Director, Bureau of Epidemiology, Pennsylvania Department of Health

By Alex McEllistrem-Evenson

In addition to his expertise as the Director of the Pennsylvania Bureau of Epidemiology, Dr. Ostroff is the Acting Physician General for the Pennsylvania Department of Health, and was employed at the Centers for Disease Control and Prevention for twenty-one years.

From your perspective as the director of the Pennsylvania Bureau of Epidemiology, what are some of the biggest concerns facing our nation’s health workforce?

There are many challenges and opportunities. There is no question that the health care workforce is going to have to adjust to whatever occurs in the area of health care reform. Any potential constraints that health care reform will place on the scope and scale of practice and reimbursement are obviously a consideration for many health care providers. In my position as director of the Bureau of Epidemiology, I’m more involved in public health issues than patient care, so I’m not too involved in some of the issues related to health care reform. But one area that involves clinical care and public health that is both very challenging and very exciting is information technology and informatics. That has upsides and downsides: certainly it offers an opportunity to improve both patient care as well as improve outcomes—especially in the area of prevention and wellness—but it also has challenges in terms of patient confidentiality, information privacy, and keeping up with the technology.

What unique challenges does the H1N1 pandemic pose to health workforce?

Health care worker protection, from my perspective, is a major issue and it comes up in three ways. One of them is the issue of vaccination of health care workers. They’ve been identified as one of the five priority groups for vaccination, but we remain very challenged in getting the workforce vaccinated both because of the current limited availability of the vaccine as well as reticence and reluctance of many workers to be vaccinated. Because of that traditional low-vaccination rate of health care workers for both seasonal influenza and what we’ve seen so far with H1N1, many institutions are moving towards more vigorous policies of mandatory vaccination. It’s unfortunate from my perspective that we have to get to that point where, in order to achieve something that makes so much sense, we actually have to mandate it – either by institution or in one instance where the state of New York decided to mandate it legislatively. I see little basis for health care workers to be concerned about receiving this vaccine.

The second area of worker protection that has been very challenging and difficult for all of us revolves around the issue of respiratory protection. There remain ongoing controversies about the issue of use of N95 respirators versus the issue of surgical masks. I think the debate surrounding respiratory protection has been quite unfortunate because to some degree it distracts from doing many of the other things that we would like to see done in the health care setting to prevent transmission of H1N1.

The third area which seems fairly straightforward, at least more so than the prior two, is getting health care workers to stay off the job when they’re sick and getting health care workers to wash their hands. Both are just plain common sense.

Could you clarify what you mean when you talk about various kinds of respiratory protection?

We’re talking about two major classes of respirators (although there are actually three). One is the plain old surgical mask. The second is a respirator, and when I say respirator what I’m talking about is the cup types known as N95s. The third are PAPRs – Powered Air Purifying Respirators. We’re not talking about PAPRs in this case [relative to H1N1] because PAPRs are not considered necessary for flu. The issue is the surgical mask versus a cup respirator. We know that these N95 respirators provide a higher level of filtration but they’re much more expensive and they need to be specially fit-tested to produce a proper seal.

The studies that have been performed to date have not shown any better protection than the surgical masks in terms of protecting health care workers; however, the federal government has made recommendations that, for H1N1, the cup respirators can be used as opposed to surgical masks which are traditionally used for worker protection from regular influenza. So that’s been very controversial.

To your knowledge, do health education programs adequately prepare future health workforce to deal with pandemics on a practical scale?

I would say that in this particular circumstance, the health care workforce was well prepared. The reason for that is that we’ve had a lot of time to educate health care workers about influenza because concerns first arose in 2003 with the bird flu. Ever since the bird flu came up, there have been many training opportunities, both hands-on as well as educational sessions targeted to the health care workforce and exercises looking at pandemic preparedness.

Most of that was in place before the current pandemic arose. A lot of this training targeted to the health care workforce was highly relevant to the pandemic, even though we ended up talking about a different virus. The overall level of severity of this pandemic was considerably milder than was addressed in most of the training courses that were put on for bird flu. Those training courses were mostly targeted towards very severe illness, high levels of mortality, an overwhelmed and overstressed workforce, and high rates of absenteeism among the workforce. That really hasn’t occurred with H1N1. Most of the stress on the health care setting has been in the outpatient and emergency department area, not the inpatient area. We haven’t heard of many health care facilities—either here in Pennsylvania or anywhere else in the country—that have been overwhelmed with inpatients, where the ICUs were overflowing, where there weren’t enough ventilators, and so forth.

Most of the impact has been seen with emergency departments, where they’ve set up triage units and looked at ways to see patients elsewhere by setting up alternative care sites for people with the flu. We haven’t seen large numbers of health care workers out ill. That could be because the age group that’s been most impacted has been those between five and nineteen years of age, so most of the health care workforce has been relatively spared from the full brunt of H1N1.

Why does it seem like these pandemics have occurred more frequently? Is it just the result of media saturation?

This is actually the first pandemic that we’ve had since 1968, so it’s been a long time. Everyone was anticipating that when the bird flu was first identified and it started to spread in Asia that it would be the next pandemic. It hasn’t happened yet because that particular virus doesn’t spread very easily from one person to the next. Everybody was really focused on that virus because of its lethality – more than 50% of all of the cases of this virus have died –asking “when is it going to change and better adapt to people,” and “will it become the next pandemic strain.” Then out of nowhere this other one shows up. That’s just the nature of influenza. Nobody knows whether or not the bird flu, which is the H5, is ever going to get to the point where it will produce a pandemic.

How do you feel this pandemic may impact our health workforce pipeline? Is it likely to scare people away or encourage people to enter health professions?

It’s hard to know the impact of these types of disease situations. The other recent ones you can think about are SARS a couple of years ago, the anthrax attacks, and West Nile virus. These other emerging diseases didn’t scare people from entering the health care workforce, and I don’t think that most people who consider careers in health care are going to be scared off by this one either.

The only recent example we have of a disease that may have led some people away from careers in health care is probably HIV back in the 1980s. That really did disconcert a lot of people about risk. I think most people have gotten over that, and those who go into health care are much more comfortable with everything related to HIV now and so I don’t think they’d really be put-off by things like influenza pandemics.

Maybe it will be just the opposite. There are lots of people who become very intrigued with health when things like pandemics happen. It just raises their level of awareness and makes them feel it’s a very exciting and interesting area to work in. I hope that one of the positive outcomes of these types of situations is that it will encourage more people to get into public health because it’s a workforce that’s clearly being eroded.

We need to get more people into public health work. With one of the focus areas of health care reform being prevention and wellness, there will be opportunities for people to engage in careers in public health. I think that’s a good thing. Any many job seekers recognize that the health care arena is one of the growth areas of the economy. When we have a down economy in a lot of other areas, people realize that there are career opportunities in health care and this will more likely than not stimulate them to get into health care rather than discourage them.

You mentioned that the public health workforce is “being eroded.” Can you elaborate on that?

It’s because of the ebb and flow of available funding. For public health, there was a substantial increase in resources just after 9/11 and the anthrax attacks. That funding has been dwindling downward as well as in some other streams that support public health activities. The consequences of that are that the public health workforce is declining over what it was a number of years back.

The second problem is that public health workforce is aging. A recent survey showed that a very substantial proportion of that workforce is close to retirement. There have to be job opportunities for people to get into public health, and if there aren’t any, the current workforce will continue to decline.

You recently spoke on a number of topics at the annual meeting of the American Public Health Association in Philadelphia. What sorts of topics were most discussed relative to public health and workforce?

I think that there is continued great debate around the issue of health care reform and the opportunities it offers. At least from my perspective, it would be somewhat unfortunate if the ultimate outcome of health care reform was simply doing more of what we’ve been doing in the US in the health care arena, which is caring for people when they’re sick.

A lot of what I heard at APHA, as well as elsewhere, is that at some point we have to shift our paradigm over to doing more to promote wellness than to treat sickness. Both of them are very important, but you get so much more bang for your buck by keeping people healthy in the first place than you do by taking care of them once they become sick. I think that there needs to be a much greater emphasis on promoting healthy lifestyles and wellness. Ultimately, that will save us a lot of money and it will make us a healthier country.

Please note that the views expressed in this article are the opinions of the interviewee and do not reflect the official policies, positions, or opinions of the Health Workforce Information Center or its funder.