Much has been written in the popular press about the looming shortage of physicians, nurses, and allied health professionals (Corwin, 2015; Grant, 2016; Mishoe, 2004). Comparatively little ink, however, has been used to discuss the looming shortage of public health workers. Why? I would venture to guess that much like housework and lawn mowing, unless it is not done, few note when it is done. The workers, like the labor involved, are invisible—until there is a disaster or the mess is on the Mayor’s front porch, as it was in the nine-day long New York City garbage strike of 1968 and the seventeen-day long strike of 1981.
In 1968, the overworked and underpaid sanitation workers turned on their own union leader until he called for the strike. Tons of trash and stinking garbage rotted on the streets. Hospitals, in particular, were concerned about what to do with their dangerous medical waste. I was a senior in high school and the garbage strike was in the news daily. Our science teacher took this as opportunity to point out how these workers were in the “front lines” of public health. Left unchecked, he said, we could revert to living in the time of cholera. He may have exaggerated to bored high school seniors to get their attention, but he had a point. Without sanitation and public health workers, we could revert to times best left behind us.
Why is there an ongoing and growing shortage of public health workers despite the surge of educational programs? Hilliard and Boulton (2012) conducted a 25 year retrospective review of public health workforce research and found reasons similar to those for the growing shortages of nurses, physicians, and allied health professionals.
- Aging of the workforce and retirements, some early due to working conditions;
- Numbers of entrants from educational programs not catching up with the loss of practitioners;
- Concerns about skills and competencies in a discipline that requires hands-on experience;
- Administrative barriers to recruitment and retention; and,
- Employee wages, opportunities for advancement, and job satisfaction.
They also found a dearth of current studies on public health workers as the individual unit of analysis with respect to quality of work life.
Overlaid on all of the above is perhaps the most obvious: budget cuts at local, county, state and federal levels have chipped away at programs and employees, leaving fewer positions to apply for, and fewer services provided. This situation is not new.
About ten years ago I met with the Maryland Association of County Health Officers (MACHO) to assess the feasibility of and interest in the development of a B.S. in Applied Nutrition and Food Safety. Officers in attendance at that meeting reviewed the proposed curriculum, which included a semester long internship, and unanimously agreed that it was good. However, they had one question. “How can we pay for these people? We’re not competitive now. Employees get trained and leave as soon as they can for better wages. How will these graduates be different?” Every county represented at the table had stripped down budgets and was working a skeleton crew of shoe leather epidemiologists and sanitarians. The MACHO men and women loved the idea, but their realistic sides shone through with that simple question. Funding was tight then and it continues to be tight now. Even the Bureau of Labor Statistics seems pessimistic. Under the heading of Occupational Health and Safety, the projected job growth from 2014-2024 is “4%, Slower than average.”
What will it take for our nation to shift priorities and make a greater investment in public health? Do we need a garbage strike? Or has a natural experiment already occurred? Researchers Realmuto, Hunting, and Parkin (2013) examined data for the years 2005, 2007, and 2009 on routine inspections for East Baton Rouge Parish, Louisiana restaurants. They selected those establishments which had been categorized as a 3 or 4 risk for food borne outbreaks. The authors found an association between the time between inspections and critical violations. The authors pointed to the fact that there were fewer workers due to layoffs, cutbacks and hiring freezes and this worker shortage may have a negative impact on the “outcomes of routine food safety inspections” (p. 32). Bottom line: the fewer the workers, the larger the workload, the longer the time between restaurant inspections, the more likely customers are to take home more than a doggie bag.
What should public health workers do? I’m not suggesting unionization or strikes, as attractive as they might be for media coverage. Instead, I recommend practitioners and grass roots workers join forces with the researchers and educators to martial data that demonstrates the danger of an over extended workforce. Aiken and her colleagues did this with nurse education and staffing in hospitals and demonstrated greater mortality rates when nurses were under-educated and over extended ((Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Aiken, Clarke, Cheung, Sloane, & Silber, 2003). The nation woke up and now hospitals are racing to attain Magnet Hospital status (ANCC, 2014).
What if public health departments wanted to be centers of excellence and blue ribbon employers? Would they become magnets for a public health workforce? What would it take to create this public health utopia? It’s a four letter word, one every public health student knows.
Using data to drive the agenda, public health leaders have an opportunity to wake up the new President of the United States to the dangers of ignoring the invisible men and women. It is time to make the public health workforce visible.
Sharon Buchbinder is Professor and Program Coordinator for the MS in Healthcare Management at Stevenson University in the Graduate and Professional School and former chair of the Association of University Programs in Health Administration (AUPHA). She is also the author of three books from Jones & Bartlett Learning: Introduction to Health Care Management, Cases in Health Care Management, and Career Opportunities in Health Care Management.
Here are some resources if you are interested in this topic:
Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., & Silber, J. H. (2003). Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association, 290 (12), 1617–1623.
Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288 (16), 1987–1993.
American Nurses Credentialing Center (ANCC). (2014). Magnet recognition program overview. Retrieved from http://www.nursecredentialing.org/Magnet/ProgramOverview
Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2016-17 Edition, Occupational Health and Safety Specialists. Retrieved from http://www.bls.gov/ooh/healthcare/occupational-health-and-safety-specialists.htm
Corwin, T. (2015, Nov 22). Looming doctor shortage threatens care: Specialties, underserved areas will be first affected as physician totals drop. Retrieved from http://chronicle.augusta.com/news/health/2015-11-22/looming-doctor-shortage-threatens-care
Grant, R. (2016, Feb 3). The U.S. is running out of nurses. Retrieved from http://www.theatlantic.com/health/archive/2016/02/nursing-shortage/459741/
Hilliard, T. M. & Boulton, M.L. (2012) Public health workforce research in review: A 25-year retrospective. Am J Prev Med, 42 (5S1):S17–S28.
Maryland Association of County Health Officers (MAHCO). http://www.mdcounties.org/index.aspx?nid=120
Mishoe, S. (2004). Crisis is looming in allied health professions. Retrieved from http://chronicle.augusta.com/stories/2004/11/19/op__434960.shtml#.V5-26KKmnUU
Poster, T. & Mallon, J. (2016). New York City garbage strike of 1968: Trash piles up on sidewalks after sanitation workers walkout in 1968. Retrieved from http://www.nydailynews.com/new-york/great-garbage-strike-1968-workers-walkout-1968-article-1.2517880
Realmuto, L., Hunting, K., Parkin, R. (2013). State health agency workforce shortages and implications for public health: A case study of restaurant inspections in Louisiana. Journal of Environmental Health, 76 (5): 32-37.
Thomson, S.C. (2013, Jan/Feb). Public health workers needed: Educational programs grow as shortage looms. Health Progress. Retrieved from https://www.chausa.org/publications/health-progress/article/january-february-2013/public-health-workers-needed-educational-programs-grow-as-shortage-looms
Young, G. (2014). The Christmas trash strike of 1981. http://1981.nyc/christmas-trash-strike-1981/
Young, S., Acord, L., Schuler, S. and Hansen, J. M. (2014), Addressing the community/public health nursing shortage through a multifaceted regional approach. Public Health Nurs, 31: 566–573. doi:10.1111/phn.12110