Epidemiology at the state level is shrinking

I'm an epidemiologist and I train epidemiologists so you expect me to think epidemiology is important to public health. Epidemiology describes the pattern of diseases in the community and tries to figure out why some patterns exist and not others. It is used for both applied health research (causes of disease and disease outbreaks), disease control and for administrative purposes (how many hospital beds will we need, for example). When I was in medical school most epidemiology, such as there was, was done by medical doctors or employees of federal, state and local health departments. Starting in the sixties, academic programs in epidemiology started to take off, and now there are many masters and doctoral level training programs in epidemiology. But still not enough epidemiologists to meet the need, apparently. And we aren't moving forward. We're sliding backward.

Periodically since 2001 the Council of State and Territorial Epidemiologists (CSTE) (a non-profit organization of state epidemiologists that advises CDC and promotes the interests of epidemiology in state service) does a survey of the states to see what's happening in the epidemiology workforce and capacity to perform epidemiological functions. The latest results were just reported in CDC's Morbidity and Mortality Weekly Reports (MMWR) and the present the kind of dismal picture we all could see with our own eyes without a formal survey. Almost everything in public health at the state and local level is deteriorating even as the demands are escalating, sometimes to the breaking level. Here, for example, are two graphs showing what has happened between the last survey in 2006 and this one (2009) and the current state of affairs for various program areas:


The bars on the left are the number of states have substantial to full (>50%) full capcaity in four key program areas are for 2006. The bars on the right are for 2009. Except for research, which went from 9 states to 10 states, the other program areas showed smaller capacity. The survey was done between April to June of this year, concurrent with the first wave of the swine flu pandemic. The sudden demand to count cases, prepare new programs, measure spread, interpret data and all the rest of the things the public and press was clamoring for feel on fewer shoulders than just 3 years ago. As a result, personnel were borrowed from other essential public health functions, which suffered even more.

This graph shows the status of those other functions before they were stripped to handle the pandemic:


What you are looking at here is the percent of state health departments that have substantial to full capacity (>50%, left bar) and minimal capacity (less than 25%) in key public health program areas. While infectious diseases was reasonably (although not fully staffed; the left bars are percentages of states with more than 50% capacity, not all full capacity), many important public health programs had more states that had no to minimal capacity than states that had substantial to full capacity. It's a dismal picture for routine but important public health functions.

What kind of things are we talking about here?

Here are four big functions where capacity decreased from just three years ago to the start of the pandemic:

  • Monitor the health status of the community
  • Diagnose and investigate health problems in the community
  • evaluate effectiveness and access of health services
  • Research into health problems

As the pandemic showed us (although any idiot could have seen it), this was an utterly stupid disinvestment. But we did it, and now everyone is hollering about how we haven't been able to handle swine flu. You get what you pay for.

It's a lot more than it appears on the surface, too. I'm in an academic environment where we use the latest tools in computational epidemiology and the laboratory sciences. But in state and local health departments they are starved for people and deprived of these same tools. Despite the importance of timely information and early warning, only about half (53%) the states had automated electronic lab reporting and far fewer web-based provider reporting (41%), automated cluster detection software (24%) or routine coding of location for disease or deaths (29%). Even when the tools exist, most require the basic data to be geocoded by location and that still isn't routine in more than 70% of state health departments.

I've been in public health a long time and I've seen many changes. We can do things now we couldn't dream of doing even ten years ago (cluster detection, routine mapping of disease outbreaks, data mining of routine health data, etc.). We can do them, theoretically, that is. The infrastructure, human and otherwise, that would produce the raw data for these sophisticated tools isn't there and we aren't providing it. On the contrary we are gutting state and local health.

Some things are just so stupid it takes your breath away. Not that there are enough ventilators for that problem, either.

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You write: â As the pandemic showed us (although any idiot could have seen it), this was an utterly stupid disinvestmentâ.

Well, I do not know about that. How is that obvious?

Perhaps the state of epidemiologist is better in the US. I know quite a lot about public health work in the European country where I live and work, and I am utterly convinced that the money we spend on local public health personnel, monitoring, campaigns, different sorts of programsâ¦is mostly an enormous waste of money. These folks are usually not epidemiologist, so perhaps my critique is more targeting public health programs in general.

If I could decide I would decrease public health budgets at the local level with 90% tomorrow, and rather spend them on school investments in early years (or use them to lower taxes, which I believe would create more welfare as well).

KM: Well you provide an effective counter example that it would be obvious to anyone. It just takes one person to falsify that. But those of us who are not in state service but are in public health and observed this for decades would in general disagree with your assessment. Not knowing your country or your circumstances (or your evidence) I can't comment further, but public health pays off on almost any analysis. If you have incompetent or corrupt people doing it that's another matter but a different one.

Thanks for the shout out! It is an interesting report with interesting findings - we at CSTE hope that it causes some action to pay attention to the importance of surveillance and epidemiology within the larger public health sphere. Enjoy your blog!

I felt the need to share with you the story of Jason Bromby, a 28-year-old British diplomat who has gone missing in China. This is very scary. Read more about it:


Spread the word, something needs to be done.

I am a mere local-level epi, but my agency is massive. Despite our size and scope, we are losing funds and job positions. When we lose an epi, we don't get a replacement. My workload gets bigger, but my paycheck does not.

Because we are a leading jurisdiction, we have a lot of great tools and resources like electronic lab reports. We also have automated syndromic surveillance (but in my opinion, its use and value as a tool are pretty limited). But when major flaws hit these systems (our CMR system is, IMHO, full of bugs), we sometimes don't have the money to fix them. That can seriously impact our operations.

Per you 4 major functions, I can see my office playing major roles in 1, 2 and 4 ... but 3, not so much.

By Rogue Epidemiologist (not verified) on 18 Dec 2009 #permalink

There is an additional problem not covered in your analysis. I was employed as an epidemiologist, to do disease surveillance. What I actually spend most of my time doing is unrelated admin and/or policy. I haven't cracked open R in months. The number of employed epidemiologists here looks good, but we're being made into bureaucrats instead of scientists... and then people get frustrated and quit.

By attack rate (not verified) on 18 Dec 2009 #permalink

Are there too few trained people entering the field, or not enough money, or money diverted into other areas? Is there any way to lure competent people into the field?

Have academic institutions add another 2-3 years of foreign language to their curriculum.. and a few other diversions and distractions. I would love to be/have been an epidemiologist. I went to school as an adult. Had already owned and sold 3-4 small businesses. I maintained a 4. average.

The academic process was so insulting.. infested with people who could/would not think critically. Now I just sit in my office.. investing in biotech and other companies at a rate of $200,000 plus per year. It really stinks. ;)

Sarcasm aside.. I would love have to made a contribution/career in public service.. but the academia I've experienced is a bad joke.

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QSave: I've spent my life in academia and it has changed, mostly for the worse. That said, it is remarkably heterogeneous, with experiences at one place not necessarily indicative of what one finds elsewhere.

It very well may be. However, I am but one with my time and eenrgy.. and that's we really have given to us.
I think I was a bit more savvy.. or shrewd than many students.

The way I read the process: We will teach you to value your time and energy.. by wasting big portions of it. When a presumptuous.. officious.. condescending woman started justifying foreign language to me as brain/dendrite development(The Seven Intelligences).. that's the moment.. THE converstion when I knew it was time to pursue other channels of development.

There are SO many highly intelligent people who are just not willing to run that gauntlet of stupidity in order to make a living. In my experience.. these people do as much to prevent education as they do to promote it.

And I thought an epidemiologist treated skin diseases. The truth is much more impressive.

My question is, how long before we have robot (maybe a wall panel at home) doctors (diagnosticians)? I envisage it asking questions, doing saliva/blood tests, maybe limited prescriptions. And might not robots make great surgeons?

bar: Half my family thinks I'm a skin doctor too (and probably wonder why I didn't get rich). Robots for doctors? We're almost there. They look like humans but we make them act like robots.

Funny story about so called Healthy- (insert name of province here) Initiative.....Rather than teaching newcomers practical health "things" their focus in schools is "holistic" and involves drumming sessions. Really. Yes the kids had fun, but what the heck does drumming for 35 minutes have to do with health? It is truly the craziest thing I have heard so far- but this is the government that blames citizens for their health issues on a regular basis, while slowly poisoning their air, water and ground, so what can I say. We also have an "Hope Foundation of (insert anonymous province name here)" - another health initiative kind of affiliated with our university ANDDDDDDDD our childrens hospital is a mecca for "alternative" practitioners to "heal" children holistically. Unbelievable and really stupid.

My point may be obtuse to some, so I have come back to explain. Our public health services have been decimated in the past 18 or so months, due to a number of factors, not the least being the economy. While the USA government is looking to take away some of the insurance companies powers, we in my province in Canada are trying to 'innovate" and allow private health care in. At the same time, we are wasting money on stupid in school drumming programs that are supposed to be about health of some kind, and paying for Hope Foundations and naturopaths and massueses and accupuncturists to treat children. None of these programs seem to be getting the axe, but our government is whining about costs and going to war with nurses. And if you want to see an example of a previous study on hope.... I will give you a link to show you how absolutely STUPID and embarrassing this crap truly is......


I realize that his was seven years ago, but I can't imagine things have changed much since. I looked over the foundations website and- well- just yuck.

Thank you!
There is.. imo.. far too much extraneous horse dung associated with the process of education. Most of it... again imo.. perpetuates some one's job.. with little to no discernible relevance or measurable benefit derived.
How does this continue to occur? How is it justified?

If I were going to add something to the arsenal of teaching.. it would be the art of salesmanship. The ability to attach feature to benefit.. from many points of view. To provide real world context.. dimension and purpose to the endeavor.

I worked for years as Director of a local health jurisdiction in a relatively small county, and ultimately left in frustration. Locals are at the whim of an uneducated, and often not bright, elected Board of Commissioners (Board of Health) whose only concern is the budget. Epidemiology? They could neither spell nor define the word.

Following a Rabies exposure, I was once instructed to, "Just go out and shoot the (pet) animal!"


As I look at the CSTE Survey results (particularly the second graph) I have to wonder how many of these functions are being carried out elsewhere, and therefore being undercounted...

For example... I work for a state agency that houses the two divisions most closely related to occupational safety and health - OSHA and the workers' compensation division (which oversees all areas related to workers' compensation). My agency has a rather large research section - roughly 20+ analysts - that support the agency as a whole, and a sizable portion of that support goes to occupational safety and health. In addition, our agency also runs our state's portion of the Bureau of Labor Stastics' programs, particularly the Survey of Occupational Injuries and Illnesses and the Census of Fatal Occupational Injuries.

Now, of course, our agency and the work we do was (most likely) not counted by the CSTE survey. We aren't part of CSTE - my understanding is that the CSTE members in our state are part of another agency. Furthermore, they do additional (and potentially duplicative) research in the area of occupational safety and health.

Perhaps I'm citing an abnormal example. But if it's happening here, it must be happening elsewhere in at least some cases, right?

So, I guess my point is two-fold. First, the superficial observation that the survey may be flawed. Second, the more in-depth observation that perhaps these functions are being maintained, but in a disjointed and disaggregated fashion...

Tasha: It occurred to me, too, that occupational health might be done in Labor Depts. rather than health departments, although usually those are longstanding arrangements by statute and this is a (stratified) health department comparison between two time periods. But the observation surely does hold for the capabilities part, as you note. That can be good or bad, depending on circumstances. But the CSTE picture is probably right in broad terms, although the details might be debatable. It's some of the only data we have on an important topic and it shows what most of us have seen: public health has taken a big hit just at the time when the demand has gone through the roof.