Operationalizing PH WINS 2021: Pathways to Resilience for Public Health.

Abstract

In early 2020, public health workers across the United States were called to respond to an emerging threat: COVID-19. Seemingly overnight, COVID-19 became a pandemic and, as many transitioned from offices and schools to home-based settings, essential workers braved the risk of infection to face the emergency and maintain essential health services. The pace of the response and the scale of the loss of life in the United States were unprecedented in recent history. Public health workers demonstrated their dedication to their mission by rising to these challenges, often stretching themselves beyond their capacity to meet the demands of the crisis. In the months and years since the first case of COVID-19, there has been a seismic shift in the way society engages the public health workforce. The 2021 Public Health Workforce Interests and Needs Survey (PH WINS) provides a snapshot of the burden carried by the public health community. Even before the emergence of COVID-19, many public health workers have moved from one emergency response to the next with little pause for recovery, exacerbating systemic challenges. Our experience managing multiple simultaneous and overlapping public health emergencies has demonstrated the fragility of our public health infrastructure and eroded public trust. As we face an increasing frequency and severity of public health disasters in the contexts of climate change and organized health disinformation, a deepening distrust of science has forever changed the nature of our work. In addition, as the field of public health recognizes systemic racism as a public health crisis and takes meaningful steps to dismantle it, it is threatened with mounting hostility from outside and within our government structures. These experiences, reflected in PH WINS 2021, have also brought to light a world of opportunities to build a better public health system that will sustain through and beyond the emergencies of the future (Table). TABLE - Pathways to Resilience Build internal tracks to leadership for staff from communities that are heavily impacted in emergencies. Transform COVID-19 temporary public health workers into a new public health workforce. Develop a dynamic public health emergency response infrastructure. Build resilience in essential basic public health functions. Create trauma-responsive environments for the public health workforce. Build Internal Tracks to Leadership for Staff From Communities That Are Heavily Impacted in Emergencies The COVID-19 pandemic highlighted long-standing health inequities. Structural oppression creates community- and neighborhood-level health vulnerabilities before, during, and after public health emergencies1–3; however, the makeup of our current public health leadership is limited by generations of exclusion of people from the communities that could most benefit from public health programming. Historic definitions of expertise in public health exclude some of the most critical “qualifications”—those gained by lived experience. During the COVID-19 response, health departments in need of critical community-level information often did not have to look far; highly adept individuals from heavily impacted communities were already part of the public health workforce, but their indispensable skills and knowledge were not measured in their job titles or work assignments. Emergency responses can exacerbate or dismantle long-standing inequities perpetuated by systemic racism within governmental agencies. Public health must embrace the opportunity to unravel systems of oppression by identifying staff who live in the hardest-hit communities, uplifting them into leadership roles, and developing intentional partnerships with communities. Such approaches during emergency response can give staff the opportunity to gain leadership experience, develop skills in rapid participatory action research and qualitative methods, and forge the robust partnerships with communities necessary to develop community-relevant solutions and meaningfully improve health equity.3 Transform Temporary Public Health Workers Who Worked in COVID-19 Into a New Public Health Workforce Public health emergencies create critical opportunities to invest in a dangerously underfunded system.4,5 Funding streams emerging after public health emergency responses should be invested in remediating the systemic challenges that prolong and exacerbate emergencies, particularly by building a workforce from impacted communities. During COVID-19, while rapid scaling of a temporary workforce resulted in public health gains, many workers hired through an influx of emergency funding were laid off as the response deescalated. For example, NYC Trace, the largest contact tracing operation in the country, rapidly hired thousands of New Yorkers at a time when unemployment was high and relatively safe remote jobs were scarce. Selective recruitment from highly impacted communities at that time increased the acceptability of services while both investing in impacted communities and cultivating a pool of trained public health workers.3 Unless these workers are reintegrated into the public health workforce, the field risks losing their newly gained expertise. Given massive workforce shortages experienced by public health departments across the country, decision makers could look to approaches adopted by global humanitarian response programs and the Public Health Corps and consider developing national assignments to fill short- and long-term gaps. Not only would this fulfill urgent, mounting workforce needs and support the development of the public health careers for many essential pandemic workers but this workforce would also bring greater community-centered knowledge and practice to the field, nationwide. Develop a Dynamic Public Health Emergency Response Infrastructure As we emerge from the acute phases of the COVID-19 pandemic, we have an opportunity to revisit the structure of our public health emergency response systems, building upon a strong backbone of essential public health competencies. Across the country, public health workers were reassigned from their day jobs to emergency roles, often for years on end. PH WINS 2021 shows that all public health program areas contributed at least 20% of their workforce time to COVID-19 response efforts.6 This approach creates gaps in ongoing public health activities, burnout among employees, and limited institutional memory to inform future emergencies. To be responsive, emergency response systems need long-term investments to modernize and improve core public health functions. There is a clear need to institutionalize lessons learned and quickly integrate corrective actions. During and after a response, innovation and accountability in “hotwashes” and after-action reports could support this process but only if evaluation is followed by swift, measurable action. The resultant dynamic response system would support the translation of knowledge and skills from one response to another and produce a more efficient allocation of public health resources toward foundational infrastructure required in emergencies and core public health services. Build Resilience in Essential Basic Public Health Functions COVID-19's devastating legacy exceeds its direct morbidity and mortality. As case counts exploded in early 2020, routine public health operations and health care services screeched to a halt. While organizations worked around the clock to create electronic versions of services previously provided in person and emergency response programs incorporated wraparound services, not all services translated effectively and not all people had the same access to digital platforms. This has resulted in unprecedented setbacks in disease prevention, social-emotional learning, education, chronic and acute disease management, life expectancy, and more. At the same time, we are not seeing any reprieve from public health emergencies. These 2 are not separate: widening gaps in our public health systems multiply the impacts of public health disasters when they hit.1–3 Public health agencies must build capacity in core public health functions including surveillance and accompanying data informatics, data and risk communication systems, and robust mental health infrastructure. Instead of skirting along the edge of staff capacity and shying away from innovative modernization of public health informatics, we must invest in core functions that will not only ensure continuity of basic public health services for all people in all places in the United States but also facilitate smooth pivots to emergency response activities that rely on these same competencies. Create Trauma-Responsive Environments for the Public Health Workforce None of these initiatives or investments can move forward if no one is around to make them happen. PH WINS 2021 shows the devastating toll the past few years have had on the public health workforce, with nearly one-third of the governmental public health workforce considering leaving their organization in the next year for retirement or other reasons.7 Sector-wide burnout and related behavioral health impacts must be addressed while building sufficient capacity to prevent this scale of trauma from recurring in the next disaster. However, trauma is complex, long-lasting, and impacted by culture and environment; mitigation requires awareness and understanding. Now is the moment to build trauma-responsive environments for the public health community. Trauma-responsive environments promote healing and wellness, allow public health workers to access services and space to process their experiences, and support workers to heal. They must be built on a foundation of accessible mental health supports and integrative care approaches, which will be critical to sustaining services long after pandemic recovery funding is exhausted. Behavioral health services can only be accessible if social stigma and other barriers are reduced across the field of public health nationally. Some of these barriers are explicitly embedded in licensing and board requirements, leave policies, and organizational culture.8 Similarly, just as systemic and structurally intersectional inequities persist, so too do historical and intergenerational trauma via oppression, racism, and prejudice. Meaningful action is needed to revise policies that prevent public health workers from accessing behavioral health services. We must do more than ask our workers to “power through” because the next disaster is looming. It is time to improve our systems and way of work to build a foundation for trauma-responsive care throughout disaster response and recovery.