By Anke Richter and Denise Santiago

Abstract

The Strategy for Homeland Security stresses the need for a robust public health component to respond to and recover from a range of emergencies. However, dire problems with the current public health manpower infrastructure have been reported for more than fifteen years and continue to be a problem. Bioterrorism funding can not be used to rectify manpower issues since it is temporary. We focus on Union County, New Jersey to determine baseline staffing requirements to conduct routine public health functions as well as performing critical tasks to support the infrastructure for bioterrorism preparedness. Only if the infrastructure is sustainable can any level of public health preparedness be maintained, including the capability to mount, deploy, train, and manage a response during a crisis. Optimistically, Union County is staffed at sixty-eight percent of the needed manpower to fulfill either state/federal health objectives or bio preparedness functions. While these results are specific to Union County, the methodology for quantifying the gaps is applicable to other counties and states. Such calculations provide a useful framework for advocating for additional resources from policy makers and political stakeholders. It is imperative that the capacity of the public health infrastructure is increased as a homeland security priority. Federal and state spending priorities must be re-aligned for public health to become a partner in the mission of homeland security.

Introduction

The role of public health at the national, federal, state and local level has become an important component of the Department of Homeland Security (DHS). Homeland Security has elevated public health personnel to first-responder status. However, public health has not received sustained funding to address the new directives and tasks it has been mandated to perform. Congress passed two landmark bills, the Public Health Threats and Emergencies Act of 2000 (PL-106-505) and the Public Health Security and Bioterrorism Act of 2002 (PL-107-288), that directed approximately ninety-nine million dollars to rebuilding public health capacities. ¹ While the additional funding was helpful in initiating bioterrorism planning, the funds were only temporary. Therefore, they could only address changes in tools, hardware, communications, and similar items but not fundamental personnel issues. This funding strategy relied on the assumption that public health has a fully functional infrastructure that can simply be refocused and aimed in new directions. However, all evidence points to the contrary; public health infrastructure has been cut to a point where most health agencies are barely staffed to operate during a normal workday. ² Questions arise whether public health departments have the requisite manpower to perform the duties required of them – from basic functions of public health to managing, coordinating, and deploying bioterrorism emergency surge responses. These are not the manpower issues for solving surge-capacity limitations, but rather manpower issues for the basic public health functions and critical planning, organization, and infrastructure development supporting bioterrorism preparedness. These are not recent developments, but while the gaps have been highlighted with ensuing dire predictions, efforts to quantify these workforce gaps are missing. ³

The problems and perils associated with the current state of the public health infrastructure have been the subject of many reports and publications for well over fifteen years. A 1988 report by the Institutes of Medicine (IOM) warned of the deteriorating public health workforce. ⁴ In a 2002 follow up report, the IOM felt that little improvement had been made since the first report. ⁵ In 2001, the Centers for Disease Control and Prevention (CDC) prepared a report for a Congressional appropriations committee revealing that the public health community was still structurally weak in nearly every area and there were critical gaps in workforce capacity and competency. ⁶ Other studies conducted by prominent public health associations – the National Association of County and City Health Officials (NACCHO) and the Association of State and Territorial Health Officials (ASTHO) – supported these findings. In October 2001, NACCHO conducted a nationwide study that highlighted current infrastructure deficiencies by identifying the workforce duties and compositions of local health agencies and in 2004 reported that the lack of public health workers constitutes a crisis for national public health preparedness. ⁷

In addition, public health workforce studies reveal infrastructure shortages due to budgetary neglect and an aging workforce. Local health agencies (LHAs) have been hit hard with up to forty-five percent of staff approaching retirement, vacancy rates as high as twenty percent, and employee turnover rates as high as fourteen percent. ⁸ The closest attempt to quantify the extent of the workforce shortage was a 2004 study by Kristine Gebbie who described the scope and content of work done by the public health workforce in the field. ⁹

Despite the plethora of reports, there have been no published efforts to determine optimal workforce staffing levels needed within a community to accomplish the public health and bioterrorism preparedness mandates. It is essential that stakeholders become aware of the actual, rather than the perceived, day-to-day functions of public health. In addition to the workload required to meet basic public health mandates, it is also necessary to assess the impact of the bioterrorism preparedness mandates in the daily functioning of LHAs. In order to effectively advocate for supplemental funding from state legislators and other key political stakeholders, it is necessary to quantify the number of personnel needed for baseline functioning. This article develops an empirical method to simply and transparently determine workforce requirements. The resource requirements can then be used to develop realistic, defensible funding targets.

This article details the methodology, including detailed calculations and assumptions, for one example: Union County, New Jersey (NJ). The staffing requirements presented here are applicable only to Union County (and potentially other counties that have a similar population and public health structure). However, the framework used to estimate manpower requirements will be applicable to other counties and states in their own assessment of local public health infrastructures. The proposed estimation method (shown in Figure 1) can easily be modified to reflect the demographics and circumstances of other counties, enabling them to establish clear staffing needs and funding requests that will be compelling to their stakeholders. Investments in the public health infrastructure serve a dual purpose: improving the delivery of health services at the local level and improving the response capability of public health as a partner with other first responders.

Figure 1: Method for Workforce Estimation

Union County, New Jersey

Union County has a population of 522,541 individuals in 100 square miles. It is home to the Elizabeth Port (a critical part of the port of New York/New Jersey), major railroads and highways (including the New Jersey Transit Railroad System, the New Jersey Turnpike, and the Garden State Parkway), and the Newark International Airport. Surrounding the county is the East Coast’s largest petroleum port, the largest auto port, and Newark, the largest city in New Jersey and a major international airport hub. These illustrate the county’s target-rich critical infrastructure and opportunities for potential exposure to natural or man made biological threats.

Table 1 provides base year 2000 Census information in Union County. ¹⁰ Almost fourteen percent of the population is over age sixty-five. Approximately 8.4% of the population lives below 200% of the poverty guideline ($31,340). The Union County demographics in Table 1 are used to calculate the target segments of the population for specific public health services. This is the basis for the workload calculations; it is an underestimate of the true workload since there is a significant undocumented foreign population living within the community, but it is the most defensible estimate.

Table 1: Demographics¹ of Union County, New Jersey (2000 Census)

(Total Population: 522,541)	N	N ≤ 200% of Poverty2
Sex
Male	251,372	30,165
Female	271,169	32,540
Reportable LHER3 Categories by Age and Gender
Children ≤ 5 years of age	18,702	2,244
Children ≤ 2 years of age	14,576	1,749
Teenagers 15 – 19 years of age	31,451	3,774
Females 15 – 64 years of age	173,727	20,847
Females ≤ 20 years of age	35,776	4,293
Females ≥ 40 years of age	145,235	17,428
Males ≥ 40 years of age	146,893	17,627
Adults 22 – 61 years of age	285,766	34,292
Adults ≥ 40 years of age	146,893	17,627
Adults ≥ 50 years of age	212,651	25,518
Adults ≥ 65 years of age	117,976	14,157

There are significant manpower issues in public health in Union County and in New Jersey in general. For Union County’s population of 522,541, there are only forty-seven public health employees within ten local health departments. This represents a ratio of nine public health workers per 100,000 population. Nationally, the ratio of public health workers was 158 per 100,000 in 2000. ¹¹ Based on this statistic, Union County is well below the national average in the size of its public health workforce.

A graphic example of the workload dilemma was witnessed in April 2005 when New Jersey hosted the congressionally-mandated international terrorism exercise known as TOPOFF3 (T3). T3 was designed to identify vulnerabilities in the State of New Jersey by exercising the plans, policies, procedures, systems, and facilities of federal, state, and county/local response organizations against a biological attack. The scenario was a bioterrorist attack using pneumonic plague as the agent. Officially, the public health agencies met the expectations of the week-long exercise. However, in reality, the manpower needs were filled by mobilizing “notional” resources, interpreted as using imaginary public health workers to meet the expectations of the exercise. One epidemiologist was expected to conduct contact disease case investigations for more than 19,000 victims and participate in all public health/law enforcement responses. Clearly more manpower was needed.

In addition, the Local Information Network Communication System (LINCS) agency (a division of the county-wide public health team) was responsible for opening a Points of Distribution (POD) to provide mass prophylaxis for the entire county. Using a pharmaceutical distribution-staffing model developed by the Weil/Cornell Medical School, the Bioterrorism and Epidemic Outbreak Response Model (BERM), ¹² we can predict staffing needs for POD to provide prophylaxis for Union County. LHAs are mandated to vaccinate their entire jurisdiction within ten days. ¹³ To meet this target, BERM estimates that a staff of 1,232, each day, is necessary to accomplish the task. The Public Health Workforce Enumeration 2000 credits New Jersey with a local public health workforce of 2,244 people. Union County would need to utilize fifty-five percent of the total local public health workforce in the state to meet the target timetable. Clearly there is a need for a large surge capacity. But even supposing volunteers are drawn from local Community Emergency Response (CERT) and Medical Reserve Corps (MRC) teams, or provided by other states, public health would be responsible for the monumental tasks of set-up, coordination, and management of these individuals. When the response is to a real epidemic and no longer a practice exercise, it will be necessary to find, recruit, train, and organize thousands of real people to replace the “notional” staff positions used during the exercises. In point of fact, New Jersey does not have enough manpower or infrastructure to meet its needs as demonstrated by the exercise, but officials ignore this lesson.

The New Jersey Department of Health and Senior Services (NJDHSS) sets policy and standards for statewide public health programs; regulates and licenses health care facilities, practitioners and public health professionals; maintains a BioSafety Level 3 (BSL-3) laboratory; administers various grants for public health programs; and collects and analyzes communicable disease data. In New Jersey, a local health agency (LHA) is defined as a county, regional, municipal or other governmental agency organized for the purpose of providing health services, administered by a full-time health officer and conducting a public health program pursuant to law. ¹⁴ Public health services are provided almost exclusively at the local level, yet fifty-five percent of the entire New Jersey public health workforce is employed by the NJDHSS. ¹⁵

New Jersey LHAs are established by state statute and local ordinance and operate under a “home rule” format that grants municipalities partial autonomy of self-government. One problem with home rule is that local health agencies serve population bases that are too small to financially support the level of service required by federal and state mandates. To solve this problem, many agencies resort to contracted labor, part-time positions or employees being utilized in a dual-role capacity. The result is a pool of public health personnel being shared by multiple agencies or across disciplines. This works passably well when there is no undue stress on the system, but is easily and quickly overwhelmed with even small-scale events. In an emergency, part-time employees will be expected to discharge full-time duties in more than one municipality, simultaneously.

In 1997, New Jersey was awarded approximately sixteen million dollars to enhance the public health infrastructure at the local level for bioterrorism preparedness. The NJDHSS established twenty-two LINCS agencies, strategically positioning them in twenty counties and within two core cities. Over time, LINCS has evolved, as a matter of convenience to the NJDHSS, into the lead public health agency in every county throughout the state. NJDHSS used the existing LINCS program to channel new homeland security responsibilities and bioterrorism money to the local level. This evolution occurred without considering the existing legal structure and authority of LINCS employees within their counties. Today, the goal and vision of LINCS is to facilitate a regional response by enhancing the public health infrastructure while also being asked to fill in the gaps of providing essential health services. ¹⁶

The new response structures, established with the creation of LINCS, duplicated and complicated an existing public health communication system. Public health communications must flow to and from a newly established health command center (HCC) instead of the traditional New Jersey Office of Emergency Management (NJOEM). The HCC creates a parallel public health silo alongside NJOEM. Further complicating this issue is another NJDHSS creation, the regional Medical Coordinating Center (MCC). At this point, it is unclear what role the MCCs will play. However, they are worrisome in that there will be a third communication silo and responders will have to repeat messages three times to assure that information reaches all required receptors. This greatly increases the reporting burden associated with all bioterrorism-related tasks.

New Jersey has two significant public health mandates that provide LHAs operational direction: the Local Core Capacity for Bioterrorism Preparedness Grant (also called Attachment C) and Public Health Practice Standards for Local Boards of Health (also called Practice Standards). To conduct the manpower analysis to determine the minimum staffing level required by the bioterrorism preparedness goals stated in the bioterrorism grant and the public health mandates of the NJDHSS, a state-sanctioned manpower formula, the NJSDHSS formula “Estimating Registered Environmental Health Staffing Needs for Local Health Departments,” ¹⁷ was used. This tool was originally developed to determine the number of staff required to handle the workload for the registered environmental health staff. However, its modification for use with the other core positions is straightforward. The four core public health positions examined in this article are:

1. Public Health Nurse.
   A licensed professional who conducts the personal health programs of the LHA. This individual is required to have a master’s degree in public health nursing.
2. Health Educator.
   The Certified Health Educator Specialist (CHES) conducts health education programs designed to encourage lifestyle modifications that will eliminate or reduce risk factors of chronic diseases. This individual is required to have a master’s degree.
3. Registered Environmental Health Specialist (REHS).
   A licensed professional who conducts the environmental program, including investigations and enforcement of applicable laws and statutes.
4. Epidemiologist (EPI).
   A professional who investigates reportable disease cases and conducts infectious disease surveillance. This individual is required to have a master’s degree in public health with two years’ experience.

The staffing level required to fulfill the mandates is compared to the actual staffing level with Union County, including all the LHAs and the LINCs agency operating within the county.

Workload Estimates for Public Health Mandates

Public Health Practice Standards of Performance for Local Boards of Health, promulgated by the NJDHSS, were adopted by the state Public Health Council as the model system to provide local public health activities. The standards are intended to “assure the provision of a modern and manageable array of public health services to all citizens of New Jersey” ¹⁸ and are enforced by the LHAs. Each of the core staff positions has corresponding responsibilities enumerated in the Practice Standards; these mandates are imposed on every LHA regardless of population base or staffing levels. The core component of the Practice Standards includes disease screening, vaccinations, disease monitoring, inspections (food establishments, pools, camps, etc.), educational classes and other disease prevention activities, as well as performance monitoring and evaluation of local programming and services. LHAs are expected to conduct community surveys, health risk assessments, and resource inventories as well as form public health partnerships with outside agencies and disciplines.

To assess the workload associated with these Practice Standards in Union County, the first step was to determine the population served by the LHAs. We used a conservative approach and limited population served to individuals living below the 200% poverty line. Families above the 200% of poverty guideline will be more likely to have health insurance or have regular access to health care and are therefore less likely to need or utilize public health clinics. This calculation represents a lower limit on services requested since some services, such as cervical cancer screening services, are well established and accepted by individuals of all income categories. In addition, although the 200% of poverty guideline was also employed in the Older Adult Health Services target estimates, seniors of all income categories typically utilize these services. These calculations underestimate the actual level of need ensuring that a conservative (minimum) estimate of additional workforce requirements is calculated.

Once the target population size was determined, the target activities were calculated using the Adult Health Services Guidelines, published by NJDHSS. ¹⁹ These guidelines are performance objectives and provide detailed targets for public health services. For example, the cancer education targets are five percent of women aged fifteen to sixty-four for breast cancer and three percent of both sexes for colo-rectal cancer; eighty-five percent of children under two years of age are targeted for screening for lead poisoning. The guidelines form the basis of the Local Health Evaluation Report (LHER) that each LHA must submit to NJDHSS every year. The LHER is a very detailed assessment of a number of core tasks that forms the basis of the Practice Standards. Appendix A shows the workload for the epidemiologist, health educator/risk communicator (HERC), public health nurse, and registered environmental health specialist (REHS) positions.

When the delivered services (as reported in the LHER) are compared to the targeted services (as specified by the Practice Standards) there are numerous gaps that become apparent, especially in health education and public health nursing (data available from the corresponding author). To quantify the manpower needs to conduct the minimum service levels identified by NJDHSS we apply the formula on the State Health Department website that enables health officers and Board of Health members to estimate the Registered Environmental Health Specialist manpower needs. ²⁰

As detailed in Appendix B, we estimate an annual number of hours available for fieldwork per year to be 1,313 hours for the epidemiologist, public health nurse and HERC, and 983 hours for REHS. These two numbers differ because travel is a significant portion of the REHS’ workday, since this person inspects all food service locations (restaurants), camps, public pools, public health nuisance reports, rabies, and zoonosis control. The other positions have limited expected travel time. Dividing the number of hours needed to meet target performance levels by the hours-per-manpower year, we can determine the optimal manpower level for each position.

Tables 2 summarizes the estimated manpower needs of core public health positions to comply with the New Jersey Public Health Practice Standards. The manpower estimates for the four core positions reveal the need for three epidemiologists, three health educators, seven public health nurses and ten registered environmental health specialists to comply with New Jersey Practice Standards. These are conservative estimates since we are restricting targeting to residents living at 200% of the poverty level or less. If the income restriction is removed, the manpower deficit would increase dramatically. Providing just this minimum level of staffing would significantly increase the public health workforce in the county. This would permit the department to be in compliance with official mandates for day-to-day functioning. Even with the additional personnel, the county would still be well below the national average of 158 public health workers per one hundred thousand residents.

Table 2: Manpower Requirements and Deficits for Compliance with Public Health Mandates

Staff Position	Epidemiologist	Public Health Nurse	HERC1	REHS2
Personnel Required to Complete Workload	3	5	28	27
Available Personnel	0	2	21	17
Manpower Deficit	3	3	7	10

Workload Estimates for Bioterrorism Preparedness Mandates

The National Strategy for Homeland Security was developed in July 2002 as a directive for local, state and federal agencies in their planning efforts for protecting the homeland. ²¹ When the strategy was unveiled it made clear that public health sectors are to be involved with:

• protection of the food, water and public health critical infrastructures,
• surveillance for defending against catastrophic threats, and
• quick and effective response with other first responders. ²²

On December 17, 2003, President Bush issued Homeland Security Presidential Directive 8 (HSPD-8), National Preparedness, which establishes policies, procedures and goals to strengthen the preparedness of the United States to prevent, deter, respond to, and recover from terrorist attacks, major disasters, and other emergencies. HSPD-8 introduced the concept of “all hazards preparedness” based on the existence of plans, procedures, policies, training, and equipment to maximize the effectiveness of a multi-discipline response effort in the event of any type of emergency. ²³ The all hazards preparedness approach requires the underlying infrastructure to be solid enough to support all emergency situations.

The Public Health Security and Bioterrorism Act of 2002 allocated close to one billion dollars to improve state and local public health capabilities. ²⁴ CDC used the money to establish Public Health Emergency Preparedness “Cooperative Agreements” to aid state and local governments in their bioterrorism preparedness and planning efforts. As of 2005, the all hazards approach, stressing nine preparedness goals that measure public health system response parameters, ²⁵ was adopted in the Cooperative Agreements.

The Local Core Capacity Infrastructure for Bioterrorism Grant, aka Attachment C, is the New Jersey version of the CDC Preparedness Goal Grant with additional reporting requirements. The bioterrorism preparedness mandates for public health, specific to the core LINCS staff in Union County, requires compliance with the nine CDC preparedness goals. To better understand the workforce requirements of these mandates (presented in Table 3), they are summarized below:

Prevent:
(1) Increase the use and development of interventions known to prevent human illness from chemical, biological, radiological agents, and naturally occurring health threats.

(2) Decrease the time needed to classify health events as terrorism or naturally occurring in partnership with other agencies.

Detect/Report:
(3) Decrease the time needed to detect and report chemical, biological, radiological agents in tissue, food or environmental samples that cause threats to the public’s health.

(4) Improve the timeliness and accuracy of information regarding threats to the public’s health as reported by clinicians and through electronic early-event detection, in real time, to those who need to know.

Investigate:
(5) Decrease the time to identify causes, risk factors, and appropriate interventions for those affected by threats to the public’s health.

Control:
(6) Decrease the time needed to provide countermeasures and health guidance to those affected by threats to the public’s health.

Recover:
(7) Decrease the time needed to restore health services and environmental safety to pre-event levels.

(8) Increase the long-term follow-up provided to those affected by threats to the public’s health.

Improve:
(9) Decrease the time needed to implement recommendations from after-action reports following threats to the public’s health. ²⁶

There are many quarterly grant reporting requirements. In addition to the general reporting requirements, there are additional reporting requirements required by the NJDHSS. A conservative estimate of the “reporting-only” manpower drain is one full-time equivalent (FTE). Almost twenty percent of the county’s preparedness effort is devoted to satisfying NJDHSS oversight. This reporting time is not accounted for in these manpower estimates, to ensure that we use the most conservative approach.

Table 3 details the time estimate, evaluated by each core position, needed to complete each of Preparedness Goals and over seventy-eight required critical tasks in the Bioterrorism Preparedness Grant. To obtain these estimates, the Local Core Capacity Infrastructure for Bioterrorism Preparedness grant was reviewed by each core position and each critical task. Registered environmental health specialists do not have any specific additional duties associated with bioterrorism preparedness. Since most tasks require local health agency cooperation, a local time estimate was included, but is not specifically assigned to any of the four positions. A LINCS coordinator role was included in this analysis. The current grant funds one epidemiologist, one public health nurse, one LINCS coordinator, and one health education/risk communication specialist (HERC), as well as a government public health partnership coordinator (GPHP) and an information technology specialist (IT).

Table 3 shows that given the workload requirements, the grant-funded positions are not adequate. One more epidemiologist, one more HERC, and one more LINCS coordinator are required. In addition, successful completion of each of the grant’s critical tasks requires a significant local commitment and substantial cooperation, necessitating the addition of three FTEs at the local level.

Table 3: Estimating Manpower Requirements for Compliance with Bioterrorism Preparedness⁵

Preparedness Goals	Local Health Duties3	Epi-demiologist	Public Health Nurse	LINCS1 Coordinator	HERC2
1. A. All Hazards Planning	884	109	109	109	109
2. A. Information Collection/ Threat Recognition	40	364	7	388	364
2. B. Hazard Vulnerability Analysis	20	0	7	7	30
4. A. Health Intelligence Integration/ Analysis	385	962	234	7	982
5. A. Public Health Epidemiological Investigation	280	153	153	28	153
6. A. Emergency Response Communications	0	24	24	1,113	133
6. B. Emergency Public Information	30	64	36	47	162
6. C. Worker Health Safety	120	72	21	7	72
6. D. Isolation and Quarantine	2,120	52	52	52	60
6. E. Mass Prophylaxis/Vaccination	70	205	205	205	331
6. F. Medical & Pub Health Surge	0	46	102	18	18
7. A. Economic & Community Recovery	0	0	0	21	84
8. Recovery	0	32	4	14	32
Total Hours (Annual)	3,949	2,083	947	2,016	2,530
Manpower Needed (N)4	3	2	1	2	2
Current Staff (N)	0	1	1	1	1
Total Deficit	3	1	0	1	1

Conclusion

The mantras of “all hazard preparedness” and “dual-use functionality” cannot overcome the basic problem of insufficient manpower. All hazards preparedness begins by strengthening the response elements common to a spectrum of emergency situations. Training and equipping an inadequate workforce does little to improve preparedness. Dual-use functionality assumes that there were sufficient resources for “single” use.

Table 4 is a summary of the total manpower deficit for public health professionals in Union County, New Jersey. To be in compliance with New Jersey practice standards and conform to the bioterrorism preparedness goals, twenty-nine additional staff members must be added to the public health workforce. This is a very conservative estimate, restricting the service population to documented residents living at or below the 200% of poverty line. At its most optimistic, Union County is currently staffed at sixty-eight percent of the needed public health workforce.

Table 4: Summary of Manpower Requirements for Compliance with Practice Standards and Bioterrorism Preparedness in Union County, New Jersey

Position	Workload Hours Practice Standards	Workload Hours BT1	Manpower Needed	Current Staff (2006)	Deficit
Epidemiology	3,867	2,083	5	1	4
Health Education/Risk Communication	6,155	2,530	7	3	4
Public Health Nurse	36,402	947	29	22	7
Registered Environmental Health Specialist	26,819	…	27	17	10
LHA2 Support for Bioterrorism Grant (unspecified labor category)	…	3,949	3	0	3
LINCS Coordinator	…	2,016	2	1	1
Total			73	44	29

Susan Klitzman and Nicholas Freudenberg suggest that a standing workforce, with not only the capacity to provide recognized health services but a reserve capacity as well, is needed to effectively meet the challenges of a large-scale emergency. ²⁷ Clearly there are not enough funded positions even to provide the absolute minimum level of services required by the NJDHSS. In the 2004 edition of America’s Health: State Health Rankings; A Call to Action for People and Their Communities, New Jersey ranked a dismal forty-first out of fifty in per capita spending on public health. ²⁸ As if this ranking was not bad enough, between 2003 and 2004 New Jersey witnessed an eleven percent decrease in its public health budget. ²⁹In 2004, New Jersey fell to forty-eighth, decreasing spending from thirty-two to fourteen dollars per person. ³⁰ Public health will have a more difficult time meeting New Jersey mandated bioterrorism efforts and traditional health services at the local level as the state’s 2006 budget is posted with an expected decrease of 13.2%. ³¹ To close the manpower gap in Union County, in addition to not having a budget cut, an additional, sustained three million dollars per year needs to be added to the public health budget to fund and equip an additional twenty-nine full-time employees.

Clearly, these personnel are not sufficient to meet a surge in demand due to a catastrophe (natural or man-made). The additional personnel are for the critical planning and organizational development needed to orchestrate a response to a crisis. If the basic infrastructure is in disarray, the system will be non-functional even if supplemental (federal or state) resources are available to handle surge requirements. The system will not be able to quickly deploy the additional resources to good effect if the basic structures are not in place and operational.

This study has shown that the Union County New Jersey Public Health infrastructure is inadequate, from a manpower standpoint, to meet either state and federal health objectives or biopreparedness functions. The methodology detailed herein permits quantification, in terms of both the numbers of positions and the funding levels, to create a sustainable infrastructure. On September 13, 2006, the New Jersey legislature’s Joint Committee on Government Consolidation and Shared Services requested this exact type of information from the NJSDHSS. ³² The assistant commissioner of health was asked, “Are we able to compare what’s going on in terms of cost and number of personnel by municipality?” The commissioner replied by saying “I don’t think we’re sophisticated enough…I don’t think we have that type of formula.” ³³ This study and the methodology discussed here answers that question and can provide critical insight to key stakeholders in New Jersey in an effort to obtain needed funding and positions.

Given the reports on the state of public health throughout the U.S., we believe similar questions are being asked in many other states. Other public health departments needing a simple, transparent methodology to estimate the manpower required to support basic public health and bioterrorism preparedness mandates can apply the methods described in this article.

The Strategy for Homeland Security stresses the need for a robust public health component to respond to and recover from a range of emergencies from the biological dangers posed by an influenza pandemic to the use of toxic agents in a terrorist attack. It calls for public health to become an “indispensable pillar of our national security framework.” ³⁴ This Strategy relies on the same infrastructure that has proven incapable of meeting U.S. Department of Health and Human Services National Health objectives. Public health resources need to be aligned with the new planning goals. If manpower infrastructure capacity is not the first step in public health preparedness, each succeeding step will be addressed by taking resources from other mandated programs. Trade-offs between mandated programs will be necessary. It will not be possible to support all programs, resulting in a tug-of-war of daily priorities without concern for the actual service levels of any program. Investments in manpower capacity should be targeted according to population-based health objectives if we are to maximize the dual domestic preparedness/public health uses. Federal and state spending priorities need to be re-aligned for public health to become a partner in the mission of homeland security. This study argues that the goal of sustainable funding for public health begins with an accurate measure of the capacities of the system in relation to the demands placed upon it. Without such a measure, public health will continue to fail in its primary functions and lack the capacity to meet homeland security goals.

Denise Santiago’s professional career spans eighteen years of public health administration within New Jersey. As county health officer for the Office of Emergency Management in New Jersey, she is responsible for administering the Local Core Capacity Infrastructure for Bioterrorism Preparedness and Readiness Grant for Union County, New Jersey. Ms. Santiago has a university certification in Emergency Management, acquired the Professional Development Series (PDS) Certificate from the Federal Emergency Management Agency, and recently completed a master’s degree in homeland security studies at the Naval Postgraduate School’s Center for Homeland Defense and Security in Monterey, CA.

Anke Richter is an associate professor at the Defense Resources Management Institute at the Naval Postgraduate School in Monterey, CA. Her research interests include resource allocation for epidemic control, disease modeling and economic impact assessment, and bioterrorism. She obtained her Ph.D. in operations research from Stanford University.

Appendix A

Developing Workload Estimates for Public Health Mandates

In order to develop workload estimates for each of the core positions (epidemiologist, public health nurse, registered environmental specialist, and health educator/risk communicator), the target activities were extracted from the Adult Health Services Guidelines published by the NJDHSS. Time estimates were developed for each activity.

Table A1 details the results of the manpower estimates for the epidemiologist position. There are no local epidemiologists in the LHAs. There is only one epidemiologist employed and assigned to Union County LINCS. Therefore, all investigations were conducted by staff other than an epidemiologist.

Table A2 shows the results of the manpower estimates for the health education position. Using the LHER reported number of clients served, divided by the number of health education sessions conducted (also listed in the LHER report), yields a result of fifteen clients per session. The number of sessions conducted divided by the available health education man-hours yields a time frame of 6.3 hours per session. Based on experience, this is a reasonable figure to use for planning purposes when class preparation time, class time, outreach, follow-up, and reporting are considered as components making up one session. Health education population targets are based on Adult Health Services Guidelines, divided by fifteen clients per session, multiplied by 6.3 hours per session. This result, divided by 1,313 work hours per year, yields the estimated number of Health Educators needed to reach objectives.

Table A3 details the results of the manpower estimates for the public health nurse. Each of the required activities is assigned an hourly rate derived from LHA experience. These time estimates are multiplied by the target population number and then divided by 1,313 hours to arrive at the full-time equivalent manpower estimate.

Table A4 shows the manpower estimates for the Registered Environmental Health Specialist (REHS). Manpower estimates are obtained by following the same procedure as in Table A3. It is interesting to note that a general rule of thumb calls for one Registered Environmental Health Specialist per population of 15,000. ³⁵ Using this ratio would result in a more serious staff deficiency.

Table A1: Epidemiology Manpower Requirements for Practice Standards Compliance

	Hours per Disease Report 1	LHER2	Hours per Activity
Target Activity
Reportable Disease Investigation
Cases	0.33	2,106	695
Follow-Up	2	966	1,932
Communicable Diseases
Sexually Transmitted Diseases (STD)
Cases	1	539	539
Follow-Up	1	539	539
Tuberculosis (TB)
Cases	0.33	64	21
Follow-up	1	141	141
Annual Required Workload Hours	3,867
Annual Hours Available3 per Epidemiologist	1,3133
Epidemiologist Required to Complete Workload Hours (N)	3
Available Epidemiologists (N)	0
Manpower Deficit Epidemiologists (N)	3

Table A2: Health Education/Risk Communications (HERC) Manpower Requirements for Practice Standards Compliance

Health Education Category	Hours per Unit1	Target Number of Sessions2	Hours per Health Education Category3
Alcohol: Target 56.5% of adult population between 22-61 years of age	6.3	538	3,389
Smoking: Target 20% of adult population between 22-61 years of age	6.3	191	1,203
Physical Fitness: Target 22% of adult population between 22-61 years of age	6.3	210	1,323
Drug Abuse: Target 36% of teenage population between 15-18 years of age	6.3	38	239
Annual Required Workload Hours			6,155
Annual Hours Available4 per HERC			1,313
HERCs Required to Complete Workload Hours (N)			5
Available HERCs (N)			2
Manpower Deficit HERCs (N)			3

Table A3: Public Health Nurse Manpower Requirements for Practice Standards Compliance

Activity	Hours per Unit 1	Target Number of Clients (N)	Hours per Activity
Maternal and Child Health
Maternal and Child Health Clinics: Those at ≤ 200% poverty	0.75	2,244	1,683
Lead Screening: 85% ≥ 2 years of age and those at ≤ 200% poverty	0.40	1,487	595
Improved Pregnancy Outcome (IPO): Females ≤ 20 years of age receiving prenatal and post partum visits and those at ≤ 200% poverty	2.25	482	1,085
Childhood Immunizations: Those at ≤ 200% poverty	0.40	2,244	898
Cancer Screening and Education
Cervical/Breast Cancer Screening: 3% of females 15-64 years of age	0.45	625	281
Prostate Cancer Screening: 5% of males ≥ 40 years and these at ≤ 200% poverty	0.54	881	476
Mammography: 50% of females ≥ 40 years and those at ≤ 200% poverty	1.10	8,714	9,585
Cancer Education	0.40	10,221	4,088
Adult Health and Diabetes
Diabetes Screening: 1% of adults ≥ 50 years	0.40	2,127	851
Diabetes Education	0.40	2,127	851
Adult Health and Cardiovascular Disease
Cardiovascular Disease Screenings: 1% of adults ≥ 50 years	0.30	2,127	638
Cardiovascular Disease Education	0.40	2,764	1,106
Older Adult Services: ≥ 65 Years of Age
Influenza and Pneumonia Vaccinations: 20% of Older Adults	0.75	16,989	12,742
Health Screenings: 1% of Older Adults	0.40	1,180	472
School Health
Public School Audits	2.50	230	575
Private and Preschool	2.50	191	478
Annual Required Workload Hours 2	36,402
Annual Hours Available per Public Health Nurse 3	1,313
Public Health Nurses Required to Complete Workload Hours (N)	28
Available Public Health Nurses (N)	21
Manpower Deficit Public Health Nurses (N)	7

Table A4: Registered Environmental Health Specialist (REHS) Manpower Requirements for Practice Standards Compliance

Workload	Hours per Unit 1	Target Number of Activities	Hours per Activity
Bathing Place
Inspection	2	83	166
Re-inspection	1	22	22
Youth Camp
Inspection	2	60	120
Re-inspection	1	15	15
Food Establishment Surveillance
Inspection	2.5	3,026	7,565
Re-inspection	2	696	1,392
Complaint	2	545	1,090
Plan review	1	151	151
Public Health Nuisance
Complaint	1	5,566	5,566
Investigation	1	5,984	5,984
Childhood Lead Poisoning
Risk assessments	2	466	932
Residences abated	8	40	320
Rabies and Zoonosis Control 2
Animal bite investigations	1	1,280	1,280
Pet shop inspection	2	9	18
Other
Schools and Institutions	2.5	230	575
Court/Enforcement action	3	541	1,623
Annual Required Workload Hours	26,819
Annual Hours Available3 per REHS	1,313
REHSs Required to Complete Workload Hours (N)	27
Available REHSs (N)	17
Manpower Deficit REHSs (N)	10

Appendix B

Formula for Estimating Core Public Health Personnel Availability for Field Work per Year

Step 1: Determine total man-hours per year.

35 work hours per week x 52 weeks = 1,820 total annual work hours

A thirty-five hour work week is used because most New Jersey government employees work an eight hour day but are not paid for an hour lunch.

Thus 40 – 5 = 35.

Step 2: Determine total man-hours per year expected to be absent. Apply standard basic government benefits package of two weeks vacation, two weeks combined sick leave, and federally mandated holidays for government workers. Training time is also explicitly accounted for in the New Jersey system.

Time-Off Category	Work Hours per Day	Total Days	Total Hours
Vacation	7	12	84
Holidays	7	13	91
Sick	7	7	49
Personal	7	2	14
Training	7	7	49
Expected time off due to absences			287

Step 3: Calculate total (net) available work hours.

1,820 total annual work hours – 287 expected time-off hours

= 1,533 total available work hours

Step 4: Determine administrative requirements (travel and office time).

4a. Office Hours: Time dedicated to office coverage, filing, reporting, and research. This affects all positions.

Office Hours b	Days	Weeks of Work per year		Office time (Hours)
1	5	44	=	220

4b. Travel Time: This is a significant component of work only for the registered environmental health specialist. This position is responsible for all inspections of restaurants, food preparation locales, camps, public pools, public health nuisance complaints, rabies, and zoonosis control.

Travel Time a	Days	Weeks of Work per year		Travel time (Hours)
1.5	5	44	=	330

Step 5: Determine field hours for core positions (Step 3 minus Step 4)

	Total Available Work Hours	Office /Travel Time (Hours)	Available Field Hours
Epidemiology a	1,533	-220	1,313
HERC a	1,533	-220	1,313
Public Health Nurse a	1,533	-220	1,313
REHS b	1,533	-550	983

Step 6: Determine annual workload hours for each core position in LHA by multiplying the hourly average of each activity by the target number of activities per year

Step 7: Determine the number of core positions needed (Step 6 ÷ Step 5)

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1. United States Congress, Senate Committee on Health, Education, Labor, and Pensions, Public Health Threats and Emergencies Act: Report (to Accompany S. 2731) (Washington, DC: U.S. G.P.O, 2000). http://purl.access.gpo.gov/GPO/LPS7343 (accessed February 4, 2006).↵
2. Stephen Flynn, America the Vulnerable: How the U.S. Has Failed to Secure the Homeland and Protect Us From Terrorism (New York, NY: HarperCollins, 2004).↵
3. Elizabeth Fee and Theodore M. Brown, “The Unfulfilled Promise of Public Health: Deja Vu all Over Again,” Health Affairs 21, no. 6 (November/December 2002): 31. http://proquest.umi.com/ (accessed February 3, 2006).↵
4. Institute of Medicine (U.S.), Committee for the Study of the Future of Public Health, The Future of Public Health (Washington, DC: National Academy Press, 1988). http://www.nap.edu/catalog/1091.html (accessed February 4, 2006).↵
5. Institute of Medicine (U.S.), Committee on Assuring the Health of the Public in the 21st Century, The Future of the Public’s Health in the 21st Century (Washington, DC: National Academies Press, 2003). http://newton.nap.edu/books/030908704X/html/ (accessed February 4, 2006).↵
6. United States Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), Public Health’s Infrastructure: A Status Report (Atlanta, GA: Centers for Disease Control and Prevention, 2001). http://www.phppo.cdc.gov/documents/phireport2%5F16.pdf (accessed February 3, 2006).↵
7. Association of State and Territorial Health Officials, State Public Health Employee Worker Shortage Report: A Civil Service Recruitment and Retention Crisis (Washington, DC: ASTHO, 2004). http://www.astho.org/pubs/Workforce-Survey-Report-2.pdf (accessed July 17, 2004).↵
8. CDC, Public Health’s Infrastructure.↵
9. Kristine M. Gebbie, The Public Health Work Force: Enumeration 2000 (Washington, DC: Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Information and Analysis, 2000).↵
10. United States Census Bureau, Census 2000 Demographic Profile Highlights (2000). http://factfinder.census.gov (accessed March 5, 2006).↵
11. Public Health Security and Bioterrorism Preparedness and Response Act of 2002, Public law 107-188 (2002), http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=107_cong_public_laws&docid=f:pub1188.107.pdf (assessed February 3, 2006).↵
12. Nathaniel Hupert and Jason Cuomo, “The Weill/Cornell Bioterrorism and Epidemic Outbreak Response Model (BERM),” (Weill Medical College of Cornell University). http://www.aha.org/aha/key_issues/disaster_readiness/resources/vaccination.html (accessed February 6, 2006).↵
13. Centers for Disease Control and Prevention (CDC), “Continuation Guidance for Cooperative Agreement on Public Health Preparedness and Response for Bioterrorism.” http://www.bt.cdc.gov/planning/continuationguidance (accessed March 5, 2006).↵
14. New Jersey Department of Health, Public Health Practice Standards of Performance for Local Boards of Health in New Jersey (2003), Chapter 52. http://www.state.nj.us/health/lh/chapter_52.pdf (accessed July 17, 2005).↵
15. Gebbie, Public Health Work Force.↵
16. CDC, “Continuation Guidance for Cooperative Agreement.”↵
17. R.J. DiNunzio, “Estimating Registered Environmental Health Specialist Staff Needs for Local Health Departments,” http://www.state.nj.us/health/lh/rehscal1.htm (accessed September 18, 2005).↵
18. New Jersey Department of Health, Public Health Practice Standards.↵
19. New Jersey Department of Health, Adult Health Services: Guidelines (Trenton, NJ: New Jersey State Department of Health, Division of Epidemiology and Disease Control, 1989).↵
20. DiNunzio, “Estimating Registered Environmental Health Specialist Staff Needs.”↵
21. United States Office of Homeland Security, National Strategy for Homeland Security (Washington, DC: Office of Homeland Security, 2002). http://purl.access.gpo.gov/GPO/LPS20641 (accessed July 17, 2005).↵
22. Ibid.↵
23. George W. Bush, Homeland Security Presidential Directive/HSPD-8: National Preparedness, Homeland Security Presidential Directive: HSPD-8 (Washington, DC: The White House, Office of the Press Secretary, 2003). http://knxup2.hsdl.org/homesec/docs/whitehouse/nps05-121803-02.pdf (accessed February 4, 2006).↵
24. Public Health Security and Bioterrorism Preparedness and Response Act of 2002.↵
25. CDC, “Continuation Guidance for Cooperative Agreement.”↵
26. Department of Health and Human Services, Cooperative Agreement Guidance for Public Health Emergency Preparedness (2005). http://www.bt.cdc.gov/planning/guidance05/pdf/annoucement.pdf (accessed February 26, 2006).↵
27. Susan Klitzman and Nicholas Freudenberg, “Implications of the World Trade Center Attack for the Public Health and Health Care Infrastructures,” American Journal of Public Health 93, no. 3 (March 2003): 400-406.↵
28. United Health Foundation, America’s Health: State Health Rankings – 2004 Edition (Minnetonka, MN: United Health Foundation, 2004). http://www.unitedhealthfoundation.org/mediakit/shrmediakit/State%20Health%202004.pdf (accessed February 4, 2006).↵
29. Ibid.↵
30. Ibid.↵
31. New Jersey Department of Treasury, Office of Management and Budget, “Health and Senior Services: Department of Health and Senior Services Overview,” in State of New Jersey Budget FY 2005-2006. (Trenton, NJ: State of New Jersey, Department of the Treasury, Office of Management and Budget, 2005). http://www.state.nj.us/treasury/omb/publications/06budget/pdf/46.pdf (accessed February 26, 2006).↵
32. http://www.njleg.state.nj.us/legislativepub/pubhear/jcgo091306.pdf.↵
33. Ibid.↵
34. Sam Nunn, “The Future of Public Health Preparedness,” Journal of Law, Medicine & Ethics 30, no. 3 (fall 2002): 202-210. http://proquest.umi.com (accessed July 17, 2005).↵
35. DiNunzio, “Estimating Registered Environmental Health Specialist Staff Needs.”↵

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