It’s been a long three years since the COVID-19 pandemic began. And though the pandemic isn’t over — the public health workforce feels done. Public health departments around the country are facing low morale, high vacancy, and a workload that doesn’t want to ease up. Abdul talks about the impact of public health burnout and sits down with Elizabeth Holzschuh, director of epidemiology at a local health department in Kansas to talk about what it looks like on the ground — and what needs to be done to address it.

TRANSCRIPT

[AD BREAK] [sponsor note] [music break]

Dr. Abdul El-Sayed, narrating: COVID rates have been on a slow, steady decline for nearly two months now. A new analysis found that prison deaths jumped 50% during the first year of the pandemic, and another reveals that patients in states that did not expand Medicaid have been saddled with more medical debt and therefore lower credit scores. This is American Dissected. I’m your host, Dr. Abdul El-Sayed. [music break] When it comes to the COVID 19 pandemic. And look, we’re still not quite out of the woods yet, despite what our politicians may tell us. But when we finally are and the story of this pandemic is told in full, one of the plotlines will be how it changed the nature of work. There will have been work before the pandemic and work after the pandemic. In those first few months of the pandemic, when it felt like the Earth itself had stopped rotating, so many of us were ripped away from the lives we knew, forced into a slower, scarier version. Yet it also meant time to reflect. People connected with long lost friends, spent more time with their families and took time to invest in new hobbies. There was a nationwide shortage on bikes, workout equipment and camping gear. As the nation has begun to open back up, many of us have found that even if it was scarier, the slower reality may actually be more enjoyable, more meaningful than the one that came before it. And that’s caused so many people to renegotiate the relationship with the one thing forcing us back into our old reality, work. 

[clip of unspecified news reporter number 1] It’s being called the great resignation. A record number of Americans are telling their bosses, I quit. 

[clip of unspecified news reporter number 2] According to a new Labor Department report, 4.3 million people quit in August. That’s the highest number of people quitting on record, dating back to more than 20 years. And that’s up from 4 million who walked away from jobs in June. 

Dr. Abdul El-Sayed, narrating: Look, you may like your job, you may love your job, but getting dressed in the morning like in real pants instead of sweat pants, spending 30 minutes in traffic on your commute, those things have become a lot harder to accept. America’s changing relationship with work has shaken our economy. Commercial real estate, particularly in big cities, is cratering as work from home becomes the most common preference for anyone under 40. Housing markets in places like Bozeman, Montana, are booming as people are decoupling from HQ. Unions are organizing all over the place in sectors that haven’t had unions in the past, like podcast companies. Shout out to the Crooked Media Workers Union. But maybe less exciting athleisure is regrettably here to stay. But while many of us have been lucky enough to negotiate our relationship with work or sweat pants, we’ve been just that, lucky. Or should I say privileged because for so many, work from home was never an option. Many had to choose every single day of the pandemic between their lives or their livelihoods. Others they had no choice at all. Of all the essential workers, folks on the front line of our health bore the brunt of the worst of the pandemic. Nurses, hospital workers, doctors, they were forced to work incredible hours against the odds with limited PPE and strained hospitals. And they had it extremely tough. At first we praised their heroism. We clapped in the streets, saw them for the heroes they were. But as with so many heroes, not everyone got the recognition they deserved. Because the other group of health workers battling to save our lives, working day in and day out, night in night out to educate us, protect us, and make sure we had what we needed. They are America’s public health workers. And instead of clapping, public health workers got this. 

[clip of unspecified person number 1] You, doctor, are going to be arrested for crimes against humanity. 

[clip of unspecified person number 2] The governing body should fear the people. 

[clip of unspecified person number 3] We are pissed off. 

Dr. Abdul El-Sayed, narrating: It’s been a long three years for public health workers across this country and across the world. But the challenges didn’t start with the pandemic. That’s just where they came to a head. Public health has been underfunded for decades. Being asked to do more and more with fewer and fewer resources, all while being held accountable when things go wrong. In my day job, I’m leading a county health department. We’re facing 40% vacancy as people have up and left the profession. Those who stayed are way past burnt out, struggling under the weight of the work. Morale across health departments all over the country is near an all time low. But as I’ve shared before in this podcast, we often call this a quote, “once in a lifetime pandemic”. But that doesn’t mean it’s the last one we’re going to see in our lifetimes. In fact, between globalization and climate change, circumstances are conspiring to make the next one that much more likely. Remember that record breaking bird flu I talked about last week anyone? And what’s standing between us and that next one. The very same public health workers who are struggling to pick up the pieces from the last pandemic. Today, I wanted to talk to someone who was on the front lines of public health through the pandemic. Elizabeth Holzschuh directs epidemiology for a local health department in Kansas City. She bore witness to the best public health could be and the worst of what society could throw at us. Targeted just for showing up to protect her community. Elizabeth had to take a leave to heal from the experience. I wanted to understand her experience and to share it with all of you. After all, we’re the ones they worked so hard to protect. Here’s my conversation with Elizabeth Holzschuh. 

Dr. Abdul El-Sayed: All right. Um. Can you introduce yourself for the tape? 

Elizabeth Holzschuh: Yeah. My name is Elizabeth Holzschuh. I am the director of epidemiology at the Johnson County Department of Health and Environment, which is a health department in the Kansas City metro area. And we serve about 615,000 residents. 

Dr. Abdul El-Sayed: Tell me what drew you to public health as a career? What uh was it about this work that was exciting to you? When did you realize that this is what you wanted to do? 

Elizabeth Holzschuh: Yeah, I always had a love for science, and so that brought me in a number of different directions. I thought about medicine. I researched for a while. I actually did a lot of infectious disease and immunology bench research um throughout grad school. And um when I was getting ready to get out of my graduate degree, which is actually an interesting combination of public health, microbiology and emerging infectious diseases, was trying to figure out what I was going to do next. I thought about an MD PhD program, but research was just a little too far removed from impact. It felt like we were just sort of publishing to publish. We weren’t really making that big impact on individuals. And so looking at my graduate degree and my classes I took, I really loved infectious disease epidemiology. So I started applying for positions after grad school or at the end of grad school and landed a position at the Kansas Department of Health and Environment as an infectious disease EPI. Um. And so between the science and my nerdness uh with data, it was sort of a perfect fit for me. 

Dr. Abdul El-Sayed: Oh, that’s awesome. I um I also am an epidemiologist. I got into EPI by way of um social epidemiology, trying to understand uh differences in health between populations and all of the causes uh behind them before we get to the either physiologic or pathologic level. And uh the cool thing is you I think you captured really nicely about epidemiologists is that space where um data meets lived experiences and um it opens up a whole can of potential interventions. Um. We’re not just documenting things to document them, but we’re documenting them to change them. 

Elizabeth Holzschuh: Absolutely. I actually am a social epidemiologist now. That’s sort of the second phase of my career. When I came to the county health department, I was a population health epidemiologist, is what they called me and said, do whatever you want as long as it impacts your community and found a love for social determinants of health. And so I’m really blessed to get to work on things like criminal justice now and housing and mental health. And it’s a really beautiful space to, to your point, really impacts our community members who um have really been overlooked for so long and sort of give a voice to people whose voices have been taken away through data and through storytelling. So it’s uh something that I love and I didn’t really go into public health thinking this is where I would land, but really thrilled that I got that opportunity. 

Dr. Abdul El-Sayed: Well, I um, I appreciate that. And I’m about to I’m about to land the the most dad of dad jokes, [laughter] but we’re both social epidemiologists and social epidemiologists. Um. All right. Um. So how long have you worked uh in public health? Um uh have you been at the health department in your community your entire career, or have you sort of um been around the block, seen sort of different institutions? 

Elizabeth Holzschuh: So I started at the state health department. And in Kansas, we’re a decentralized state. So the local health department sort of holds all that power um for their community. So I actually started my career in May of 2009 in the midst of H1N1. And then in 2015, I came to the county health department um and really started digging into population health, community health and social epi. So I’ve been in the field for, I guess about 13 and a half years now, somewhere in there. 

Dr. Abdul El-Sayed: All right. Um. And in your 13 and a half years in public health, walk me through the life of a county or state public health worker. What’s that job like? What’s the work like? Um. What is it that that sort of goes through your mind every day? Is is every day kind of similar to the last day? Or do you feel like um the days differ? And I can imagine uh what your answers might be, but [laughter] I know that a lot of folks out there are kind of like, what is it that you all do um– 

Elizabeth Holzschuh: Yeah. 

Dr. Abdul El-Sayed: –in these health departments? 

Elizabeth Holzschuh: Well, that’s the thing. Right? Before COVID, nobody really knew we existed. We got a little glimpse of it during Ebola when we got thrust to the forefront. But other than that, we’ve sort of been in the shadows, which is, I think, where we operate well in. So um I think it varies, right, No matter which health department you’re in, which whether it’s a state or local, if it’s a decentralized or centralized state, everything looks a little differently. My experience has been that the state health department’s a little bit more routine in their day to day activities. They tend to be dealing with bigger, you know, from an epidemiologist standpoint, a bigger data set, sort of digging in on a single topic. But at the county health department level, at least, my experience has been that it’s incredibly varied. And I think that’s why I love being at the local health department so much. So a lot of my work has been meeting with partners, figuring out what work they’re trying to do to bring forward um and work on their initiatives and improve their communities. So I meet a lot with partners. I figure out how what data they have, what data we have, and how to sort of marry that together and tell a story to drive forward programs and policies. So in some ways it’s the same because I’m meeting a lot and I’m doing a lot of data work and a lot of presentations and storytelling, but the topic is varied, um at least my experience and for my staff, where we get to do all those different things because public health and particularly social EPI and social determinants of health are so incredibly broad. 

Dr. Abdul El-Sayed: And who are the kinds of folks that you work with every day? I imagine you have a team of epidemiologists, but who are the other folks around you that you’re interacting with every day? 

Elizabeth Holzschuh: Yeah. So our health department um is about 150 staff, and we have programs, including our child care licensing. We have environmental health within our department. Um. And so they do certain things like permits, but they also work on climate change and sustainability. We also have community health um division, which works on um both kind of disease prevention, built environment. So, you know, safe routes to school and safe streets. And we have a clinic in our health department as well that um serves our population around family planning, sexually transmitted infection testing, immunizations, and then very typical public health activities around infectious disease investigation and public health emergency preparedness. Um. And so I do have a team that actually was developed in the midst of the pandemic. We developed a Division of Epidemiology in about July of 2020. And so my staff are all social epidemiologists. And so, um you know, we work on a variety of issues, from maternal child health to, you know, suicide, opioids um pretty much anything that is not infectious disease. 

Dr. Abdul El-Sayed, narrating: We’ll be back with more with Elizabeth Holzschuh after this break. 

[AD BREAK]

Dr. Abdul El-Sayed: One thing you know that I think is really important to highlight there is that you work on the data in the science side of public health, but inside of a health department, you’ve got folks who do all kinds of things. So you’ve got the folks who, you know, ride in a van to a local restaurant and um and check out what’s happening in the kitchen to make sure that when you go eat in that restaurant, you’re not getting sick. You’ve got folks uh who are reviewing plans for buildings. You’ve got folks who are administering vaccinations or going out and knock on doors uh in the community. You’ve got folks who are inspecting folks’ homes and and supporting them uh around lead prevention, you’ve got folks who are in administrators who are working on making sure that contracts clear the the the county or the city process. Um. And all these folks have to work together around a particular goal uh and a particular set of outcomes. And um I want to ask you sort of in your work in public health. Right? So you’ve been in public health now for about 13 and a half years, um the last three of which have been the pandemic. Tell me about, you know, morale and um work culture before the pandemic. 

Elizabeth Holzschuh: You know, the thing about that I love about public health and working in a health department is that the people who are there are incredibly passionate human beings, Right? Especially if you’ve gone and got an MPH, a master’s of public health or an advanced degree around public health, you’re there because you want to help your community. And so I think that is a baseline understanding for everyone who works in a health department. Really joins everyone together behind that mission. Like you said, um for me, I love the county I work for. We um do a lot around leadership empowers all people and everybody has a voice and a say, even if you’re not in that top tier of leadership, your opinions are valued and important. And so, you know, I have loved this health department. Um. I can’t imagine spending my career anywhere else just between the work culture and the camaraderie. And again that passion, um which for me is really big. And part of the reason I do what I do is because most of us just want to help, right? It sounds really um it’s a little ridiculous, but it’s a little um idealistic, but we really just want to help our community and do good work. 

Dr. Abdul El-Sayed: So you’re telling me you didn’t get into public health for the the monstrous government paycheck huh? 

Elizabeth Holzschuh: [laughing] I had a professor in grad school who said at one point, if you want to get rich, you don’t go into public health. 

Dr. Abdul El-Sayed: No, no. 

Elizabeth Holzschuh: No. 

Dr. Abdul El-Sayed: Um. You don’t. Uh. You would have been better off going out the MD route. Um. [laughter] But then, you know, sometimes you fall off the route and you look like me, and then you just go back to public health because you actually care about um helping people. No offense to any MDs out there. I know I’m going to get a bunch of hate mail, [laughter] a lot of doctors out there doing God’s work, trying to trying to take care of good people. But I’m just saying that if you work at a health department, most of the time um the we’ll just say the the incentives for your work are less mixed. There is there is really one incentive, which is uh you care passionately and deeply about the well-being of folks in your community. Um. Tell me a little bit about those first couple of weeks of the pandemic. You realized like this is the big one. And, you know, if you uh have been in in in public health grad school, everybody and anybody has told you that there’s probably going to be a pandemic in our lifetime. But like this is the one right. 

Elizabeth Holzschuh: This is the one. 

Dr. Abdul El-Sayed: I mean. Well, this is the first [laugh] I hate to say it, there could be more than the one. 

Elizabeth Holzschuh: Oh. At least not at this scale. 

Dr. Abdul El-Sayed: But but for right now this is the one. 

Elizabeth Holzschuh: Please. 

Dr. Abdul El-Sayed: Yeah, yeah. This is this is the one for now. Um. Hopefully it’s the one for a long, long time. Um. So this is the one you start to realize that like, this is it. Tell me about your, your thoughts going into this. Going into work. What are you thinking through um tell me a little bit about how the department’s operations start to shift. 

Elizabeth Holzschuh: Yeah. So it was a really unique time for us. Um. We had been without a director at our health department. We had an interim director for about nine months at that time um in March of 2020. And our director was supposed to start, I think, right around April 1st of 2020. 

Dr. Abdul El-Sayed: Wow. 

Elizabeth Holzschuh: Yeah. Um. And I as a social epidemiologist, I had not been doing infectious disease other than when there was a measles outbreak or something where I needed to pitch in. You know, I had been working on developing a community health dashboard and all of that and had, of course, been monitoring what was happening in China and was sort of watching it. And those early days, we weren’t sure how trustworthy the data were coming out, what how much we should believe about what that situation was in Wuhan. And then I remember Italy. Um Italy is when everything changed for me, when they shut down Italy, when they had those cases that they couldn’t trace back. And seeing a country in the Western world, quarantine an entire city. I knew things were going to be dramatically different than anything we had ever experienced before. I mean, I came into my career during H1N1 so I’d experienced that but it was clearly a very different beast that we were going to be encountering. Um Johnson County, Kansas, where I work, had the first case in the States. Um. And also we sit on the state line with Missouri and Missouri had not had a case and it was sort of just flat out running from that moment forward. But it was challenging, right. So watching what was happening in the rest of the country. Seattle was having the outbreak in their long term care facility. Um so I knew that we really needed to get on top of our long term care facilities. And what most people don’t realize is there’s no centralized database or centralized contact list. There’s a lot of turnover in our long term care facilities. And so, you know, trying to focus on that, um not having our director in place was a challenge. And there was already a lot of infighting truthfully in our community, um along within our county, um with people who thought they should have been notified about the press conferences or notified about the first case. And so our interim director was getting pulled in a thousand different directions. Um. You know, I got pulled into a meeting with all of our superintendents and county leadership, and I walked in not having any idea what anybody had been said, told previously. And I sort of sat there and they were talking about closing down the schools because they were getting ready to go on spring break. And I you know, this person who most people didn’t know that I had infectious disease background or even who I was, sort of sat in a room and said, closing down your schools for two weeks isn’t going to do anything if you guys are coming off of spring break. And so decisions were being made very quickly um and at that time just such little information, right? There was not a lot of communication coming out from the federal government. Um. And I think a lot of times, at least in our community, the state health department really looks to CDC and looks nationally to provide guidance out to the locals. And so it felt like for a lot of it, we were building a plane as we were flying and then, you know, sort of disassembling and rebuilding the next time we figured something else out. And so it it was um you know, there was maybe a little bit of excitement. Right? So I worked a number of measles outbreaks. And in those early weeks of a measles outbreak, there’s a lot of adrenaline, you’re sort of constantly moving. You’ve got this big commitment to helping your community, trying to prevent people from dying. And so there’s that massive cause that everybody sort of goes behind and starts working together. And then it felt very quickly like things shifted. Um. 

Dr. Abdul El-Sayed: Can you pinpoint when that shift was like, what was it? Or when was it that you were just like, Oh my God, this is going to be a slog. 

Elizabeth Holzschuh: Yeah. You know, so in our community, we had recommended the schools close because they were already on that pathway. We didn’t really know how kids were going to be impacted. And then our governor came out and did stay at home orders and closed all the schools statewide. And so for maybe that first month, maybe six weeks, things were okay. Um. But then, you know, there was still politics involved and a lot of misinformation. I remember communicating with somebody and saying like, we just don’t have tests. Right at the in those early, early days, we weren’t allowed to test anybody who was not coming from China, even though we knew there was transmission in other communities. Um. And so, for instance, we had somebody who flew in from Iran and had symptoms of a cold and we were not allowed to test them um because they didn’t come from China. And so the misinformation of oh there’s plenty of tests. There’s plenty of tests. What are you talking about? Um. So early days, you sort of started to get a feel that there was going to be some issues. And then as time went on, um I don’t know that I can pinpoint a specific day, but it started to become politicized. Um. And in Kansas in a lot of communities, I believe, throughout the country. So most health departments are are governed by a board of health. Right. So there’s a lot of board of healths. Um. And in Kansas, our Board of County Commissioners act as our boards of health. So they are elected officials who have backgrounds in construction and business and law and you know, whatever this is. And so you have these individuals who have no science background, who have no public health background, who are now making decisions. Um. And because of things that were going on nationally, there were some of them were very emboldened with their opinions on what we were doing and how that was taking away personal freedoms. And so, you know, and we are meeting with our board of county commissioners in very public forums constantly in those early days. And it was it was really pretty brutal, um just the anger both from elected officials as well as from our community members. 

Dr. Abdul El-Sayed: And were there every any instances where that that got personal for you? 

Elizabeth Holzschuh: Absolutely. Um. I mean, it was two years of us showing up every week at our Board of County Commissioners meetings, sometimes multiple times a week. Um. I was a very public face during this. And then when school started back up in fall of 2020, or we were starting to make recommendations around virtual or hybrid or in-person, I became the face of our school recommendations. I was at every school board meeting that I was invited to, and we have six um school districts in our community. And the other thing about Johnson County is that we are a very affluent community um and parents are very, across the board no matter where you live, parents are very invested in their children’s well-being. But I feel like there’s something different in these suburban communities where um the want for sports um and the belief that their right over what public health officials are saying. Um it was very personal. So, you know, my name was getting thrown around social media posts, anything I said that that was not right. Like, for instance, there’s one board meeting where I had cited a headline I had seen, and what I didn’t see was that headline had since been um revoked or, you know, the governor came out said, no, that’s not the case. And so that was latched onto and and went around from other elected officials were writing out these posts. And it was everywhere. Um. You know, I was getting emails, I was being called out daily on social media and in public comments um which were then broadcast to thousands and thousands of people. Um. And I will say that, you know, I was shielded from some of it um because I was not the health officer or the Health department director. Um. I had people above me who were sort of out front on mask mandates. Um. And, you know, I think my experience is unique, certainly from those in rural communities in our in our state, where it’s a much closer knit. But absolutely, I was recognized out in public. Um. You know, even I was on a shuttle bus to a car rental place in San Diego after getting off a direct flight from Kansas City with my kid. Um and a woman in the bus looks at me and goes, I do recognize you. And I sort of stopped because you just never knew it was going to be one of those people who was appreciative for what you did or if it was somebody who just absolutely hated you, for your stance and for for just doing public health. 

Dr. Abdul El-Sayed: Mm. I’m really sorry to hear about your experience and that is awful. Uh. And obviously, since you jumped in to public health to do the work uh and to protect folks like that person, um I can imagine how how deep that cuts. What was the overall impact on the morale of the department? You’ve got a once in a lifetime experience. People are working you know twice as much as they uh had signed on to. And you’re now doing this months, years in, watching the department and its work get pilloried by the very people who are supposed to be supporting you. What was the impact on the morale of the department? 

Elizabeth Holzschuh: Yeah, it was not good, um as you can imagine, for all the reasons you just named. You know, early on, I’d a I have a very young staff, and at the time when we started, even before I we got the division, I mean, I did not have a single staff member who was working in those early months who’d ever even worked a measles outbreak or anything to that magnitude. So the staff were are being thrown into the space they’d never even existed in. And on top of that, there was all of the just changing guidance and trying to figure out what we were doing and let’s try this and see if this works. Um. And in those early days it was really difficult. Just we’re seeing people die, um it feels like in some spaces almost a failure of public health, right? We are there to prevent death and so to see every death that um is logged for our entire county come through our email because we worked very closely with our medical examiner, it was incredibly demoralizing to the point where, again, to try and help protect our younger staff, I needed them to understand that it was okay to not be okay. And I think in some ways all of my social epi and mental health work prior to the pandemic um helped in that space. So we actually put up a sign on our whiteboard that said number of days since last cry in the Office, because I needed my team to know it was okay that they weren’t making it through this unscathed. And so there were a lot of days somebody would go, and you didn’t have to tell anybody. You just go and wipe it and put zero. Um and I think that depending on what your role was in the pandemic, that impact on your morale differed. Um. You know, certainly if you weren’t talking with community members, you weren’t doing the investigations. There was certainly the heaviness that came with watching your colleagues be vilified and and this field that you love be attacked. Um but then there was the more personal impacts that really hit home for my staff. Um. I remember I think it was maybe May of 2020, one of my team members was interviewing a family, multi-generational family um who had COVID, and by it was Friday. And by Monday we got the notification that one of them had died. Um. And so for him, it was just this proximity to that. Um. And then, you know, when we started moving into school, that’s particularly where I think some of that impact came because we were recommending athletes and teams be quarantined because there were cases. And again, and I think this is everywhere and I’ve read about rural Kansas and how the sports parents are so intense. And we had a group that had a Facebook page called Let Them Play in the Fall of 2020, um which then got changed to let them play and learn. But what were you really focused on was playing sports. And so my staff, my team were the school’s team, so we were working directly with our school districts. We were getting cases reported to us. We were recommending quarantines, um so people staying home when they would have been exposed and then they were talking to parents and it was the parents who are calling them up and cursing at them. Um one of my staff had somebody tell them that they hope she died. Um. You know, and just again, these people who came into this field to do the work and who are so incredibly compassionate for this community are having that thrown in their face on a daily basis. And on top of that, they’ve already been working for months on end, way over the number of hours that anybody should work for that period of time. Um with all of themselves invested in the work. There was never a break even when you went home, there were still phone calls coming. There was still, for me, um being a leader, I would come home and I would have to read Twitter, which is where I got a lot of my information from epidemiologists and researchers throughout the world. Um. And so there was never a time where I was able to shut off. And I know that was the same for my staff because, you know, you were either working or you came home and there were fires to put out or you needed to figure out what was coming next the next day. Um. Or it was just sort of that heaviness and sort of the emotional toll that the work took on you. Um. You know, I had staff who were dreaming about cases and families that they had interviewed or or had been monitoring. And it was brutal. It was really, really difficult, uh and particularly for those staff who were talking to families and talking to community members. And then again, seeing those deaths come in was just also really demoralizing. 

Dr. Abdul El-Sayed: What was the impact on even just staffing levels? I imagine a lot of folks just quit um and that just forces more work onto the folks who stay, which then increases the probability that they quit. You know, I just um recently came back to a county health role and we’re operating at a 40% vacancy. Um. And a lot of that is holdover from the pandemic where folks just left and we weren’t able to hire back. Um. How has that impacted your uh working environment and what does that then mean for all the other folks who have to keep doing the work? 

Elizabeth Holzschuh: So I will say we are very fortunate at my health department and I don’t know, going back to your question about work culture, um our culture was very strong and there was a large sense of camaraderie um among the staff. And, you know, I will say that my director also had a very um high importance on mental health. So when he did come in and he actually started working a few weeks earlier than he was supposed to, within one day of him being there, he pulled me aside and said, you and your staff need days off, like take time off. You need to rest and keep your mental health in check. And so I will say for my team um and as far as some of those frontline staff, we did not see the turnover that I know a number of other communities saw. Um. Certainly in our clinic um and I think that’s a bit more from the current health care workforce um issues that are going on where, you know, certain like hospitals are paying a lot of money for nurses to come on board. So we’re losing those staff. Um. But I do know that, you know, we were understaffed and underfunded for decades ahead of COVID. And so to have this pandemic come in, we didn’t have the workforce and certainly not the trained workforce to do it. So in our office, we relied very heavily on contractors. Um which brings this whole other set of issues that come along with that. But I know from colleagues in other departments that absolutely the moment you have staff who are leaving because they just it’s just too much, it puts that extra weight and there’s always things that you just can’t do. And that also weighs on you when you know that there’s not enough time in the day to do that important work. And so it’s what piece of this are you not going to do? And then you start thinking about all the impacts that that one piece may have. 

Dr. Abdul El-Sayed: Yeah, we’re still uh in the pandemic and, you know– 

Elizabeth Holzschuh: Yes. 

Dr. Abdul El-Sayed: –400 plus people dying every day um is nothing short of a public health emergency. And at the same time, the intensity of the pandemic has waned substantially um with time. Do you feel like you or your team have recovered or do you feel like this is something that is going to scar a generation of public health workers? 

Elizabeth Holzschuh: So I feel like there’s always going to be some holdover, um I will say, from my team. Um. And it started with me. I knew I was going to have to take extended leave. I was so broken truthfully by April or May of 2022 that I was strongly considering leaving this job that I loved, um at least– 

Dr. Abdul El-Sayed: Wow. 

Elizabeth Holzschuh: –the job I loved prior to the pandemic. As I was thinking about it, I was like I was looking at my vacation accrual and how much time could I take? And I was going to bleed all my vacation down to take, you know, four or five weeks of leave. And I had this moment of saying, why am I taking vacation leave for something that this department and this community and this pandemic caused? Right? I was having massive mental health issues and I thankfully was under the care of a therapist uh who I had had established before the pandemic began. And I went to her and I after looking at FMLA rules and I realized I could take FMLA, I could use sick leave for mental health diagnoses. And so um my therapist apologized for not having brought that up to me, but I ended up taking leave. It started as five weeks and ended up at eight weeks of leave for PTSD associated with the pandemic. And I had encouraged all of my staff to talk to their providers. Most of my staff uh were very mental healthy in my office again must have had therapists or providers that they were seeing throughout the pandemic. And I suggested they all talk to their providers to see whether or not that was something that they would want to do, if that was something that was reasonable for them. And so I will say that more than half of my team took some amount of FMLA, sometimes a couple of weeks, sometimes four weeks for various mental health diagnoses that were either caused by or exacerbated by the pandemic. Um anxiety, depression, PTSD. And so truthfully, that I think, is what saved my team, that ability to step away, to have that protected time, to reflect, to do extra therapy, whatever it was that they needed to do um in order to try and heal from the [?]. That sort of intensity of the pandemic response and the just being vilified and the compassion fatigue and all of that brought on. And so, you know, like I said, mine started as five weeks. It was not I was not ready to come back. And I came back at eight weeks and still wasn’t 100% sure I would stay. But coming back and with phenomenal leadership, who was very understanding and very encouraging of my taking that time off um was able to come back and find that love for public health. And I think I’m seeing that for my staff. But still, you know, when you have a mental health crisis, like I think a lot of individuals in public health had and have, it does take time. There’s still moments where I’m working through that with my team members um and sort of those long lasting effects. 

Dr. Abdul El-Sayed, narrating: We’ll be back with more with Elizabeth Holzschuh after this break. 

[AD BREAK]

Dr. Abdul El-Sayed: Yeah. I want to ask you right, I’m glad that you got to take the time off. And um that’s so important. And I’m thankful that you had the compassion and um foresight to recommend that to your team. I think about how many folks in departments around the country, right? 3000 health departments in this country um who won’t have that opportunity, who could just leave, right? Who will just say, you know what, I’m out. I don’t want to do this anymore. Um. And this is crazy. Across our discipline and frankly, across um county and city public health. What do you think is going to be the lasting impact of this pandemic on our workforce? 

Elizabeth Holzschuh: We are going to have a mass exodus. We already have. Um. And I think we were already in this really um this inflection point in public health where we have a lot of senior or older um public health workers who are on the brink of retiring. And so you have those people who are just like, nope, I’m done. And then you have the younger staff who were in this and just said, no, it’s not worth it for me. I am encouraged by what I’m reading is an increase in applications to public health programs. Um. And we’re seeing some development of undergrad public health programs. And so I think that there’s a large interest in it now because we’ve been thrust to the forefront. But we have been irreparably damaged. We as a discipline, have been irreparably damaged by the pandemic across the board. And what that ultimately means is that our communities will be damaged because we won’t have public health workers who’ve been in the field, you know their communities, who understand how to do the work with that passion and that empathy being there to do it anymore. 

Dr. Abdul El-Sayed: Knowing what you know, if you had the opportunity to have a conversation with all of Congress and the President and HHS leadership about what we needed to do to be ready for the next one, what would you tell them? 

Elizabeth Holzschuh: I mean, money always. So I think one of the struggles with the way public health has been funded over the years is it’s always feast or famine. Right? And that really started around 9/11 with the anthrax letters where public health gets this really big influx of funds. But it’s only for five years and you’re only allowed to use that for this set of things, for this specific disease, this specific issue. Um we saw it with Ebola. We saw it with H1N1. So you can’t ever have there’s never a sustained level of funding to continue staffing, to continue that preparedness um across all diseases. Right. We have seen Ebola, which is transmitted differently than COVID was. But then we saw Zika in there. Right. Diseases are transmitted very differently. And each of those requires a different kind of preparation and different kind of training and different PPE. Um. And so without sort of flexible funding and sustained funding, we can’t be prepared for the next one. And we need an increase in funding if we want to actually have trained public health professionals who can respond in an adequate way. I mean, I employed at some point up to 50 contractors who were doing case investigation and contact tracing and we train them and some of them were very good. But that’s not the way that they did the work was not the way that people who had been in the field for ten years would have done the work and to that level. Um. I also think technology, you know, public health, we still use faxes, which is the most asinine thing ever– 

Dr. Abdul El-Sayed: Yeah. 

Elizabeth Holzschuh: –in 2023 that we use faxes to have information transmitted from our hospitals to our local health departments around cases, around individuals hospital records. You know, the number of times I stood up in front of our board of County Commissioners who act as our Board of Health, and they railed me for not having better hospitalization data. Well, I don’t have access to their hospitalization data. I have to get each of my hospitals and working in a metro region, that’s a lot. And I have patients who and residents who go across state lines. So I can’t get access to those records. I don’t have any visibility on it. I don’t have any visibility on how many people are in the ICU. And while the feds did implement um some systems later on, they weren’t consistently reporting, the data was not clean. We didn’t have access to the backend data. We relied on our statewide partners or our metro partners. You know, and one of the biggest issues for me was our children’s hospital. We have a phenomenal children’s hospital here in Kansas City, but they’re based in Missouri. They’re based in Kansas City, Missouri. And so I would call them and say, hey, can you tell me how many Johnson County kiddos are currently hospitalized with COVID? And A.), they apparently don’t have county as a field in their EHR, so they weren’t able to pull that, um at least not in a report for me. And B.), because of the statute, they told me they had to report to the Kansas City, Missouri Health Department. And then it was incumbent upon the Kansas City, Missouri Health Department to parse out that spreadsheet that they got into the individual counties. It’s not efficient. We don’t they didn’t have the staff. KCMO didn’t have the staff to do that. So we flew blind constantly on these most severe cases, which from an elected officials perspective, that’s what they cared about. They didn’t care about the cases in the community. They cared about the people who are in the hospital and particularly around hospital capacity, which I understood. I just as a data person, I couldn’t answer their questions because our data infrastructure is so disjointed. 

Dr. Abdul El-Sayed: Thinking about the next you know 5 to 10 years and the pipeline that we need to build. If you got the opportunity to sort of talk to every graduating senior who is thinking about a career in public health. What would you say to them? 

Elizabeth Holzschuh: Oh, that’s a good question. You know, certainly if you’d asked me four years ago, my answer would be very different. Or at least it wouldn’t be sort of clouded by the last few years. You know, I think that public health is this wonderful field where no matter your interests, as long as you want to help your community, this is a space for you. You can find something to hold on to and work for, um that you can pour all of yourself, your heart, and your passion and your intelligence into and for that, this field, in my opinion, is unlike any other. Um. It’s something I love. I can’t imagine doing anything other than public health. And I think particularly governmental public health, there’s so much power in that because you are working directly with your community, you are seeing maybe not seeing impacts. Right. It’s a little different than physicians. And I tell my staff this a lot, you know, physicians or nurse pracs or nurses, they can save a life and see them walk out of a hospital. We don’t see that in public health. You implement programs and policies and you hope that down the road, maybe in ten or twenty years sometimes that that will save lives. But the power of working at a population level of having impact on more than one person at a time, it’s incredibly powerful. And as long as you can see that, you can find a place here. Now, what we’ve been through for the last three years was unprecedented. It was hopefully a once in a generation pandemic that we don’t see again, although, you know, given the way of our world, I’m not sure that’s the case. Um. But hopefully we have learned lessons from the last three years. From shortcomings, hopefully electeds will see that we need to be prepared. I’m not you know, I don’t have a ton of faith in that, but I don’t think that I could ever imagine working with a better group of individuals, my colleagues, um and not just in my health department. You know, I’ve worked with the state, I’ve worked with people across our state as well in other health departments. You can’t find a better group of individuals who are working for a common cause. So I certainly still believe in the cause of public health and the work that we do. And I’m excited for people who saw what happened in the pandemic, who wanted to go into public health and who will hopefully come out um with that same level of passion and come into our fields. That’s not always easy. And I will also always advocate for people taking care of their mental health because that’s you know, you made the comment about the people across the the country, the 3000 local health departments. You didn’t have that opportunity to take FMLA. Part of the reason I was able to is because my leadership was supportive. My leadership was very focused on mental health. Um. And so I think for public health leaders, we also need to be focused on that because we do have a burned out and traumatized workforce that if we don’t continue to hold mental health, the mental health of our staff at the forefront of our minds, we will continue to lose people and we will not be able to keep people, especially with the continued politicization of public health across the board. 

Dr. Abdul El-Sayed: I really appreciate you sharing your perspective, and I, I can’t help but reflect on one piece that you shared, which is um clarity of purpose. You know, there are a lot of jobs and roles where you can do really good for people. Um in public health that is really the only reason. Uh. And for folks who want and need that clarity of purpose. Um. This is one of those fields that I think, you know, as difficult as this pandemic was, as many mistakes were made, as much of a failure that we we watched, particularly around communication, public health still remains undefeated in being out there for the right reasons. And um and I think what it takes from us now is to learn the lessons of this pandemic so that the next time we have the communications infrastructure, capacity, lessons, we have the data infrastructure and technology put in place. That we have the funding um that is not feast or famine, as you talked about. And I believe in that future. And I think um I think a lot of other folks do, too. The question is whether or not we as a society, as we talk about a lot on this podcast, um are willing to to invest in that future. But I know, you know, doing a bit of teaching and looking at that next generation coming in, that clarity of purpose is what what brings them to the field. And um I think that is you know almost singular uh in this particular field. We appreciate you being one of those folks and your team uh in Johnson County, and we appreciate you coming on the show to share your experience uh and what it should tell us about the future we need to build. Thank you. 

Elizabeth Holzschuh: Absolutely. Thank you. 

Dr. Abdul El-Sayed: Our guest today was Elizabeth Holzschuh. She’s the director of epidemiology at the Johnson County Department of Health and Environment. Thank you so much. [music break]

Dr. Abdul El-Sayed, narrating: As usual here’s what I’m watching right now. Let’s start with some good news. COVID infections, hospitalizations and deaths have been trending downward now for nearly two months. Average daily deaths are almost as low as they’ve ever been in the pandemic era. But that just means that an average of 327 people died of COVID every day last week. More than 300 people a day, folks. That’s still the equivalent of a 9/11 every week and a half. So, no, the pandemic isn’t over. But it does mean that we may be nearing the end of the tunnel. I say may, because, well, we just can’t really know. Viral evolution is a beast. That possibility that the virus could zig when we’re expecting a zag is only one reason I worry about prematurely calling this over. The other is that in a hurry to walk away, we may never actually take full stock of what happened. Of what we need to do to prevent the next one. Look, I know I sound like a broken record on this, but literally one of the most important things we can do is take a look at what went wrong and how to make sure it doesn’t go wrong again. And the reason I raise that is because although COVID touched all of our lives, it didn’t touch all of them the same way. Don’t forget 1.1 million people and counting don’t get to walk away from this alive. Their family members, their loved ones, their friends, their neighborhoods, their communities, all of them have holes in them. In a recent analysis from The New York Times found that that was particularly true if you were in prison during the pandemic. Prison death rates jumped by 50%. That’s absurd. One and a half times as many people died in prison in 2020 as the year before and 2020, that wasn’t even the deadliest year of the pandemic. But it wasn’t just COVID, it was all the ways that COVID compounded the health challenges incarcerated people face, but without the autonomy or resources to defend themselves. And those investments of resources, they matter. States with the highest rates of prison mortality before the pandemic saw the highest jump in mortality, meaning that if it was unsafe before COVID made it even worse. And that meant that for nearly 2000 more people who died in prison in 2020, compared to 2019, COVID turned a prison sentence into a death sentence. Before I let you go, there’s another analysis I want to share with you, credit scores. They are those odd composite scores that banks and other institutions use to judge credit worthiness. Or probably more aptly, to discriminate against poor folks. If you apply for a credit card or apply for a mortgage or auto loan, banks will check them. It turns out that credit scores, well, they vary wildly by state. Now, look, I know this is not a personal finance podcast, but there’s a reason I’m talking to you about credit scores. That’s because as we’ve tried to establish so many times on this podcast, health is wealth. But also, it turns out that wealth is health. Let me explain. An analysis from the Washington Post used data from a recent economics paper to try to understand why credit scores are so different across states. And guess where they found credit scores were the worst? The South. Sure, Southern states tend to be poorer generally, and you can imagine people are more likely to default on debt. There’s something more. A considerable factor in Southern credit scores, hint, it has a lot to do with what we talk about on this show almost every week. Medical debt. And guess why that is? Well, if you look at the 12 states that have yet to expand Medicaid, you know that government health insurance designed specifically to protect poor folks from financial ruin if they get sick. Well, almost all those states that never bothered to expand it, you guessed it. They’re in the South. So it’s not just poverty. It’s the way that politicians in those states have failed to protect folks from the insecurity imposed by spiraling health care costs in the context of crippling poverty. It’s just another reminder that physical and mental health are also financial health because health is wealth. That’s it for today. On your way out, don’t forget to rate and review. It goes a long way. Also, if you love the show and want to rep us, I hope you’ll drop by the Crooked store for some America Dissected merch. We’ve got our logo mugs and t shirts and our science always wins sweatshirts and dad caps are also available. [music break] America Dissected is a product of Crooked Media. Our producer is Austin Fisher, our associate producers are Tara Terpstra and Emma Illic-Frank. Vasilis Fotopoulos mixes and masters the show. Production support from Ari Schwartz and Ines Maza. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Duran, Sara Geismer, Sandy Girard, Michael Martinez and me. Dr. Abdul El-Sayed, your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and guests and do not necessarily represent the views and opinions of Wayne County, Michigan, or its Department of Health, Human and Veterans Services.