Assessment of Public Health Infrastructure to Determine Public Health Preparedness

IntroductionThe role of public health at the national, federal, state and local level has become an important component of the Department of Homeland Security (DHS). Homeland Security has elevated public health personnel to first-responder status. However, public health has not received sustained funding to address the new directives and tasks it has been mandated to perform. Congress passed two landmark bills, the Public Health Threats and Emergencies Act of 2000 (PL-106-505) and the Public Health Security and Bioterrorism Act of 2002 (PL-107-288), that directed approximately ninety-nine million dollars to rebuilding public health capacities. 1 While the additional funding was helpful in initiating bioterrorism planning, the funds were only temporary. Therefore, they could only address changes in tools, hardware, communications, and similar items but not fundamental personnel issues. This funding strategy relied on the assumption that public health has a fully functional infrastructure that can simply be refocused and aimed in new directions. However, all evidence points to the contrary; public health infrastructure has been cut to a point where most health agencies are barely staffed to operate during a normal workday. 2 Questions arise whether public health departments have the requisite manpower to perform the duties required of them - from basic functions of public health to managing, coordinating, and deploying bioterrorism emergency surge responses. These are not the manpower issues for solving surge-capacity limitations, but rather manpower issues for the basic public health functions and critical planning, organization, and infrastructure development supporting bioterrorism preparedness. These are not recent developments, but while the gaps have been highlighted with ensuing dire predictions, efforts to quantify these workforce gaps are missing. 3The problems and perils associated with the current state of the public health infrastructure have been the subject of many reports and publications for well over fifteen years. A 1988 report by the Institutes of Medicine (IOM) warned of the deteriorating public health workforce. 4 In a 2002 follow up report, the IOM felt that little improvement had been made since the first report. 5 In 2001, the Centers for Disease Control and Prevention (CDC) prepared a report for a Congressional appropriations committee revealing that the public health community was still structurally weak in nearly every area and there were critical gaps in workforce capacity and competency. 6 Other studies conducted by prominent public health associations - the National Association of County and City Health Officials (NACCHO) and the Association of State and Territorial Health Officials (ASTHO) - supported these findings. In October 2001, NACCHO conducted a nationwide study that highlighted current infrastructure deficiencies by identifying the workforce duties and compositions of local health agencies and in 2004 reported that the lack of public health workers constitutes a crisis for national public health preparedness. 7In addition, public health workforce studies reveal infrastructure shortages due to budgetary neglect and an aging workforce. Local health agencies (LHAs) have been hit hard with up to forty-five percent of staff approaching retirement, vacancy rates as high as twenty percent, and employee turnover rates as high as fourteen percent. 8 The closest attempt to quantify the extent of the workforce shortage was a 2004 study by Kristine Gebbie who described the scope and content of work done by the public health workforce in the field. 9Despite the plethora of reports, there have been no published efforts to determine optimal workforce staffing levels needed within a community to accomplish the public health and bioterrorism preparedness mandates. It is essential that stakeholders become aware of the actual, rather than the perceived, day-to-day functions of public health. …