By Michael Ollove, Stateline

Even as frontline health workers have been celebrated during the COVID-19 pandemic, many others working to track the virus, stem its spread and help Americans avoid infection have found themselves under siege.

Those public health workers have been vilified by a portion of the public and attacked by some political leaders and media figures. They have been fired or forced from office. They have been subjected to protests—some on their own front lawns—as well as curses, threats and even, on at least one occasion, racist taunts. 

All that while working endless hours, sometimes in unfamiliar roles, to save as many people as possible from a virus that has so far killed more than 614,000 Americans.

“A feeling of helplessness settles in when you promote all these practices, but part of the community feels antagonistic at your efforts or feels you have an ulterior motive,” said Alison Krompf, deputy commissioner of the Vermont Department of Mental Health. “It can cause you to question your sense of purpose.”

Now the costs of performing in that crucible have become clear.

A large-scale survey conducted by the federal Centers for Disease Control and Prevention released last month found that more than half of people working in public health at the state, tribal, local and territorial levels during the pandemic reported symptoms of at least one serious mental health condition.

Those conditions are depression, anxiety, suicidal thoughts and post-traumatic stress disorder.

The results mirror those for frontline health care workers except in one notable regard, said Carol Rao, a CDC epidemiologist and a lead author of the report.

“The prevalence of PTSD was 10 to 20% higher for public health workers than for frontline health workers and the general public,” she said. “And that’s what stood out to us the most.”

For many public health workers, the results are painful. “It’s very challenging to see colleagues be hurt, be disparaged, be burnt out,” said Dr. Ruth Lynfield, Minnesota’s state epidemiologist and medical director of the Minnesota Department of Health as well as a co-author of the CDC report.

The resilience of the public health workforce is far from inconsequential.

Unless the well-being of these workers is addressed, said Amber Williams, a senior vice president of the Association of State and Territorial Health Officials, “we will continue to get what we are getting now, which is a burned-out workforce and less robust response to a pandemic.”

She noted that the system’s capacity to address the problem is questionable. “There’s very little bandwidth to make the changes that are needed,” she said. It remains an all-hands-on-deck situation that requires long hours and workers assuming unfamiliar roles.

Rao said that while the top-level findings of the report weren’t unexpected, some incident details were.

Nearly 12% of the 26,174 public health workers surveyed said they had received job-related threats since the start of the pandemic. Nearly a quarter said they had felt bullied, threatened or harassed as a result of their work.

“Given the length of the response of pandemic, we had a feeling that public health workers were under immense amount of stress,” said Rao. “The amount of threats, harassment and bullying, that was the surprise.”

Overall, according to the CDC survey, which was conducted in late March and the first half of April, 53% of respondents reported symptoms of at least one adverse mental condition in the previous two weeks: 37% relayed symptoms of PTSD, while 32%, 30% and 8.4% reported depression, anxiety and suicidal ideation, respectively. Suicidal thoughts were more frequent for workers under age 29, people who are transgender or nonbinary and those who identify as multiracial. Prevalence of PTSD symptoms was higher among workers with postgraduate educations.

Rao said the CDC is further analyzing the results and expects to release more detailed information, such as time on the job and job roles.

Departures

While clinicians treat one patient at a time, the job of public health workers is to protect the health of populations. That means promoting healthy lifestyles and prevention of disease and injury, and detecting and responding to communicable diseases.

Public health has been under-resourced in the United States for many years, leaving workers overstretched and tired, according to many who work in and study public health. A 2017 survey commissioned by the Association of State and Territorial Health Officials found that although public health workers enjoyed high levels of job satisfaction, nearly half of roughly 48,000 respondents said they planned to leave their jobs within the next five years—22% to retire and 25% for other reasons.

And that was before the pandemic hit.

According to tracking conducted by the Associated Press and Kaiser Health News, since the early days of the pandemic, 248 local and state public health leaders in 41 states have resigned, retired or been fired.

And that’s just upper-level officials. Local public health agencies have seen unusually high numbers of departures throughout their ranks during the pandemic, and expect more to come.

“People are going to retire or leave the workforce as soon as they can catch their breath,” said Lisa Macon Harrison, director of the health departments serving Granville and Vance counties in North Carolina, and president of the National Association of County and City Health Officials.

Dr. Michael E. Kilkenny, CEO and chief medical officer of the health department serving West Virginia’s Cabell and Huntington counties, said in an interview that his department, which typically has little turnover, had lost 9 of 30 full-time staffers during the pandemic. “That was a huge turnover that we have not seen before,” he said. He ascribed the resignations to the stress of the job, interminable hours, working in unfamiliar roles to meet the needs of the crisis, and abusive treatment from the public.

He said he was trying to keep an eye particularly on employees doing contact tracing work, in which they might have to recommend that residents who have been exposed to the virus quarantine themselves.

“It’s those people who are getting cursed out five times a day every day; those are ones I am concerned about,” he said.

The hours have been unrelenting, said Harrison. “The pace in which we are working does not slow down and has not slowed down for the better part of 18 months, and now we’re ramping up again,” she said, referring to the latest surge fueled by the delta variant.

In the CDC survey, public health workers who said they were unable to take time off from work were nearly twice as likely as others to experience adverse mental health conditions.

However, of those saying they were unable to take time off, fewer than 20% said it was because their employer didn’t allow them to. They were much more likely to say they didn’t take time off out of feelings of guilt, because there was no one to take their place or because they worried about work building up in their absence.

Harrison said overworking is a common problem in public health and one reason that her agency is now trying to insist that employees schedule time off. “I’m saying at the very least, everyone needs to take a full week off, with no emails and no phone calls, to get away from this for a minute,” she said.

‘I’m Worried About Them’

Public health officials say other factors during the pandemic have taken a toll.

Many workers had to shift away from usual jobs and schedules during the pandemic’s early days, and then had to scramble to find personal protective gear, ramp up contact tracing of people infected with the virus or help those experiencing homelessness quarantine after testing positive.

Often that meant having to learn new skills or work on unfamiliar teams, said Dennis Worsham, interim director of public health for Seattle and surrounding King County, Washington state. It also meant, he said, seeing backsliding in other areas they had devoted themselves to.

“Our syphilis rates are just the highest I’ve ever seen them,” Worsham said. “Because we had to move contact tracers away from STDs to COVID, things just got undone.”

Those retreats are hard to bear, Worsham said, as is the frustration of seeing public health directives such as masking and getting vaccinated hit resistance. Even though King County’s vaccination rate of 67% is among the highest in the state and nearly 20 percentage points higher than the national average, Worsham said, it’s exasperating to his staff that it’s not greater. 

“Here we have a tool that will save lives and we have 700,000 still unvaccinated with 400,000 of them eligible,” he said. “That’s where this fatigue comes in and we say to ourselves, ‘What more can we do?’”

Worsham said fortifying his staff is one of his primary priorities. But that’s hard to address, he added, as the pandemic persists and other emergencies arise. “On top of COVID we had that heat spell, and gun violence is off the chain now,” he said.

And now, COVID-19 case counts are again on the rise, meaning no respite for Worsham’s exhausted staff.

“Our workforce is hurting and yet there is the delta variant and so many other crises out there. How do you handle that?” he asked. “I don’t know. I’m worried about them. I’m really worried about them.”

Stateline, an initiative of The Pew Charitable Trusts.