As covid-19 raged, roughly 4,000 highly skilled epidemiologists, communication specialists, and public health nurses were hired by a nonprofit tied to the Centers for Disease Control and Prevention to plug the holes at battered public health departments on the front lines.

But over the past few months, the majority of the CDC Foundation’s contracts for those public health workers at local and state departments have ended as the group has spent nearly all of its almost $289 million in covid relief funding. The CDC Foundation, an independent nonprofit that supports the CDC’s work, anticipates that no more than about 800 of its 4,000 hires will ultimately staff those jurisdictions, spokesperson Pierce Nelson said.

That has left many local and state health departments facing staffing shortages as the nation eyes a possible winter uptick in covid cases and grapples with the ongoing threat of monkeypox, exploding caseloads of sexually transmitted infections, and other public health issues.

The public health workforce in the U.S. has been underfunded for decades — just before the start of the pandemic, only 28% of local health departments had an epidemiologist or statistician, a 2020 Associated Press-KHN investigation found. Then, after the pandemic began, public health officials left in droves as they were lambasted for instituting covid rules, blamed for the economic downturn, and grappled with burnout.

And even if funding were available to retain all 4,000 foundation employees, that would not have met public health staffing needs, according to new research in the Journal of Public Health Management and Practice. The research says at least 80,000 new employees are required for state and local public health departments to implement the minimum package of public health services.

However, the funding for the foundation jobs was always time-limited because it was intended to help the emergency response to covid. And although the American public’s covid concerns have waned, public health experts warn this is yet another example of the failure to properly fund the public health sector with annual, guaranteed money — leaving the country unable to prevent and properly fight outbreaks.

“So the boom-and-the-bust cycle continues despite losing a million American lives to covid,” said Brian Castrucci, who co-authored the report and heads the de Beaumont Foundation, which advocates for increasing support for the nation’s public health. “How many American deaths is it going to take until we fix this problem?”

Unlike the thousands of inexperienced contact tracers hired to follow up with covid patients to stem the spread amid the surge, this CDC Foundation workforce typically had public health expertise that also could fill preexisting gaps. The foundation’s head, Dr. Judy Monroe, said local and state officials loved the foundation’s ability to cut through hiring red tape, telling her “it was like the cavalry showed up.”

In Chicago, CDC Foundation employees made up about as much as a tenth of the city’s public health workforce, said Dr. Allison Arwady, commissioner of the city’s public health department. Although she got 26 of those 66 employees extended into December, she said it’ll hurt to lose the rest. They’ve contributed to everything from public health nursing to communicating the latest guidance about the pandemic to Chicagoans.

Cayenne Levorse, a CDC Foundation leader who helped organize the foundation’s response in Ohio until her contract ended in October, said her 20 employees had to set down not only covid projects but also helping local health departments track cancer clusters, rural health disparities, and environmental health problems.

“Those jobs are just sitting there, all that work left unfinished,” she said.

Five people hired for CDC Foundation covid contracts told KHN they were under the impression their contracts would likely be extended or they would be hired by local or state governments receiving a flood of covid dollars. Only one of them had a contract as of Nov. 8.

Senior epidemiologist Katie Schenk, who has a doctorate in public health, did covid surveillance for the CDC Foundation at the Illinois and Washington, D.C., health departments. Both contracts ran out, and she was left without a job this summer.

“How do you explain that there is no funding for employment in our field when there is clearly so much work to be done?” she asked. “It’s to the detriment of the public health system, which is shedding staff like there’s no tomorrow.”

Sometime in November, state and local health officials are expecting $3 billion in covid relief money targeted at buttressing the public health workforce. But that funding is coming after most of the CDC Foundation contracts have expired and those employees have moved on with their lives.

Although that sum is substantial and will help close the 80,000-worker gap, many public health officials and experts stressed that the cash is short-term and slated to last five years — which can make positions harder to fill as candidates seek job stability. It also is divided among 50 states, U.S. territories, and multiple large health departments. And some state and local officials, such as those in Missouri and Michigan, have refused to spend covid dollars on public health departments amid the backlash against the pandemic response.

State and local governments sometimes have caps on hiring full-time employees even if federal money is available to do so, Monroe said. Some localities have pay freezes or are not willing to spend more on health officials than on other government employees, making highly skilled workers such as epidemiologists harder to hire, she said. And the CDC Foundation salaries and benefits were sometimes better than what is available at local and state-level jobs, Monroe said. Many of the foundation workers could face a pay cut if they wanted to stay on with the local departments.

“You certainly don’t go into public health to get rich,” said epidemiologist Susan Knoll, who took a private-sector job as a health consultant after working for the CDC Foundation in Ohio. “You get a grant-funded job. And then you’re always looking for another job.”

That’s “the reality of how we fund public health in this country,” said Chrissie Juliano, executive director of the Big Cities Health Coalition.

“We ramp up, and we ramp down, and we don’t think about routine work,” she said. “We should not as a field be losing qualified people who are committed to working in public health. Those are the people who need to be saved.”

At least 38,000 public health jobs at the state and local level were lost from the 2008 recession through 2019. Then covid hit, and 1 in 5 Americans lost a local public health leader amid the political backlash of the first years of the pandemic, a 2021 AP–KHN investigation found.

Some of the remaining workforce is eyeing the door. The director of North Carolina’s Granville Vance Public Health department, Lisa Macon Harrison, said that even after instituting flexible benefits, she’s seeing 15% to 20% turnover, which she blames on burnout.

Levorse noted that epidemiologists and other staffers with advanced degrees have student loans to pay off and worry about losing health insurance each time a grant runs out.

The lack of a steady source of money from year to year is jeopardizing health department programs, Chicago’s Arwady said. She estimates the city will lose 86% of its current grant funding in two years, putting wastewater tracking, some of her department’s IT staff, and community-based outreach on the possible chopping block.

“We’re not going to be able to do half a dozen things that the city of Chicago clearly expects we should be able to do. Forget ‘Can I bring vaccine to your house?’ It’s ‘Can I even stand up, like, a vaccine clinic in your neighborhood?’” she said. “It’s that level of how far backwards I’m afraid we’re going to slide.”

Harrison said she’s seen this all before: A flood of funding for pandemic preparedness came after 9/11, and then the money for staffing went away, leaving departments flat-footed for covid.

Castrucci, of the de Beaumont Foundation, rued how the current funding structure ensures that the public health sector, which exists to prevent outbreaks and disease, won’t be given the staff to do so until an emergency arrives.

“You’re basically saying, ‘We will wait for the fire to burn until we hire the firefighters,’” he said.

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