Shortage of U.S. Public Health Workers Projected to Worsen: About 250,000 New Workers Needed

Teddi Dineley Johnson

Nations Health. 2008;38(4) 


Alarms signaling an impending public health work force shortage are growing more urgent. New findings show that the U.S. shortage will grow increasingly worse over the next four years, but that few Americans are aware that a crisis exists.

At a public health work force briefing on Capitol Hill in late February, the Association of Schools of Public Health released a first-of-its-kind assessment of the looming public health work force shortage, which has been growing steadily worse since 1980. According to the report, at least 23 percent of the current public health work force — nearly 110,000 workers — will be eligible to retire during the next presidential term. By 2020, an additional 250,000 public health workers are needed to dodge a work force shortage that would leave the nation vulnerable to a range of pending threats, including infectious diseases such as pandemic flu, bioterrorism and natural disasters.

Between 1980 and 2000, the public health work force dwindled by 50,000 workers. At the same time the U.S. population grew and is expected to increase 19 percent from 2000 to 2020. The aging U.S. population will also put new demands on health workers. The current work force is performing more services for more people with fewer resources, but the public's health will be "drastically" compromised if the trend continues, said the assessment, "Confronting the Public Health Workforce Crisis."

"People are more efficient, but no matter what you say, there is a huge crisis here," said Harrison Spencer, MD, MPH, president and chief executive officer of the Association of Schools of Public Health. "The functions that public health professionals serve are vital to us all, and if these functions don't get done, our health will suffer."

Globally, the picture is even bleaker. According to a 2006 World Health Organization report, at least 57 countries, most of them in sub-Saharan Africa but including Bangladesh, India and Indonesia, face "crippling" public health work force shortages.

Staffing shortages and a lack of specialized training lead many public health professionals in poorer countries to seek public health jobs in wealthier western nations. According to a study published in the January 2008 issue of APHA's American Journal of Public Health, between 23 percent and 28 percent of physicians in the United States, Canada, the United Kingdom and Australia received their medical degrees outside of their host countries. Of those, 40 percent to 75 percent came from low- to middle-income countries.

Schools and programs of public health in the United States will play a key role in building capacity globally, said Linda Rosenstock, MD, MPH, dean of the University of California, Los Angeles, School of Public Health and chair of the Association of Schools of Public Health's Work Force Taskforce.

"It is important that we have a sufficient number of domestically trained public health workers so that we don't contribute to the 'brain drain' of having public health professionals come here when they are needed at home," Rosenstock said.

Accredited schools of public health in the United States graduate between 80 percent and 85 percent of the nation's public health work force. To replenish the work force and deflect the crisis, schools of public health will have to graduate three times the current number of graduates over the next 12 years, according to the assessment.

Achieving that goal will not be easy, and will require broad-based support from local, state and national leadership — public and private — as well as strong grassroots support, said Ciro Sumaya, MD, MPHTM, founding dean of the School of Rural Public Health at Texas A&M Health Science Center.

"There is a major need to get the word out of the importance and impact of public health to the general public," Sumaya told The Nation's Health. "There is a prime need to improve the pipeline of prospective students entering the field of public health. A combination of new schools of public health and expansion of existing schools, along with increased enrollment in public health programs, are essential in producing a larger pool of quality public health professionals."

Health professions programs, including health career opportunity programs, minority centers of excellence programs and loan forgiveness programs that operate under the U.S. Health Resources and Services Administration, need to incorporate students with public health interests, Sumaya said, noting that career counselors at institutions of higher education will need a better understanding of the public health profession if they are to improve the awareness and interest of potential future public health students.

Additionally, federal legislation aimed at increasing the capacity of the public health work force is critically needed to expand the number of workers, said Sumaya.

Legislation introduced recently on Capitol Hill is targeting public health work force shortages. On Feb. 26, Rep. Doris O. Matsui, D-Calif., introduced the Public Health Preparedness Workforce Development Act of 2008, known in the House as H.R. 5496. And last summer, Sen. Chuck Hagel, R-Neb., introduced the Public Health Preparedness Workforce Development Act of 2007, known in the Senate as S. 1882. Both bills would amend the Public Health Service Act to establish various programs that would increase recruitment and retention of public health workers and eliminate critical public health work force shortages in federal, state, local and tribal public health agencies. Additionally, both bills would provide for public health work force scholarship programs, loan repayment programs and grants that would provide additional training to mid-career professionals in the public health work force.

Ensuring the public's health and safety must be a top priority, Matsui said.

"Our public health work force is facing a critical shortage, as many workers are nearing retirement, and fewer workers are entering into the public sector," Matsui told The Nation's Health. "Every day we hear new reports of cases of tuberculosis, West Nile and rabies. It is clear that we must take steps now to recruit and retain public health workers. They are the backbone of our communities' continued health."

Graying of work force adding to shortage

Across the United States, shortages of skilled state and local public health workers are being documented and forecasted as tens of thousands of workers enter or prepare to enter retirement. According to data released in March by the Association of State and Territorial Health Officials, the average age of a public health worker in state government is 47, and by 2012 more than 50 percent of some state health agency work forces will be eligible to retire.

However, a recent poll conducted by the Center for State and Local Government Excellence found that most Americans are unaware that state and local public health departments are facing a serious shortage of skilled professionals that could put their lives and health at risk.

The findings, released in March in a report called "Facing the Future," found that only 24 percent of Americans see the graying of the work force as a problem for local governments.

One reason for the lack of concern may actually point to a silver lining: One in five respondents said they would be very interested in taking a job at some point with a state or local government, and one in three said they would be very interested in someday working in a hospital or public health organization.

"That people are drawn to jobs where they can make a difference to society is heartening," said Elizabeth Kellar, MS, executive director of the Center for State and Local Government Excellence.

Right now, however, shortages of qualified state and local workers are having "very real" impacts, said C. Earl Hunter, MA, commissioner of the South Carolina Department of Health and Environmental Control.

"We on the front lines are having a difficult time both recruiting and retaining people in a number of professional areas," said Hunter, noting that within his agency, vacancies for public health nurses, epidemiologists, environmental workers, laboratory personnel and public health physicians are among the most difficult positions to fill.

State and local budget restraints have kept many states from being fully staffed, and competition is further adding to states' staffing woes as some health workers realize that jobs in the private sector may come with more pay and less bureaucracy.

According to a brief released in April by the Center for Studying Health System Change, local public health officials most frequently cite uncompetitive salaries as the reason for not being able to attract qualified candidates. Hiring skilled nurses is especially difficult because acute-care nurses can make as much as $15,000 to $20,000 more in the private sector. Also, sign-on bonuses of $10,000 or more are often used to lure nurses to the private sector, the brief found.

"There are more and more demands being placed on public health, and fewer and fewer workers, which increases the risk of something major happening," Hunter said. "Our ability to respond or contain an outbreak is diminished. It is not a matter of if, but when, that will happen."

For a copy of "Facing the Future," visit For a copy of "Confronting the Public Health Workforce Crisis," visit For more news from The Nation's Health , visit


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