The COVID-19 Response: The Vital Role of the Public Health Professional

By Jennifer Horney

The COVID-19 Response: The Vital Role of the Public Health Professional explores population health during a pandemic and how is it different than clinical medicine. Other sections cover federal, state and local responses to COVID-19, testing for COVID-19, the implementation of public health control measures, the use of public health emergency powers, health equity, the resignation and firing of public health leaders, vaccination planning, and the future of public health post COVID-19. Leaders and practitioners working in public health practice and academia, as well as students in public health undergraduate and graduate level programs will find this book extremely useful.

• Clarifies the role of public health in a pandemic emergency
• Assesses the indirect impacts of the COVID-19 pandemic, which include excess deaths from dementia, diabetes and heart disease, and will soon include the potential for global epidemics of preventable diseases like measles, diphtheria and polio
• Explores the impact of lack of trust in science and public health leadership
• Describes a way forward for the public health system to be prepared to respond to future threats

• Language: English
• Publisher: Academic Press
• Release date: Sep 22, 2022
• ISBN: 9780323972796

Jennifer Horney

Jennifer Horney is a Professor and Founding Director of the Epidemiology Program and Core Faculty at the Disaster Research Center at the University of Delaware. Her research focuses on assessing the health impacts of disasters, including inequitable impacts among physically and socially vulnerable groups. She is currently a member of the Board of Scientific Counselors for the Centers for Disease Control and Prevention’s Center for Preparedness and Response, a member of the National Academies of Sciences’ Gulf Research Program’s Enhancing Community Resilience Committee, and a member of the Publications Board of the American Public Health Association. She has provided technical assistance to public health agencies globally around disasters, emerging infectious disease outbreaks, and pandemic influenza planning and response.

Book preview

Chapter 1: What is a population health approach?

Jennifer A. Horney     Epidemiology, University of Delaware, Newark, DE, United States

Abstract

Although nearly everyone is familiar with the medical model of disease, which focuses predominantly on the identification of individual, physiological causes of disease, few outside the field of public health understand the differences inherent in the population health approach. While population health does share clinical medicine's focus on health outcomes, it differs in its focus on the upstream, or distal, determinants of health as well as the essential need to reduce measurable disparities and increase health equity. While the COVID-19 pandemic has been devastating from any perspective, it has starkly highlighted the pathways through which the injustices resulting from differences in social conditions that include poverty, employment status, and housing, among others, lead to excess morbidity and mortality. The COVID-19 pandemic has shone a light on public health, which has previously suffered an invisibility crisis. However, the light has not been bright enough for public health to emerge from the shadows of the frontline healthcare response nor to show clearly how clinicians and public health professionals must work together to successfully respond to a public health emergency. There remains a great deal of misunderstanding as to the roles and responsibilities of the public health system and of the vital role of public health professionals in the COVID-19 response.

Keywords

Causes of disease; COVID-19; Medical model; Population health; Public health

Who and what is public health?

Since the late 19th century, public health services in the U.S. have been provided by a complex amalgam of governmental and other agencies operating at the federal, state, and local levels. State and local health departments were established in the U.S in the late 19th century as the modes of transmission and causes of disease became more apparent due to advances in bacteriology, sanitation, and advancing laboratory practice (Institute of Medicine, [IOM], 1988). By 1912, the U.S. Public Health Service was formed and its leader, the U.S. Surgeon General, was given more authority (IOM, 1988). Federal and state public health programs continued to grow through both the New Deal legislation of the 1930s—Title VI of the Social Security Act of 1935 assigned responsibility for establishing and maintaining public health services and training staff to carry out those services to states, counties, and health districts (Cohen, 1983)—and the Medicare & Medicaid programs enacted in 1965. However, funding cuts to many public health programs and a vacuum in federal leadership followed, culminating in the failure of the public health response to the HIV/AIDS epidemic in the 1980s and 1990s. In 2010, the Patient Protection and Affordable Care Act established the Prevention and Public Health Fund, with a focus on reemphasizing the importance of public health to improving population health outcomes and increasing health equity (Chait & Glied, 2018).

For much of the COVID-19 pandemic response, the most visible aspect of the public health response has been the Centers for Disease Control and Prevention (CDC). Formed in 1946 as the Communicable Disease Center, their only mission was the prevention of malaria in the U.S. With a budget of $10 million and around 400 employees, the CDC subsequently established disease surveillance programs for rabies, tuberculosis, typhus, dysentery, poliomyelitis, viral encephalitis, plaque, Q fever, and brucellosis (CDC, 2021a). In 1947, the CDC was designated as the official response agency for epidemics and disasters following its response to chemical explosions in Texas City, Texas (CDC, 2021a). Over the next several decades, the CDC began to manage more programs administrated by the U.S. Public Health Service, including in 1967, the Quarantine Service, which is now the Division of Global Migration and Quarantine, monitoring more than 28,000 flights and 1 million people in 300 points of entry to the U.S. each day (CDC, 2021b).

There is no census or enumeration of the public health workforce, in part because they work in governmental and community-based agencies, academic and independent research institutions, hospitals, pharmaceutical companies, and health insurers. Beyond their workplaces, another challenge of documenting the public health workforce is the range of jobs they do, which includes doctors and nurses, occupational and environmental health specialists, epidemiologists, biostatisticians and data analysts, health educators, health economists, and more (Rosenstock, 2008). While the U.S. Bureau of Labor Statistics manages to include nearly 50 healthcare occupations—from Athletic Trainers to Veterinarians—in its Occupational Outlook Handbook, public health workers are dispersed across categories including Life, Physical, and Social Science, Occupational Health and Safety, Health Education Specialists and Community Health Workers, and Mathematicians and Statisticians (BLS, 2021).

After relying mostly on data collected in the 1960s, 1970s, and 1980s to describe the public health workforce (Miller et al., 1977; Public Health Foundation, 1987), in 2000 the Health Resources and Services Administration, part of the U.S. Department of Health and Human Services, surveyed state and territorial health officers and gathered data from the U.S. Office of Personnel Management, the U.S. Department of Defense, professional associations, and other organizations with a public health mission to estimate a public health workforce (Gebbie et al., 2003; Merrill et al., 2003) (Fig. 1.1). Subsequently, in 2012, the University of Michigan's Center for Excellence in Public Health Workforce Studies combined data from more than 15 data sources to develop a definition of a public health worker and conduct an enumeration study (Beck et al., 2014; University of Michigan, 2012). Finally, in 2014 and 2017, a group of more than 30 public health membership organizations, affiliate groups, and governmental partners implemented the Public Health Workforce Interests and Needs Survey (PH WINS) to collect more relevant data on public health jurisdictions, services, workforce, and governance (Leider et al., 2015; Sellers et al., 2015, 2019).

According to the 2017 PH WINS survey, 72% of the state and local governmental public health workforce are female and 64% are non-Hispanic white (Bogaert et al., 2019), making it more predominately female, but also more diverse—with nearly 16% Black or African American, 13% Hispanic, and 5% Asian—than the overall state and local government workforce (Center for State and Local Government Excellence, 2020). Nearly a third of the public health workforce is over the age of 55 (Bogaert et al., 2019), and their impending retirement has long been a focus of research on the public health workforce (Rosenstock et al., 2008). However, concerns over retirements, as well as younger workers leaving the field of public health, have intensified due to the high levels of burnout reported among public health workers involved in the COVID-19 pandemic response (Stone et al., 2021). The impacts of this may have huge implications for the future of the workforce. More than half of those considering leaving public health have less than 5 years of experience in a public health agency, so many potential years of public health workers will be lost when they leave the field. Those planning to leave public health in the next year are also more likely to have a public health degree (18% compared to 10% among those planning to retire and 14% among those planning to stay) (Fig. 1.1).

The number of public health degrees awarded between 2000 and 2015 more than tripled, with by far the largest growth—1622 to 10,938—among those awarded bachelor's degrees in public health (Leider et al., 2018). This aligns with the expansion in the number of schools and programs of public health and potentially bolsters a governmental public health workforce where few employees have formal academic training in public health (Resnick et al., 2018). However, students working toward careers in public health face low levels of federal funding for graduate education in public health and a lack of access to specific data about forecasted future workforce needs. Similar to the current public health workforce, public health students are also more likely to be female than male; however, more Asian and Hispanic students were obtaining public health degrees in 2016 compared with 2003 (Resnick et al., 2018). To increase rates of racial and ethnic minority students in public health degree programs—and subsequently the public health workforce—calls by public health advocates for the National Institutes of Health and other agencies to introduce targeted loan forgiveness focused on public health graduates working in racial and ethnic health disparities should be addressed (Rosenstock et al., 2008).