every year for the next five years: “We’re going to hire 10 more of me,” he said.

“That way, when the next crisis hits those 10 people will be able to hire and train 10 more people under them.”

With 624,000 residents, Vermont will receive the minimum state allocation from a $1 billion fund included in this year’s American Rescue Plan Act, the most recent COVID-19 relief package. Nationwide, the funds are designed to more than double the number of disease investigators and contact tracers working at state and local health agencies. And that money is just one part of the $7.6 billion fund included in the package for public health workforce development.

But not all state public health officials are as certain as Daltry about where they’re going to aim the firehose of new federal money. And not all state and local public health professions were as generously funded; there was no money specifically earmarked for epidemiologists, for example.

In most states, the public health officials charged with deciding how to spend billions of new federal dollars are facing mountains of bureaucratic challenges while battling soaring delta variant cases.

Despite the hurdles, the extra money should bring significant changes. By this time next year, said David Harvey, executive director of the National Coalition of STD Directors, the number of disease investigation specialists in public health departments ideally will have grown from 2,000 to more than 4,000.

“It’s great that new funding is coming in,” said Jeffrey Levi, professor of Health Management and Policy at the Milken Institute School of Public Health at George Washington University. “But states need more federal guidance on how to spend it.”

The Biden administration’s $1.9 trillion American Rescue Plan Act includes a $7.6 billion fund for public health workforce development. About half the money already has been allocated to states by the federal Centers for Disease Control and Prevention. And unlike much of last year’s emergency money that had to be spent immediately, federal workforce money is available for two to five years.

Roughly $2 billion of the $7.6 billion workforce development will go to states for hiring and training a broad range of public health professionals, including administrative, grant writing and finance staff, as well as for updating data and other IT systems.

States and major cities also will receive $1 billion—or $200 million annually for five years—for hiring disease investigators and contact tracing professionals, who have been in short supply during the pandemic.

Another $337 million is designated for staffing state public health laboratories, which have been working around the clock analyzing COVID-19 test samples and tracking variants.

And there’s even more money in the pipeline at the state and local level. In addition to the usual, roughly $7 billion, in annual federal funding for public health, the fiscal year 2022 budget is expected to include supplemental funding to shore up state and local health agencies.

Bureaucratic Hurdles

Starting this month, state and local health agencies must submit plans to the CDC for some of the already allocated workforce development funds.

So far, the agency has not asked states to provide an overall strategy for spending the entire $7.6 billion workforce development fund, plus a portion of the $350 billion state and local fiscal recovery funds in the American Rescue Plan Act that can be spent on public health.

According to Levi, “states should be required to submit plans that say, ‘This is how we started the pandemic, these are the needs we have now, and these are the long-term structural needs that we are going to begin filling with this money.’”

The way the money was appropriated and the way it is rolling out—through separate funding streams with varying timelines—present major challenges for state health agencies, said Amber Williams, senior vice president for workforce at the Association of State and Territorial Heath Officials.

Disease investigation money, for example, is spread over five years. For most states, that means the federal grant will be considered permanent funding, which will trigger the need for legislative approval, said Brian Sigritz, director of state fiscal studies at the National Association of State Budget Officers.

There’s no question the federal money is critical to the future of state public health departments, Williams said, but it’s coming at a time when already exhausted public health professionals are battling another COVID-19 surge.

Burnout among state public health workers is exacerbating those obstacles. More than half of a surveyed group reported they are experiencing symptoms of mental health conditions brought on by the pandemic, according to a recent CDC report.

States and cities vary widely in the amount of money available for public health per person. Arizona and New Mexico spend less than $5 per resident, while Maine, Maryland and the District of Columbia spend more than $100 per resident.

“The pandemic showed us that we’re only as strong as our weakest link,” said Adriane Casalotti, chief of public and government affairs at the National Association of County and City Health Officials.

Because the $2 billion portion of the workforce development money covers a range of needs, Casalotti said, the hope is that with adequate support staff, previously underfunded agencies will be able to compete for disease-specific grants in the future that they missed out on in the past.

“We all hope that this pandemic actually is a once-in-a-lifetime event,” she said. “It’s not possible to be staffed up to the level needed for something of this nature. But what we can do is have our health departments staffed up enough to address the daily crises they deal with all the time.”

In the decade before the pandemic, the number of state and local public health workers declined by more than 16%, from 110,069 workers in 2000 to 91,540 in 2019. And public health experts have calculated that annual federal funding for state and local health agencies falls short of what’s needed to provide basic public health services by roughly .5 billion.

Missing Epidemiologists

While disease investigation units and public health labs received a historic windfall through this spring’s relief package, there was no money to hire more of the epidemiologists who detect and analyze looming public health threats.

Epidemiologists have to compete with everybody else for a piece of the flexible parts of the workforce development fund, said Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists.

That’s despite an estimated need for roughly 8,000 more state and local epidemiologists, according to an unpublished state health department survey conducted by the council and reviewed by Stateline. In 2017, the CDC estimated the nation’s total number of epidemiologists to be 3,369. According to Hamilton, that number likely has not risen since then.

Although most of the focus now is on COVID-19, she said, the need for epidemiologists with expertise in a range of other public health threats is great. For example, only four epidemiologists in the country specialize in mental health and only four specialize in genomics research, both of which are rising public health issues.

“We in epidemiology are being demonized for our recommendations, because we’re coming up with scientific data that people don’t want to hear,” Hamilton said.

“I’ve always been proud of our work in public health,” she said, “but these days it almost feels like you don’t want to identify yourself.”

As the public and politicians continue to take out their pandemic ire on public health officials, Hamilton said she worries about retaining the nation’s existing epidemiologists, much less finding enough new ones.

“It’s hard for the public to understand what epidemiologists do and how we do it,” she said. “It’s much easier to identify a need for more testing and more contact tracing. The reality is that we need to increase the number of all professions in the public health workforce.”

Public Health Labs

When the COVID-19 pandemic hit U.S. shores, the first big problem was inadequate testing capacity. Federal workforce development funding aims to ensure that doesn’t happen again.

Currently, more than 5,000 people work in the nation’s more than 128 public health labs, with at least one lab in each state and others located regionally and in large metro areas. The number of people working in each lab varies widely, from a thousand or more to less than a dozen.

In almost every state, the number of employees needed to process COVID-19 tests fell far short of what has been needed during the pandemic, causing public health officials to scramble for new recruits while existing personnel worked around the clock, said Peter Kyriacopoulos, chief policy officer for the Association of Public Health Laboratories.

In Colorado, for example, the state lab had to expand its number of employees from 80 to more than 350 to keep up with COVID-19 testing demand in 2020, he said.

The $337 million fund designated for public health labs is expected to be used by existing laboratories to recruit, hire and train qualified public health professionals, substantially boosting overall staff levels.

Disease Investigation

Since the pandemic began, Daltry has run the Vermont health department’s COVID-19 contact tracing operations while investigating diseases and caring for patients himself as the only full-time disease investigator on staff.

“I was 25% disease investigator,” he said. “The rest of my time was spent managing a contractor who provided contact tracers that we trained on the fly. We had people deployed to us from the education department, the National Guard, the department of public safety and alcohol and drug assistance programs, and we had to rapidly train those folks.

“What I love about the new money is that it will give us 11 people, instead of one, who can train at least 10 others when the next crisis comes,” Dalton said.

For now, Vermont has largely escaped the delta surge that’s overwhelming much of the rest of the country. And Daltry said he’s left the bureaucratic hurdles involved in spending the new federal money to the health department officials he reports to.

With $1 million per year to build an exponentially larger disease investigation staff, Daltry said, Vermont will be well prepared for the next crisis. But more important, he said, “We’ll be able to care for patients with HIV, gonorrhea, syphilis, chlamydia, hepatitis A, hepatitis C and other communicable diseases the way they should be cared for.”

During the pandemic, Daltry said his agency has quickly moved from containment to mitigation, including encouraging mask-wearing and shutting down schools. “That’s not the way disease investigation and contact tracing is supposed to work.”

“When I came here from a similar job in Philadelphia 15 years ago, they told me I might get bored,” Daltry said. “I haven’t been bored since the first day I stepped foot in Vermont. Until the pandemic hit, we didn’t see much morbidity here. And when we did see it, we were able to stop it from spreading. The new money will help us keep it that way.”