support for educational programs working well (IOM, 2004). Certainly this makes sense in light of how essential these programs could be to assuring a workforce that can better meet patients’ needs, enhance quality care, and practice in a manner that manages costs.

The Public Health Workforce

The workforce needs of the public health sector often take a back seat, though it is worth remembering that 25 of the 30 years of improvement in longevity in the United States in the twentieth century are attributed to public health improvements (Turnock, 2004).

The inadequate number and training of the nation’s public health workforce was brought vividly to national attention following September 11, the anthrax attacks of autumn 2001, and Hurricanes Katrina and Rita (Gebbie and Turnock, 2006; Lister, 2008).

Unfortunately, HRSA’s workforce training programs may at present be an undervalued asset. Public health workforce training, in particular, has dramatically declined since 2002. That year, Title VII support for public health, preventive medicine, and dental public health stood at $10.5 million, declining to under $8 million in 2006, and zeroed out in the President’s 2009 budget request. A recent IOM committee justly concluded, “the future of Title VII remains unclear” (IOM, 2007b).

In 2005, only 6 percent of local health departments were large—serving populations over 500,000—whereas 41 percent served fewer than 25,000 people. On average (median), these small departments had four professional staff (NACCHO, 2006). Of necessity these individuals must wear many hats, and not all of them fit. They inspect restaurants and other food service establishments as well as environmental health problems; track diseases and intervene in disease outbreaks; improve emergency preparedness through complicated drills and exercises; maintain vital statistics; provide health education; and even, in some cases, provide mental health care, immunizations, school health services, home health services, maternal and child health services, migrant health screenings, and many other functions for vulnerable populations and community residents at large. Finally, in rural areas they spend remarkable amounts of time driving to outlying areas of their jurisdictions. Despite federal expectations, their capacity to respond in a major emergency (“surge capacity”) is limited (GAO, 2008b).

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