Beth Heath’s biggest frustration as Madison County nurse manager is when she can’t help someone, when she has to turn someone away.

“There are patients that leave [the health department], and we worry about them because we don’t know what they’re going to do,” said Heath.

Karen Palmer, RN-BSN, administers a tuberculin skin test to Jasmine Freeman of Martin, Georgia, at the Stephens County Health Department in Toccoa. The test is required for entering Georgia colleges. Freeman will be a freshman this fall. Health departments offer childhood, adolescent and adult immunizations along with many other services. (Photo by Dave Palmer, public relations coordinator for District 2 Public Health in Gainesville.)

As Georgia’s public health resources shrink, so does the list of conditions the health departments can treat. Since Heath has been with the health department, ear infections, pink eye, sinusitis, and sore throat have dropped from the list. The Northeast health district used to have a nurse that provided acute care, but she was laid off.

While Georgia’s population has grown by an estimated 1.5 million since 2002, the public health nursing workforce is nearly 22% smaller. In 2002, the state had 1,817 filled public health nursing positions; today there are 1,423, according to Meshell McCloud, assistant chief nurse for the Georgia Department of Community Health, Division of Public Health (DPH) Office of Nursing.

The state has also lost scores of other public health professionals, all a result of layoffs and high turnover due to the state’s severely low salaries.

With annual salaries at approximately $20,000 below market, fewer nurses are taking and keeping jobs in public health. The starting pay for a public health staff nurse in Georgia is $36,753, while Georgia’s market starting rate is upwards of $61,200.

Nurses and other specialists who’ve stuck with public health take on the duties of those who’ve left, and many also work second jobs so they can afford the first.

“It’s very worrisome to know that many personnel are working two jobs to make ends meet or they’re either getting food stamps or they’re borderline food stamp candidates. We worry about their ability to stay well and concentrate,” said Carole Jakeway, R.N., director of field operations and chief nurse of the Office of Nursing for the Georgia Department of Community Health, Division of Public Health. The impact of health departments short-staffed with overworked employees is significantly more serious than sore throats.

West Central Health District, based in Columbus, currently has six unfilled nursing positions, down from ten as the district was recently able to fill four positions, according to Eileen Albritton, R.N., District Nursing & Clinical Director. The district now has 86 nurses on staff.  Other critical vacancies include one for a communicable disease specialist and two nutritionists for WIC, a program that ensures mothers, infants and mothers-to-be are getting enough healthy foods.

“We find that the quality of some of the respondents isn’t what it used to be,” said Zsolt Koppanyi, M.D., M.P.H., director of the West Central district. “Because of the lousy salaries and the furloughs, it isn’t as attractive.”

For patients in this district, understaffing translates into long waiting lists for pap smears, which women must undergo before receiving birth control pills, and for screenings for sexually transmitted diseases (STDs), which according to Koppanyi are at an all-time high.

“For every hour that we have a vacancy for a nurse in the STD program, we’re missing opportunities to prevent the transmission of STDs like chlamydia, syphilis, gonorrhea, hepatitis and HIV,” Jakeway said. Georgia’s STD rates are among the highest in the country, according to the Centers for Disease Control and Prevention.

Women forced to wait one to two months for birth control pills are at risk for unwanted pregnancy, Koppanyi said, which has consequences for taxpayers. In Georgia, 50% of births are paid for by Medicaid, according to The March of Dimes Data Book for Policy Makers: Maternal, Infant, and Child Health in the United States 2010.

In addition to helping women prevent pregnancy, public health provides services and care that private medical practices cannot. In the event of a syphilis outbreak, like the one in Rockdale County in 1996 that exposed more than 200 young people, public health staff tracks down the sexual contacts of infected people so the spread can be stopped. Private doctors are not equipped to do this sort of public health sleuthing, Koppanyi said.

Nor are private doctors in a position to control outbreaks of diseases like norovirus, which spreads easily in schools or nursing homes and causes one to three days of vomiting and diarrhea.

“When a nursing home or school sees several cases of vomiting or diarrhea, they call us,” said Eileen Usman, epidemiologist for the West Central district. When the health department confirms the presence of norovirus, it provides the school or nursing home with research-based recommendations on visitors, isolation and sanitation. The health department responded to an outbreak at a nursing home last year and recommended limiting visitors and isolating infected residents.

In the event of outbreaks or terror attacks, every health department has emergency preparedness plans, but few have the staff to carry them out. “We came up with a beautiful formulation, but it’s not realistic. In vain do I put pallets on the floor, if I don’t have nurses to take care of the patients lying on them,” Koppanyi said.

In an emergency, public health agencies are responsible for dispensing the national stockpile of antibiotics, vaccines and other emergency medications as well as emergency shelter, health and medical services and telephone triage. The 2006 Final Report of the Georgia House Study Committee on Public Health predicted that these services “will not function as designed,” in an emergency, “and will lead to mass disruption, unavailability and degradation of care.”  “In the event of a pandemic, the medical system in Georgia will collapse,” the committee reported.

Nursing shortages might make it impossible to carry out an emergency response plan for H1N1 flu, for example, in districts such as the North District, which is based in Gainesville and serves Hall and twelve surrounding counties, according to Karen Palmer, R.N., area nurse manager.

Dr. David N. Westfall

In this district, at least twelve nurses have been lost from a total nursing staff of 106 since 2007, said Janice Austin, district human resources manager. It’s unknown, however, how many of the positions still exist. “We’ve had critical hire requests in for months and months that have not been acted on, so it’s hard to determine whether the positions are vacant or eliminated,” said David. N. Westfall, M.D., district director.

Among the vacant critical positions are county nurse managers for Dawson and Stephens. The positions are open, but the district does not have the money to fill them, Westfall said. In the meantime, area nurse managers like Palmer, who is now Stephens County interim nurse manager, step in.

“We lose the ability to see the same volume of patients that we were able to see previously,” Westfall said. “The area nurse manager can only pick up a little bit of that load.”

When Palmer learned that more than 200 5th graders in the Stephens County school system had not yet gotten the required chicken pox vaccine, there was not a nurse available to deal with the situation. So Palmer left her desk – where she is responsible for making sure the clinics in her area are always staffed – and went to Toccoa Elementary herself.

Palmer isn’t just doing the work of two nurses. In order to supplement her salary, Palmer works two weekend shifts per month at Stephens County Hospital.

“Sometimes when I get a check from the hospital, I have to remind myself why I still do it,” Palmer said of her determination to remain in public health.

“I enjoy empowering women in my family planning clinics to take care of their bodies,” Palmer said.

Some nurses are drawn to public health because the system provides intensive training in family planning and other specialties. “It’s so attractive that after nurses complete their training, it makes them very marketable for the private sector,” said Georgia DPH Assistant Chief Nurse McCloud.  “In these hard economic times, they are often recruited away.” According to directors of many districts, however, local public health professionals are always sought after by private and federal agencies regardless of the economic climate.

Many public health graduates begin their careers in state or local public health settings, gain valuable experience, and leave for higher salaries after a couple of years, said Phillip Williams, Ph.D., dean of the University of Georgia College of Public Health.

When nurses leave for higher paying jobs, the state faces the challenge of recruiting new ones. “We can’t talk about retention until we get that person through the door, but the salaries are so low we can’t even get them through the door,” said M. Rony Francois, M.D., state health officer and director of the Georgia Department of Community Health, Division of Public Health. Faced with the impending retirement of the baby boomers, the Office of Field Operations has launched a recruiting initiative that will involve, if approved, raising salaries for entry-level nurses as well as five other public health disciplines.

A below-market salary explains why it took more than a year to fill a nurse practitioner position in Lowndes County, said Lynne Feldman, M.D., director of the South District that serves Valdosta and the surrounding area. “And I don’t know if she’s going to stay,” Feldman said. “You can make a lot more money than the state can pay.” This type of turnover further slows the delivery of care as it takes 12 to 15 months to train a public health nurse.

In Clayton County, four nursing positions have been open for more than a year because the district has not had the money to fill them, said Alpha Bryan, M.D., district director. In the Rome-based Northwest Health District, nine positions, including three nursing positions, are open and need to be filled. Still the district has 51 other vacant positions, of 395 total positions in the district, and no budget to fill them.

Public health is not only nurses in free clinics. “Public health is as much for people who have nice jobs with wonderful benefits as it is for people who live in public housing,” said Williams.

“We take for granted that we can drink from any water fountain, order off of any menu. Seatbelts, no smoking in restaurants, that’s all public health,” Williams said.

Environmental health professionals who inspect restaurants and drinking water, among a host of other duties, are also in short supply. In Fiscal Year 2008, there were a total of 493 environmental health specialist positions statewide. By Fiscal Year 2010, 46 of those positions had been eliminated and another 43 positions were vacant –a 20% total decrease in manpower, according to the environmental health branch of the Georgia Division of Public Health.

Recruiting and training one new environmental health inspector costs about $44,000, which is another barrier to filling these vacancies, according to Chris Rustin, deputy director of the state Environmental Health Office. As a result, “We are forced to focus on quantity versus quality of inspections as we are mandated to inspect facilities a certain number of times per year,” Rustin said.

Environmental health, due to a shrinking workforce, has been reduced to restaurant, hotel, pool and septic inspections, according to C. Todd Jones, Chatham County environmental health director. In some counties, Jones said, specialists can no longer assist homeowners with well testing, septic evaluation, food service training, or pest control. In some parts of the state, surveillance for West Nile virus and investigation of hazardous molds have been abandoned.

The fact that some districts have only one environmental health specialist for multiple counties weakens emergency preparedness.

“A sufficient workforce is critical to the ability to prevent or mitigate the spread of disease, mobilize a response to any disaster and to ensure the health needs of the community are met during these events,” said Annette L. Neu, R.N., director of emergency preparedness and response for the Coastal Health District.

“Unfortunately, public health seems to be moving towards a diminished workforce and a weakened infrastructure, and the consequences may prove disastrous in a bio-terrorism attack or other public health emergency.”

This article is the first of a series developed by the Public Health News Bureau, a project funded by Healthcare Georgia Foundation. The Bureau is staffed by graduate students from the health and medical journalism concentration in the University of Georgia’s Grady College of Journalism and provides information about the state’s public health system that is distributed via the Partner Up! For Public Health advocacy campaign.

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Sonya Collins

Sonya Collins

Sonya Collins is an independent journalist whose recent stories about public health, medicine and biomedical research have appeared in Yale Medicine magazine, [email protected], and print and online publications served by the Georgia Public Health News Bureau.  She has also contributed news stories, columns, features and travel pieces to local and regional publications in New York, Georgia, and Brazil.  While earning an M.A. in Health & Medical Journalism at the University of Georgia, Sonya was a two-time science writing fellow at research conferences sponsored by the National Academies of Science and held in Irvine, CA.

Before becoming a journalist, Sonya earned an M.F.A. in creative writing at The New School, where she was a teaching fellow. She has also taught writing at Hunter College of the City University of New York, where she earned her B.A., and at the University of Georgia. During her teaching stint at UGA, she contributed an article on author Elizabeth Gilbert (Eat, Pray, Love) to the Encyclopedia of Contemporary American Fiction published in 2010.

Fluent in Portuguese, Sonya has translated literary and scholarly texts for publication.  She lived in Brazil for two years, where she wrote a collection of essays about life on the island of Florianópolis.