COVID's crushing impact on public health

The impact on those who treat the sick and dying has been the focus of much study and the exhaustion of health care workers pulling extra shifts and covering for inadequate staffing is well documented.

But the true measure of this scourge is yet to be known.

Now a new study, published Thursday, Oct. 14 by PLoS ONE, shows another layer of impact -- how response to the virus has pounded the U.S. public health system, especially its workers and the critical services they deliver to millions.

The study, led by Jennifer Horney, professor and founding director of the University of Delaware's Epidemiology Program, sheds chilling light on the state of the public-health workforce and raises significant questions about how public health services and programs can be sustained in the future.

Of special concern is the fact that many public health workers have been redeployed to COVID-related duties during the pandemic response, leaving other critical public health issues with reduced or suspended services.

That means investigation of other communicable diseases, food-related illness, public-health surveillance, chronic diseases and other critical services have suffered.

"That impacts the overall health of the population," said Horney. "Those things didn't just go away. People still had high blood pressure, they were dying of substance abuse in increasing numbers, but those programs were put on hold."

She and her collaborators wanted to capture some of that data and look down the road, too.

"What does the workforce look like going forward?" she said.

It's a troubling snapshot, based on survey responses from 298 people working in public health roles, including government agencies and academic departments. The surveys measured professional experience, mental and physical health status, and career plans, with some reflection of how their views and experiences had changed from pre-pandemic days to mid-pandemic days.

But how do you define the population of public-health workers? It's not easy, Horney said. It includes everyone from epidemiologists, laboratory workers and environmental health specialists to those who work in prevention programs and those who work to educate the public on a wide array of health issues. Because state systems vary so widely, it is difficult to get a clear picture of how many public health workers there are in the U.S.

What is known is that the system was badly understaffed and underfunded before the pandemic hit, Horney said. Now, many of the most experienced leaders and workers have had enough.

"The people with experience -- the people who worked through H1N1 or Zika or Ebola -- they are leaving public health or retiring," she said. "Unfortunately, the public health workers who are the most experienced are also the ones who are the most burned out."

The Centers for Disease Control and Prevention in August released results of a large-scale survey reporting on the effect the pandemic has had on public health workers' mental health.

Researchers say the situation is even more taxing because of pressures from external forces, which have affected public trust and sometimes led to firings, resignations and accelerated retirements.

"I've definitely had my moments during this thing," Horney said. "But I love this work and so do most who choose a career in public health. This is the real deal. I wish so much that people understood all that public health encompasses."

Studies such as this can help to explain the broad range of issues addressed by public health workers, especially when they don't have to be diverted to pandemic response.

COVID-related redeployments produced significant reductions in several areas, including chronic disease (39% reduction), maternal-child health (42% decrease), substance abuse (28% reduction), environmental health (26% reduction) and injury (37% reduction), as well as 47% decreases in programs focused on HIV/sexually transmitted diseases, health disparities and others.

Program evaluation and health education also saw significant declines. By contrast, the number of workers in infectious disease and preparedness remained constant from pre-pandemic to mid-pandemic periods, the study showed.

Most workers were on the job for many more hours, too. Pre-pandemic, about 21% of the 282 respondents who were working in public health in January 2020 said they worked more than 40 hours per week. That grew to more than two-thirds by mid-pandemic (August to October 2020). About 7% said they worked more than five days a week before the pandemic. By mid-pandemic, two-thirds of them were working more than five days a week.

The study points to the need for increased funding and enhanced educational opportunities, both critical to addressing these issues and preparing for the future.

"What remains unknown, but critically important to quantify, are the impacts to the public's health that will result from these interruptions during the COVID-19 response," the study says.

Horney's collaborators on the study include Kristina W. Kintziger of the University of Tennessee at Knoxville, Kahler W. Stone of Middle Tennessee State University, and Meredith Jagger of Austin, Texas. Stone was a doctoral student of Horney's and Kintziger was a mentee on a prior National Science Foundation grant.

Future studies are already underway to explore several issues in greater depth and to explore how views and experiences have changed through the challenges of 2021.

Researchers note several limitations in the study, including an over-representation of female, white respondents under the age of 40, and the inability to generalize findings because of the wide differences in health departments throughout the nation.