Public Health Surveillance Workforce of the Future

Patricia A. Drehobl, MPH1

Sandra W. Roush, MPH2

Beth H. Stover1

Denise Koo, MD1

1Scientific Education and Professional Development Program Office, CDC

2National Center for Immunization and Respiratory Diseases, CDC

Corresponding author: Patricia A. Drehobl, MPH, Office of the Director, Scientific Education and Professional Development Program Office, 1600 Clifton Road, NE, MS E-94, Atlanta, GA 30333. Telephone: 404-498-6319; Fax: 404-498-6505; E-mail: pdb2@cdc.gov.

Although electronic data systems that monitor for health threats are becoming increasingly automated, human expertise is, and always will be, critical to recognizing potential cases of disease, diagnosing disease, reporting diseases or conditions, analyzing and interpreting data, and communicating results to all stakeholders. For this reason, the nation's health professionals from all disciplines and at all levels are fundamental to sustaining and enhancing public health surveillance capacity.

Surveillance data come from different sources. Clinicians recognize diseases and other conditions, intentional or unintentional injuries, poisonings, or other health threats and report findings to state and local health departments (1). After collecting the surveillance data, public health workers synthesize, analyze, interpret, and act on the findings. Professionals from diverse disciplines — working in the nation's health system and at all levels of government and geographic jurisdictions — provide the skills necessary for the components of a surveillance system to work effectively.

Traditional disciplines performing surveillance include epidemiologists, environmental health specialists, laboratorians, physicians, nurses, infection-control professionals, and public health managers (1). Other disciplines have become increasingly important, including informaticians, pharmacists, law enforcement, coroners, medical examiners, and analytic specialists (e.g., statisticians and mathematics modelers), information and decision scientists (i.e., scientists who use highly advanced modeling, statistical tools, and behavioral predictive models to inform decision makers on public health policy), natural language processing specialists, analytic data management programmers, and knowledge managers (i.e., professionals representing varied fields who apply concepts of information systems, computer science, and business administration to improve knowledge sharing, reuse, learning, collaboration, and innovation within a public health organization).

Although the astute clinician remains a crucial link in surveillance, persons from other disciplines (e.g., laboratorians, pharmacists, and law enforcement) are often the first to recognize events that require prompt interventions of public health workers. In light of the importance of each professional to the effectiveness of the nation's surveillance system, workforce initiatives are needed to ensure that the right talent is in the right job at the right time. Such efforts would focus on enhancing the skills and availability of public health workers and also the diverse disciplines that contribute information and expertise to the surveillance process. Strengthening the nation's public health surveillance capacity requires commitment of resources and creative solutions to extend the skills and reach of the workforce. These solutions can create job opportunities, training, and viable career paths for health professionals at federal, state, and local levels.

This report proposes a vision for the public health workforce of the future, identifies challenges and opportunities, and suggests approaches to attain the vision. This topic was identified by CDC leadership as one of six major concerns that must be addressed by the public health community to advance public health surveillance in the 21st century. The six topics were discussed by CDC workgroups that were convened as part of the 2009 Surveillance Consultation to advance public health surveillance to meet continuing and new challenges (2). This report is based on workgroup discussions and is intended to continue the conversations with the public health community for a shared vision for public health surveillance in the 21st century.

Vision

A knowledgeable, skilled, and effective workforce to meet the diverse needs of public health surveillance.

Challenges

Workforce Shortages and Need for Analysis

Serious public health workforce shortages exist in disciplines that perform surveillance functions, and these shortages limit the nation's capacity and plans for enhancement. Throughout the country, states and communities report a need for more public health nurses, epidemiologists, laboratory workers, informaticians, and environmental health professionals. The Association of Schools of Public Health (ASPH) estimates that 250,000 more public health workers will be needed by 2020 to maintain capacity (3,4). Data are lacking for the numbers of workers in the diverse disciplines that perform surveillance functions.

Although reports indicate that the number of public health workers is insufficient, enumeration studies of the public health workforce are dated, incomplete, and lack specificity (5–7). For example, the Council of State and Territorial Epidemiologists (CSTE) reports biannually on epidemiologic capacity as determined by each state epidemiologist, but this type of information for other disciplines is lacking or incomplete (8). Knowledge also is limited regarding the disciplines that are new to performing or supporting surveillance. Their roles, contributions, and extent of their surveillance activities have not been described and warrant articulation. This is doubly important in the context of health reform, as public health practice is changing and the effect on the public health workforce is not yet known.

An ongoing systematic approach for monitoring the workforce is needed, including strategies that characterize the workforce for surveillance — who they are, where they work, and their roles by discipline, program areas, and geography. More information is needed regarding existing surveillance workforce gaps and the diversity and balance or mix of disciplines to determine which are underrepresented, what new disciplines are needed, and where they are needed.

Need for Continuous Learning and Core Competencies

Numerous reports document the status of academic education for health professionals (e.g., public health professionals, physicians, and nurses) and the need for continuous learning (9–18). Addressing the education of both health care and public health professionals, a Global Independent Commission on Education of Health Professionals for the 21st Century stated, "Professional education has not kept pace with 21st century challenges, largely because of fragmented, outdated, and static curricula that produce ill-equipped graduates. The problems include a mismatch of competencies to patient and population needs ... and efforts to address the deficiencies have mostly floundered, in part because of the tendency of various professions to act in isolation or even in competition with each other" (10). This commission called for "a new round of more agile and rapid core competencies based on transnational, multiprofessional, and long-term perspectives to serve the needs of individuals and populations."

Recommendations have been made for improving U.S. public health education over several decades (12–14). The majority of public health workers lack formal training in public health (i.e., only 20%–25% of the public health workforce graduates from an accredited school or program of public health) (11,13). In 1988, The Institute of Medicine (IOM) recommended that schools of public health should focus on the training of leaders and that professional education be grounded in real world public health, adding practicum experiences to the curriculum and formal linkages between schools of public health and public health agencies so that students could learn from instructors with hands-on experience (11,13). The 2003 IOM report "Who Will Keep the Public Healthy" examined the education of public health professionals in the 21st century and provided a framework and recommendations for strengthening public health education (14). Among the recommendations were curricula and teaching approaches to incorporate enhanced participation in the educational process by those in senior practice positions; expansion of supervised practice opportunities and sites, such as community-based public health programs, delivery systems, and health agencies; and establishment of relations with other health-science schools, community organizations, and health organizations.

In a 2005 symposium, public health scholar/practitioners reassessed the status of practice-oriented scholarship (15). They acknowledged that changes had occurred and the early vision for practice-oriented scholarship had been realized. However, comments from some of these leaders indicated ongoing challenges, including "the public health faculty member with practice experience is a rare commodity" and "high proportions of public health faculty are classic academics with PhDs whose scope of experience is research, publishing, and academic conferencing" (15). In 2009, ASPH stated that schools of public health had essentially met the challenges raised by the 1988 and 2003 IOM reports on enhancing academic-practice linkages, but acknowledged that practice-based service for public health remains challenging (11,14,16 ).

Further complicating workforce capacity for surveillance, many physicians, nurses, and other health professionals graduate with little to no grounding in the concept of prevention or population health (1,16,18). Although multiple IOM reports addressed the importance of a population health perspective in preparing physicians, multiple publications indicate the implementation has been neither consistent nor effective (9-12,14,18,19). Health promotion and disease-prevention education that includes a surveillance component added to the curriculum for health professionals would raise clinician awareness of their roles in public health surveillance (9,19,20 ).

To guide workforce development activities for improving education and to support recruitment and career paths for health professionals and others who contribute to public health surveillance, competencies are needed. General competencies have not been developed for the workforce that contributes to surveillance, and discipline-specific competencies with levels and tiers are incomplete. Epidemiology and informatics have general and discipline-specific surveillance competencies with levels and tiers, whereas other disciplines do not (21,22).

Because many public health workers, clinicians, and those new to roles in surveillance have not had academic preparation in public health or surveillance, life-long learning is critical (11,12,23). Vital to improving the nation's surveillance capacity is the establishment of a framework for continuous learning and training to ensure that current and future workers are prepared to meet the challenges ahead. The workforce work group of the 2009 Consultation on CDC's Vision for Public Health Surveillance concluded that such a framework would

• articulate professional roles and competencies for what various disciplines need to know, and establish levels of proficiency;
• base training and education on competency requirements and instructionally sound programs throughout the educational continuum, from academic curricula for students to continuing education programs for current workers;
• include new, evolving curricula and use various learning methods to combine face-to-face instruction and distance learning with the aim of providing realistic and practical opportunities for learners;
• include evaluation for a continuous improvement loop for program accountability; and
• offer training and career-development paths to increase the proficiency of those who serve in a surveillance role.

Despite the documented recommendations for improvements in education and training, funding for these programs has been unstable. Enhancements are challenging in an era of shrinking budgets even for CDC's established, highly regarded, applied epidemiology and informatics fellowship training programs. These fellowship programs, other CDC training programs (e.g., the National Laboratory Training Network), training at all levels of the public health system, and development of surveillance training for health-care practitioners are critical to effect workforce improvements of public health surveillance. Investments in education and training must be a priority for sustainable changes to occur.

Organizational Obstacles

Organizational, operational, and human resource challenges influence workers' ability to do their jobs. Public health agencies often have rigid classification systems that hamper the creation of new positions and lack the organizational support structure (e.g., supervision, technical assistance, and technology) for integrating new positions. Lack of job classifications affects both hiring and career paths in public health agencies. In certain cases, position descriptions are not available for newer disciplines to facilitate hiring for certain skill sets (e.g., informatics). Also, without a job classification, no clear path exists for promotion or career advancement. Assessments are needed to identify administrative gaps and inefficiencies (e.g., the effects of inadequate support staff on surveillance functions) and to ensure the workforce has access to technology and other tools with which to do their jobs.

Budget and Staffing Context

Budget shortfalls and staff shortages at local, state, and federal levels affect the public health surveillance workforce. Examples of challenges related to solving public health workforce shortages include the volume of retiring workers, an insufficient supply of trained workers to replace retirees, need for training funding, and uncompetitive salaries and benefits (5). Inequities in pay and benefits (between federal and state or local government and between government and private sectors) and the frequent use of cost-cutting measures that restrict staffing (e.g., hiring caps or freezes, travel freezes, and furloughs) compromise the ability to attract and retain qualified public health workers. As federal, state, and local funds have diminished, positions are being eliminated when workers leave, creating long-term losses. Consequently, positions are unavailable for new disciplines to support surveillance activities. In addition, at a time when critical infrastructure needs have been identified (e.g., training for new skills and information technology support for surveillance), resources to meet those needs are lacking.

The U.S. economic recession further complicates the situation. Although certain public health workers might be delaying retirement, others are being forced to leave jobs because of layoffs. The Association of State and Territorial Health Officials (ASTHO) conducts semiannual surveys of budget cut effects on public health. Before the September 2009 Surveillance Consultation, ASTHO reported accelerating job and program cuts and that 44% of states had a vacancy rate of ≥10% (24). The March 2011 ASTHO survey reported that approximately 15,250 jobs have been lost and that, since 2008, 87% of all state and territorial health agencies have experienced job losses (7). The National Association of County and City Health Officials (NACCHO) reported in March 2011 that 29,000 cumulative jobs were lost in local health departments across the country from 2008 to 2010 (6). If resources to secure necessary workers continue to be scarce, state and local public health workforce shortages are likely to worsen and impact public health surveillance.

Opportunities

Health reform provides an opportunity to clarify or redefine surveillance workforce needs, roles, and disciplines. The emphasis on prevention drives closer alignment of health care and public health professionals to practice in an era of accountability. It also provides impetus to strengthen links among federal agencies and partnerships with other public health and professional organizations to support workforce recruitment, training, and retention. Collaboration among traditional public health partners (e.g., CDC, ASTHO, NACCHO, CSTE, ASPH, and the Association of Public Health Laboratories) and other stakeholder organizations (e.g., Health Resources and Services Administration, American Medical Association, National Environmental Health Association, and American Medical Informatics Association) can be strengthened to better articulate roles, determine training needs, and guide standards and policy development. In addition, existing partnerships might be underdeveloped and new partnerships are needed (e.g., those aimed at improving links between the nation's public health and health-care systems). If these potentials are actualized, the workforce will be stronger, more competent, and better prepared to enhance surveillance capacity and to improve individual health and that of communities. The American Recovery and Reinvestment Act (ARRA) of 2009 and the 2010 Patient Protection and Affordable Care Act (ACA) present opportunities for strengthening the workforce for public health surveillance (25,26).

ARRA provided a one-time investment in public health to help offset deep budget reductions of state and local public health departments. An investment of $50 million was authorized to support surveillance in states and prevention of health-care–associated infections (HAIs), encourage collaboration, train the workforce in HAI prevention, and measure outcomes (27,28). ACA has selected provisions designed to eliminate shortages of public health workers and to strengthen workforce capacity (29). ACA provisions focus on improving public health workforce analysis and capacity and expanding Epidemiology and Laboratory Capacity grants to public health agencies for advancing surveillance and workforce roles related to surveillance functions. ACA also expands CDC's fellowship programs in applied public health epidemiology, public health laboratory science, and public health informatics to address documented workforce shortages in state and local health departments. With ACA's provisions related to public health infrastructure, training, surveillance, and epidemiology and information technology, potential exists for establishing a comprehensive framework for public health workforce improvement. Appropriation decisions will determine the degree to which the provisions can be implemented (29,30).

Conclusions

Developing the workforce to support public health surveillance requires multiple actions. A workforce analysis is necessary to provide information about the composition and numbers of workers. This activity would include enumeration of the workforce and existing gaps, forecasting and identifying future needs, and monitoring how a workforce analysis is applied to addressing programmatic needs. Immediate training needs could be addressed by conducting a surveillance training needs assessment and job task analysis; developing surveillance competencies that complement other competency sets; designing, developing, providing, and supporting training for the existing workforce; establishing systems for continuous learning and making resources available; and evaluating the effectiveness of existing and future training.

Adequate support structures and access to essential tools are necessary for the surveillance workforce to perform their jobs. Additional actions might include the following:

• conducting job task analysis with representatives of different disciplines;
• identifying administrative inefficiencies (e.g., conduct cost analyses) and needed technologic tools;
• acquiring resources to ensure access to those tools;
• providing opportunities for career advancement; and
• monitoring workforce retention.

Finally, partnerships among stakeholders can be strengthened to increase visibility of workforce needs and influence supportive policies within organizations and at federal, state, and local levels. Partner collaborations can include identifying and sharing successful interventions, developing an overarching workforce strategy, identifying existing laws and policies relevant to the public health workforce and leveraging these among the stakeholders and their constituencies, and monitoring and evaluating the effect of policy changes on the workforce (e.g., accreditation standards and ACA).

Because of the changing epidemiology of diseases and related reporting requirements, combined with the opportunities offered by the advances in information technology and enhanced public health surveillance, education and training are critical to strengthening public health workforce capacity. An adequate, educated, knowledgeable, and skilled health workforce that is equipped with necessary tools is vital for an effective public health surveillance system. To achieve these goals, collaboration with partners is essential for enhancing the public health surveillance workforce of the future.

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