by Brian C. Castrucci
When we talk about public health achievements, we often cite fewer people smoking, containing an outbreak like Ebola or MERS, and wearing our seatbelts. Over the last century, life expectancy increased by 30 years, and 25 of those years are attributable to these and other amazingly impactful public health interventions.
We are living longer and healthier lives than we would have ever thought possible one hundred years ago. The unsung heroes behind this achievement are the individuals in the public health workforce—the people who identify, manage, and execute the programs needed to improve population health. However, few people really seem to know who makes up the public health workforce or what these individuals do.
In the 1980s, a series of HHS reports and the 1988 Institute of Medicine report, The Future of Public Health, all reached similar a conclusion—that the data needed for effective, long term workforce planning and policy development were simply unavailable. Fifteen years later, the Institute of Medicine reiterated the need for data about the public health workforce in The Future of the Public’s Health in the 21st Century.
Recent years have shown progress toward learning more about who works in public health. Federally-supported enumeration studies provided unprecedented information on the size and composition of the workforce. Annual “profile” surveys conducted by ASTHO and NACCHO provide information on health department funding, staffing levels, and programmatic activities, among other important topics. Despite progress, significant knowledge gaps remained.
Until now, we have had extremely limited information on important demographics, like diversity. Other than anecdotes, we had next to no data on the beliefs, attitudes, opinions, and experiences of individual public health workers. While we had copious lists of training needs, we didn’t have a good sense of the workforce’s prioritized training needs, which are especially critical in this transformational time in health and healthcare.
Today, governmental public health agencies face extraordinary challenges, from managing the implementation of the Affordable Care Act to adapting to the advent of big data and availability of electronic health records. We need data to ensure that we have the public health workforce that we need—one that is prepared not only for the problems of today, but for the challenges yet to come. The Public Health Workforce Interests and Needs Survey (PH WINS) does just that.
PH WINS provides crucial new information and nearly endless opportunity for analysis. The first 15 peer-reviewed articles discussing the survey’s results are included in a supplement of the Journal of Public Health Management and Practice. To get a taste of what’s available, let’s start with four things you probably didn’t know about the public health workforce before now.
1. About 1 in 5 governmental public health workers plan to leave the workforce in the next year.
Eighteen percent of PH WINS respondents reported an intention to leave the governmental public health workforce in the next 12 months, either to retire or to pursue work elsewhere. Thirty-eight percent plan to leave governmental public health before 2020.
In the face of continued budget reductions, there is a real threat that we will see sustained staffing shortfalls in our state health departments or that these positions will not be filled at all. States have already experienced a 28 percent reduction in the number of public health workers per 100,000 people between 1980 and 2000. Only 1 in 4 vacant positions at state health agencies are currently being recruited for and filled.
As the workforce shrinks, so does the number of workers available to inspect the restaurant where you might eat tonight, to prepare for the impact of natural disasters, and to investigate whether your co-worker has the seasonal flu or the start of a nationwide or worldwide pandemic.
This is not just a numbers game: it’s also about quality. When we lose public health workers early and mid-career, we lose institutional knowledge and the chance to develop experienced managers and leaders. Even though it is challenging in the context of government employment, public health agencies need to prioritize improving both succession planning and strategies to identify and retain high-performing staff.
2. Policy training is needed.
Most of the greatest public health achievements of the 20th century were the result of new regulations or policies that had an outsize impact over time, like fluoridating our water, mandating seatbelts, and improving access to family planning services.
Today, there is a renewed recognition that our health is defined by factors that are outside of the healthcare system but are affected by policy and regulatory decisions—housing and community safety, for example, or access to clean food, air, and water. Bans on trans fats, policies promoting indoor air quality, calorie counts on restaurant menus, and requirements to incorporate green space in new developments are all examples of how policy can be used to make health the default choice and why it is vital for the public health workforce to be able to use this strategy.
Three-quarters of PH WINS respondents agree that it is important to have the skills to influence policy and understand the relationship between public health policy and public health problems, but one-third of that group reported either beginner-level ability or no ability at all in these areas. As training needs are considered in the context of strategies to improve population health, policy training should be considered a priority for the public health workforce.
3. State health agency workers are satisfied with their jobs and their organizations, but not their pay.
Generally, members of the state agency public health workforce are satisfied with their jobs and organizations. Nearly 80 percent of PH WINS respondents reported being satisfied with their jobs and 65 percent reported being satisfied with their organizations. However, 40 percent reported being dissatisfied with their pay. Earning less than $35,000 a year was one of the more common characteristics among those intending to leave governmental public health in the next 12 months.
The good news is that job satisfaction is proven to be more important for retaining employees than pay satisfaction. PH WINS demonstrated that job satisfaction reduced employees’ intention to leave by 24 percent, while pay satisfaction was associated with a 9 percent reduction in intention to leave.
The bad news is that the same may not be true for new graduates deciding whether to enter public health. Public health is one of the most popular undergraduate degrees in the United States, which holds promise for the future of the workforce. However, given the cost of college and graduate education and the student debt crisis, perceived salary dissatisfaction among the governmental public health workforce may prove to be a recruitment barrier.
4. Women dominate the workforce, but not the pay.
Despite the fact that nearly three in every four public health workers are women, women earn an average of 90 to 95 cents on the dollar compared with men after adjusting for other factors. This gap is considerably greater for supervisory roles.
The pay gap pales in comparison to those reported in other sectors of government or the private sector. However, the advantage enjoyed by men—which is also seen in the woman-dominated field of nursing—remains puzzling.
This post first appeared in the Huffington Post on Oct. 29, 2015, and was updated Dec. 6, 2017.
New studies of the public health workforce reveal signs of unprecedented change ahead. Notably, 38 percent of state public health workers plan to leave the public health workforce by 2020, either to retire or to pursue positions in other sectors.
“We have been concerned for some time that an aging state agency workforce would be retiring. This survey shows that many younger workers also plan to leave their public health positions,” said ASTHO Executive Director Paul Jarris, MD, MBA. “Maintaining a vibrant, well-educated, and agile public health workforce is vital to supporting our efforts to serve the health of the nation, and we face a larger challenge than we expected in retaining a talented, effective public health workforce.”
The Journal of Public Health Management and Practice (JPHMP) compiled the new studies in a special supplemental edition that analyzes data from the Public Health Workforce Interests and Needs Survey (PH WINS). PH WINS is the largest-ever study of the public health workforce and was conducted by the de Beaumont Foundation and the Association of State and Territorial Health Officials (ASTHO). The JPHMP supplement is made up of peer-reviewed research and expert commentaries examining workforce characteristics, public health skills and capacities, and policy trends.
“This survey points to issues we must work together to address,” said Edward L. Hunter, CEO of the de Beaumont Foundation. “We need to redouble our efforts to reinvent workforce structures to reward creativity and innovation, provide opportunities for ongoing professional development, and engage with young and mid-level public health professionals in order to retain our best and brightest and build the workforce we need for the future.”
Key findings included:
- Considerable workforce turnover. According to the survey, 38 percent of workers plan to leave their current position before 2020. Of those planning to leave, 25 percent plan to retire and 13 percent plan to leave for a position outside of public health. Of note, those most likely to leave for reasons other than retirement include individuals aged 25-40, racial and ethnic minorities, and those with fewer than 10 years of experience in public health.
- Progress on pay gaps by gender and race. Pay disparity in public health is better than the private sector and other areas of government, but more work remains to be done. Women and people of color make less than their white male counterparts despite the fact that the public health workforce is predominantly female and relatively diverse. On average, both women and people of color in state public health agencies earn 90 to 95 cents on the dollar compared to their male and white counterparts, after matching for seniority, experience, and educational attainment. There is no pay gap between Asian staff and their white counterparts.
- Need for continued efforts to improve diversity. Only 7 percent of public health workers are Hispanic/Latino, compared to 17 percent of the general population. However, both the Black and Asian public health workforce are represented in proportion to the population as a whole, at 13 percent and 5 percent, respectively. Nevertheless, 70 percent of the workforce identifies as white, indicating room for improvement in supporting people of color in public health.
The de Beaumont Foundation, in collaboration with the Health Data Consortium and the Department of Health and Human Services (HHS), today announced the winners of the U.S. Obesity Data Challenge at NHS England’s Health and Care Innovation Expo 2015. The challenge is part of a joint U.S.-England initiative designed to harness the power of health data in tackling the epidemic of adult obesity in both countries.
A total of $40,000 in prizes are being awarded for the top three submissions and two honorable mentions. HealthData+, a partnership between the Public Health Institute and Live Stories, was selected for the top prize of $20,000. RTI International won second place with its Neighborhood Map of U.S. Obesity, and a collaboration between GeoHealth Innovations and Community Health Solutions secured third place for their Health Demographic Analysis Tool. HeartSmartKids received an honorable mention for its patient-focused application, and the U.S. Obesity and Healthy Living Locator received an honorable mention for its consumer focus.
“In order to have a meaningful impact on the obesity epidemic in the US, we need innovative solutions that integrate multiple perspectives. The creativity shown in the Obesity Data Challenge entries reinforces the promise of technology and data in helping address some of our most vexing health problems,” said Ed Hunter, President and CEO of the de Beaumont Foundation. “The winners show that there are tools that can help improve access to data by health officials, improve public and patient awareness of obesity and steps to address it, and bring sophisticated data to life without requiring users to have advanced analytic skills.”
The diverse panel of judges evaluated entries based on five criteria:
- How creative and innovative is the proposed solution?
- To what degree does this solution utilize evidenced-based treatments or approaches?
- What is the potential impact on health care or population health?
- Will clinicians and public health practitioners find this solution both usable and applicable to their work?
- How functional is the proposed tool or solution?
Additionally, all entries had to incorporate at least one source of open government data.
“We were happy to see that people used a wide variety of government datasets and visualization tools to develop their ideas. The diversity of submissions speaks to the importance of opportunities like this Challenge to bring different perspectives together onto one platform to meaningfully address obesity,” said HHS Chief Technology Officer, Susannah Fox.
The winning entries are:
- Healthdata+Obesity (1st place) — This simple, curated dashboard helps health officials tell a powerful story about the root causes of obesity. The dashboard provides customizable data visualizations at the national, state, and local level as well as an interactive map, national benchmarks, and written content to contextualize the data. Developed by HealthData+, a partnership between the Public Health Institute and LiveStories.
- The Neighborhood Map of U.S. Obesity (2nd Place) — This highly-detailed, interactive map incorporates obesity data with a GIS database to provide a localized, high-resolution visualization of the prevalence of obesity. Additional data sources can also be added to the map to allow researchers and health officials greater flexibility in customizing the map to support analysis and decision-making on a community level. Developed by RTI International.
- The Health Demographic Analysis Tool – Visualizing The Cross-Sector Relationship Between Obesity And Social Determinants (3rd Place) — This interactive database maps the relationship between the social determinants of health (factors like educational attainment, income, and lifestyle choices) and health outcomes in order to illustrate what plays a role in community health. The powerful images generated by this tool provide compelling material for new health interventions as well as a way to look retrospectively at the impact of existing public health campaigns. Developed by GeoHealth Innovations and Community Health Solutions.
- U.S. Obesity and Healthy Living Locator (Honorable Mention) — This data visualization tool provides a user interface that integrates obesity data with county-level information on physical activity, access to nutritional food, and socioeconomic status. Researchers are able to compare these statistics at a glance in order to inform more precisely-targeted public health interventions. Developed by Auychai Suvanujasiri and Hongwei Zhang.
- Obesity Prevention Through Conversation (Honorable Mention – Consumer-Focused) — This app creates a template for clinicians to engage patients in productive, data-driven conversations about their health. Combining a patient risk summary with a health dashboard and discussion prompts, this tool facilitates positive, patient-centered counseling around obesity. Developed by HeartSmartKids.
“The impressive breadth of solutions submitted to the Obesity Data Challenge reflect the transformative power of open health data to ignite innovation and foster collaboration among health data users and stakeholders for the benefit of all people,” said Chris Boone, Ph.D., Chief Executive Officer of Health Data Consortium. “We must all strengthen our commitment to making data accessible and actionable so that innovative organizations like these Challenge awardees can continue to put data to work to improve the health of individuals and our communities.”
by Brian C. Castrucci
Last night, a mother hurriedly gathered clothes, insurance cards, toys, and medications. She was heading to the ER again because of her daughter’s asthma. She was worried about missing work the next day. She was concerned about the number of school days that her daughter had missed. She was not sure what else to do.
The next day, following advice from the ER, she heads to the pediatrician. The pediatrician sees the chart before entering the room and pauses. She’s seen that chart before. Despite her efforts — all the right treatments, everything she could do in her clinic — nothing has worked. She is not sure what else to do to help her patient.
What the pediatrician probably doesn’t know is that this same situation is repeating itself in the practice down the street, the clinic around the corner, and even with other patients in her own practice. Like most pediatricians and other primary care providers, there is no easy way in her busy practice to look at how her patients distribute throughout the community. So she doesn’t know that several of the persistent asthmatics in her practice all live within seven blocks of each other, indicating that something in the neighborhood may be causing their asthma.
At the same time, local health department leaders are reviewing hospital discharge data from two years ago — the most current data they have. They are identifying zip codes where asthma rates are elevated, but the data are old and zip codes are too imprecise.
If the local health department had access to real-time data at more precise geographies (census tracts, block groups, neighborhoods) from clinics and primary care providers in the community, it could provide more timely and precise neighborhood disease profiles. Epidemiologists, the “disease detectives,” could investigate community-based causes of disease supporting the clinicians working in the communities and improving health. Without these data, their impact is limited.
In this hypothetical, but believable and likely story, the mother wants her daughter to be healthy and return to school, and she wants to be able to go to work to support her family. The pediatrician wants better outcomes for her patients, and the local public health department wants a healthier community.
Too many remain at risk, though, because our health care system is full of data dead ends instead of accessible streams of information.
Our communities face complicated health challenges. Asthma, heart disease, diabetes, and other chronic diseases are the result of complex, interdependent economic, social, educational, environmental, and other factors — often referred to as the “upstream” causes or social determinants of disease.
Medicine can help manage the symptoms of these diseases, but it will never address the root problems. The bottom line is: If we want to live healthier lives, we are going to have to build healthier communities.
Change will not come easily. While the merits of “moving upstream” seem self-evident, we are still a long way from documenting the evidence of effectiveness that will compel action. Before we can expect changes in national policy, we need learn from communities that break the mold and are willing to reach across sectors to find ways of improving health that aren’t necessarily tied to the clinic or hospital.
That’s what we are trying to achieve with the BUILD Health Challenge. In partnership with The Advisory Board Company, the Colorado Health Foundation, the Kresge Foundation, and the Robert Wood Johnson Foundation, we have funded community partnerships that are improving the public’s health — not through medical interventions, but by strengthening their communities.
Not only will we be providing hands-on support for the 18 cities who received BUILD grants announced in June, but we will be working to support more multisector partnerships and develop tested models for other communities to follow.
The BUILD Health Challenge is about fostering collaboration at the community level and getting partners that would not normally talk to each other to work together. It seeks to maximize the strengths of community stakeholders, health care and hospital executives, AND public health leaders to achieve our goal of a healthy, thriving population. Not with a pill or medical intervention, but with upstream partnerships across sectors.
Fortunately, the BUILD Health Challenge is not alone in its commitment to understanding, promoting, and replicating an upstream focus for downstream health gains. Parallel efforts like HICCup’s Way to Wellville, the Institute for Healthcare Improvement’s 100 Million Healthier Lives campaign, the American Public Health Association’s Healthiest Nation in One Generation project, the Practical Playbook: Public Health and Primary Care Together, and the National Committee on Quality Assurance’s Population Health Framework Action Guide are each working toward systems-level partnerships and community-based solutions to our healthcare problems. These efforts will develop the evidence so that what is now a theory will grow into a movement that can change healthcare.
We can’t stop at treating individuals who are sick. Our strategies and collaborations need to match the complexity of our problems.
The BUILD Health Challenge believes in a future where architects, planners, and business leaders are working shoulder-to-shoulder with public health and healthcare leaders to improve population health. Together, the BUILD communities will tackle problems, learn from each other, and find strategies to improve collaborations. From this work, we can improve the health of these 18 communities and show the way forward for countless others.
This post first appeared in the Huffington Post on Aug. 28, 2015, and was updated on Dec. 6, 2017.
Photo courtesy ep_jhu (CC BY-NC 2.0)
by Brian C. Castrucci
There is an 1895 poem by Joseph Malins titled “A Fence or an Ambulance.” The poem recounts two opposing perspectives on what to do about a perilous cliff that had caused injury to many. Some said, “Put a fence ’round the edge of the cliff;” others, “An ambulance down in the valley.”
One hundred and twenty years later the debate between prevention and treatment still rages, but in the US healthcare system, the ambulance is winning — and by a sizable margin. A recent article in the New York Times (“A Sea Change in Treating Heart Attacks“) by Gina Kolata is wholly emblematic of our nation’s focus on treatment over prevention.
The article opens with a review of the many factors that contributed to a 38 percent decline nationally in the death rate from coronary heart disease between 2003 and 2013. These include better control of cholesterol and blood pressure as well as reduced smoking rates.
However, as is often the case when discussing health in the U.S., the article focuses on improvements in treatment. Although the story features Camden, N.J. — one of America’s poorest and most dangerous cities — where “heart disease risk factors abound…” and where “obesity is rampant, as are high cholesterol levels, high blood pressure and smoking,” it only examines the clinical successes of Camden-based Our Lady of Lourdes hospital — the ambulance down in the valley.
An Obsession with Treatment
While the article is certainly valid and accurate in its own right, its singular focus is representative of our nation’s obsession with medical innovation and invention. It is representative of our quick fix culture — where a pill is preferable over real behavior change. This approach comes at a cost, though. Nearly half of all U.S. medical spending can be attributed to about 5% of the population, with 1% accounting for one-fifth of all spending.
When treatment is episodic and quick, the system works. A patient can show up at the doctor’s office with an infection, receive treatment, and likely be cured. The costs and care were contained. Today, with chronic disease like asthma, heart disease, or diabetes much more prevalent and 60 percent of our adult population obese, care is continuous-and the bills start adding up. Nonetheless, as a nation, we continue to value, if not celebrate, treatments over prevention.
Addressing What Really Makes Us Sick
As in Camden, most of what makes people sick has to do with where they live, how active they are, what they eat, and their daily stress levels.
While prevention is often oversimplified to a conversation about individual choices, those choices are made in a broader context. They are shaped and compounded by factors outside of any one person’s control — high concentrations of alcohol and tobacco outlets and advertising; mold, insect and rodent infestations in rental and low income housing; “food deserts” with no access to fresh meat, fruits, or vegetables; exposure to high crime areas; and no or limited access to parks or playgrounds.
While more people in the US may have health insurance than ever before as a result of the Patient Protection and Affordable Care Act (ACA), little has been done to help people actively manage their health, improve their activity levels, or regulate their diets.
Photo courtesy Simon Yeo (CC BY 2.0)
A Balance Between Prevention and Response
In other fields, where lives are at stake, we recognize that a more balanced approach between prevention and response is appropriate.
Earthquakes, like heart attacks, happen. They are devastating realities of our world. However, our approach to earthquakes is not limited to clean up and repair. We work to prevent negative consequences through policy, such as changes to the building codes, and educational campaigns that can shape personal, behavioral choices, like securing bookcases to the wall and not hanging heavy objects over beds.
In other fields, bombs are diffused, air bags deployed, and smoke detectors installed. All of this is done to manage the known risks of everyday life. In the US health system, on the other hand, the focus is all too often on improving treatments while failing to prioritize prevention. One explanation may be the unique payment structures that drive the US healthcare system.
In the article, the head of the Our Lady of Lourdes hospital’s cardiovascular disease program, Dr. Reginald Blaber, acknowledges that “Heart care is the hospital’s specialty, and without its revenue… Lourdes would have to close its doors.” This quote is a stark reality and illustrative of how treatment is incentivized.
The entire medical industrial complex relies on the small percentage of society that require extensive medical intervention for its continued existence. This is the result of a system in which reimbursement is based largely on illness.
Imagine a system in which hospitals and medical providers are incentivized to partner with local public health agencies and community organizations to ensure the health of the overall population. While progress is slow, payment structures appear to be evolving in this direction.
The movement toward Accountable Care Organizations (ACOs) and, more broadly, Accountable Care Communities is a start. These healthcare organizations offer a payment and care delivery model that ties reimbursements to quality metrics and reductions in the total cost of care for a group of patients. New entrepreneurial endeavors are also developing, like Dr. Farzad Mostashari’s firm Aledade that will assist independent primary care providers form ACOs.
While payment structures begin to change, it is important to look to those who aren’t waiting, who see the value of partnerships between health care and public health and what they can accomplish together.
The Practical Playbook, a joint project of Duke University Medical School’s Department of Family and Community Medicine, the de Beaumont Foundation, and the Centers for Disease Control and Prevention, is documenting partnerships between primary care and public health across the US that prioritize prevention by altering community level factors that contribute to disease.
The 18 BUILD Health Challenge awardees are also working to understand how hospitals, public health, and community leaders can work together to change their communities and improve health.
Photo courtesy ep_jhu (CC BY-NC-ND 2.0)
Without Prevention AND Treatment, Nothing Can Change
“A Fence or an Ambulance” presents a complex situation as a dichotomous choice, but we know it isn’t.
We actually want both — we want the preventive measures up front, as well as the access to medical innovations or new treatments when needed. Kolota’s piece focuses on the part of the healthcare system that the US does exceptionally well: treatment. If you are sick and in need of treatment, there’s no better place to be. However, treating greater numbers of people at increasing costs is not sustainable.
Bad things happen. It’s a reality of our world, but we have a choice. We can sit passively by and wait for disaster, or we can work together to try to stop it. This will require a reprioritization that starts to focus on and fund prevention. We already have great ambulances. Now we need to build better, more effective fences.
This post first appeared in the Huffington Post on July 2, 2015, and was updated on Dec. 6, 2017.