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Supporting the Public Health Workforce Requires Collective Actions to Address Harassment and Threats

Invited Commentary | Public Health
Supporting the Public Health Workforce Requires Collective Actions
to Address Harassment and Threats
Sarah E. Gollust, PhD
Elsewhere in JAMA Network Open, Topazian and colleagues
report the striking finding that more
than 1 in 5 US adults believe that harassing or threatening public health officials because of business
closures during the COVID-19 pandemic is justified. Specifically, the authors analyzed 2 waves of a
nationally representative panel survey of US adults, in November 2020 and July to August 2021, and
found increases in the share of adults who endorsed harassments and threats for public health
workers, with 25% of respondents justifying harassing and 21% justifying threatening such officials.
This important study not only documents the overall prevalence of these concerning beliefs, but it
goes deeper to identify particular groups who are more likely to endorse either of these beliefs at 1 or
more of the time points: men, those with lower income and education, Hispanic people, younger
people, and those with less trust in science. Surprisingly, given persistent partisan differences in
other types of pandemic attitudes and beliefs even very early in the pandemic, Republicans were no
more likely to endorse holding these beliefs than were Democrats in November 2020. However, a
partisan gap emerged in 2021: 34% of Republicans believed harassment of public health officials was
justified in 2021, compared with a still sizable 19% of Democrats. Furthermore, the authors detected
growth in reporting these views in 2021 among groups with higher education and more trust in
science—findings the authors suggest may be because of the public’s “pandemic fatigue” with
restrictions but could also reflect changes in perceived norms, such that respondents felt less social
desirability bias in reporting their beliefs endorsing harassment as the pandemic went on.
To be sure, readers might respond that these estimates are measures only of beliefs, not of
behaviors; after all, these are study participants’ top-of-head perceptions when asked to respond to
a survey on a topic they may not have considered before. Are these responses meaningful?
Unfortunately, data from other sources strongly suggest these beliefs endorsing the permissibility of
harassment translated to actions taken. In fact, the focal article of the May 2022 issue of the
American Journal of Public Health quantified actual reported experiences of harassment and threats
among workers at local health departments (LHDs) in 2020.
Ward and colleagues
found that of
583 LHDs that responded to their survey, 335 departments (57%) reported at least 1 instance of
harassment targeting leadership or staff, ranging from social media backlash, broadcast of personal
information, threatening messages, demonstrations, and vandalism. These experiences of
harassment are consequential: they contribute to public health workers leaving the workforce
facing significant mental health challenges.
A recent large-scale study of the national public health
workforce (44 732 participants) conducted between September 2021 and January 2022 found that
56% of public health workers reported at least one symptom of posttraumatic stress disorder; 22%
reported their mental health as fair or poor; 41% of public health executives reported being bullied,
threatened, or harassed; and 32% said they are considering leaving their positions.
It is important to contextualize these findings within broader trends in public attitudes about
public health and about politics. First, the practice of public health, particularly the work of
governmental public health officials, has always been political.
However, for the most part, their
efforts have been relatively invisible to the public. In fact, a truism in the field of public health is that
when public health is effective, it is invisible. The COVID-19 pandemic rendered public health
extremely visible, and as a consequence, public health as a field and public health workers became
more visibly political. Indeed, the survey conducted by Topazian and colleagues
suggests a
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Open Access. This is an open access article distributed under the terms of the CC-BY License.
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conflation between public health workers and politicians, since they found that the vast majority of
respondents who justified harassment and threats toward public health officials in 2020 justified the
same for politicians.
This key finding echoes broader trends: in the 2022 book Radical American
Partisanship, political scientists Nathan Kalmoe and Lilliana Mason use extensive survey data (more
than a dozen nationally representative surveys) to document an increase from 2017 to 2021 in the
public’s willingness to endorse political violence, including support for threats of violence against
political leaders and members of the opposite political party.
Notably, just as Topazian and
observed similar levels of reporting of violent beliefs toward public health officials across
the political spectrum in 2020, so too do Kalmoe and Mason
: they found that rates of violent views
toward the opposing party were similar for Republicans and Democrats through 2020, after which a
partisan difference emerges, with Republicans reporting more support for violence. These data
collectively suggest that the endorsement of violence against public health officials is a symptom of
a broader illness in contemporary US politics, with potentially grave consequences.
What can be done? Given the threat to the public’s health posed by a depleted and demoralized
workforce, investment in the workforce and in strategies to neutralize antagonism amongthe public
are needed. For the latter, one positive finding that Kalmoe and Mason
report is that messages
communicated by political party leaders denouncing violence can reduce support for such violence
among the public, particularly among those who have strong attachment to their partisan group.
Their work suggests that if party leaders were to strongly endorse antiviolence and support for public
health workers, this could have promise in mitigating these views. In a recent commentary, Michael
Fraser, the chief executive officer of the Association of State and Territorial Health Officials, similarly
endorsed the promise of a communication strategy to “remind all Americans about the importance
of our collective good”
to help mitigate antagonistic attitudes. Investment in communication
research is critical to assess which of many possible messaging approaches can best neutralize
negativity and bolster support for public health, and as Topazian and colleagues note,
communication and engagement strategies should be nuanced and tailored to different subgroups.
More tangibly, however, direct and immediate investment in the public health workforce is
critical. Ward and colleagues
describe a range of needed resources for the public health workforce,
including funding, bolstered staffing, worker safety protections, better reporting of violence, and
legal support for workers. Social science research affirms that no one silver bullet will reduce the
hostility of political discourse at the moment, whether about politics in general nor public health in
particular. However, the price of inaction and hopelessness is too high. The evidence provided by
Topazian and colleagues
should activate all readers to consider the many ways in which they can
advocate for more investment in public health, including advocacy for investment in the training and
education of future public health professionals, supporting increased resource allocation to protect
the safety and mental health of the current workforce, and individual acts of outreach to support and
thank public health workers in our communities—all of which could better protect those workers on
whom our collective health and well-being depend.
Published: July 29, 2022. doi:10.1001/jamanetworkopen.2022.23501
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Gollust SE.
JAMA Network Open.
Corresponding Author: Sarah E. Gollust, PhD, Division of Health Policy and Management, University of Minnesota
School of Public Health, 420 Delaware St SE, MMC 729, Minneapolis, MN 55455 (
Author Affiliation: Division of Health Policy and Management, University of Minnesota School of Public Health,
Conflict of Interest Disclosures: None reported.
JAMA Network Open | Public Health Supporting the Public Health Workforce
JAMA Network Open. 2022;5(7):e2223501. doi:10.1001/jamanetworkopen.2022.23501 (Reprinted) July 29, 2022 2/3
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1. Topazian RJ, McGinty EE, Han H, et al. US adults’ beliefs about harassing or threatening public health officials
during the COVID-19 pandemic. JAMA Netw Open. 2022;5(7):e2223491. doi:10.1001/jamanetworkopen.
2. Ward JA, Stone EM, Mui P, Resnick B. Pandemic-related workplace violence and its impact on public health
officials, March 2020–January 2021. Am J Public Health. 2022;112(5):736-746. doi:10.2105/AJPH.2021.306649
3. Smith MR, Weber L. Public health off icials are quitting or getting fired in throes of pandemic. Kaiser Health
News. August 11, 2020. Accessed June 22, 2022.
4. De Beaumont Foundation. Rising stress and burnout in public health. March 2022. Accessed June 22, 2022.
5. Mullan F. Don Quixote, Machiavelli, and Robin Hood: public health practice, past and present. Am J Public
Health. 2000;90(5):702-706. doi:10.2105/AJPH.90.5.702
6. Kalmoe NP, Mason L. Radical American Partisanship: Mapping Violent Hostility, Its Causes, and the
Consequences for Democracy. University of Chicago Press; 2022. doi:10.7208/chicago/
7. Fraser MR. Harassment of health officials: a significant threat to the public’s health. Am J Public Health. 2022;
112(5):728-730. doi:10.2105/AJPH.2022.306797
JAMA Network Open | Public Health Supporting the Public Health Workforce
JAMA Network Open. 2022;5(7):e2223501. doi:10.1001/jamanetworkopen.2022.23501 (Reprinted) July 29, 2022 3/3
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... 40 This harassment, consistent with the hostility that has hit science and related fields during the pandemic, requires broader protections and support for PHWs, whether it be legal, technological, security, or mental health. 41,42 An in-progress review of the COVID-19 response has also indicated the need for increased availability of risk-communication training to better equip PHWs with the tools necessary to communicate with the public during a public health emergency. 6 ...
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Objective: Understanding the challenges public health workers have faced is critical to reinforcing, revitalizing, and strengthening the public health workforce. We measured and identified the level and causes of psychological distress among public health workers during the COVID-19 pandemic in New York State. Methods: We used a knowledge, attitudes, beliefs, and behaviors survey to ask public health workers at local health departments about their experiences working in public health during the pandemic, including questions relating to harassment from the public, workload, and work/life balance. We used the Kessler-6 scale to measure participants' psychological distress using a 5-point Likert scale, with higher scores indicating greater psychological distress. We calculated descriptive statistics and conducted a regression analysis to determine the factors associated with public health worker psychological distress, and we coded open-ended comments for qualitative analysis. Results: During September 7-20, 2021, 231 public health workers from 38 local health departments completed the survey. Respondents were predominantly non-Hispanic White (89.6%), female (82.1%), full-time employees (95.1%), and located in Upstate New York. On a bivariate level, the strongest predictor of distress was job satisfaction (-0.388), followed closely by COVID-19 fatigue (0.386) and feeling bullied or harassed by the public (0.331). In the regression analysis, 2 additional factors were associated with distress: considering leaving their job due to the pandemic and concerns about exposure. Themes from the qualitative analysis strongly supported these findings. Conclusions: Understanding the challenges public health workers have faced during the pandemic is critical to inform the actions needed-stronger state laws protecting against harassment, workforce incentives, and commensurate funding-to reinforce and revitalize our frontline public health workforce.
Full-text available
Since the mid-19th century, when the first formal health departments were established in the United States, commissioners, directors, and secretaries of public health have functioned as senior members of the staffs of public executives, mayors, governors, and presidents. They have provided important political, managerial, and scientific leadership to agencies of government that have played increasingly important roles in national life, from the sanitary revolution of the 19th century to the prevention of HIV/AIDS and the control of tobacco use today. Although public health officials come from a variety of backgrounds and oversee agencies of varied size and composition, there are philosophical themes that describe and define the commonality of their work. These themes are captured metaphorically by 3 celebrated figures: Don Quixote, Machiavelli, and Robin Hood. By turns, the public health official functions as a determined idealist (Don Quixote), a cunning political strategist (Machiavelli), and an agent who redistributes resources from the wealthier sectors of society to the less well off (Robin Hood.) All 3 personae are important, but, it is argued, Robin Hood is the most endangered.
Importance: The rise in attacks on public health officials has weakened the public health workforce and complicated COVID-19 mitigation efforts. Objective: To examine the share of US adults who believed harassing or threatening public health officials because of COVID-19 business closures was justified and the factors shaping those beliefs. Design, setting, and participants: The Johns Hopkins University COVID-19 Civic Life and Public Health Survey was fielded from November 11 to 30, 2020, and July 26 to August 29, 2021. A nationally representative cohort of 1086 US adults was included. Main outcomes and measures: Respondents were asked how much they believed that threatening or harassing public health officials for business closures to slow COVID-19 transmission was justified. Adjusted differences in beliefs regarding attacks on public health officials were examined by respondent sociodemographic and political characteristics and by trust in science. Results: Of 1086 respondents who completed both survey waves, 565 (52%) were women, and the mean (SE) age was 49 (0.77) years. Overall, 177 respondents (16%) were Hispanic, 125 (11%) were non-Hispanic Black, 695 (64%) were non-Hispanic White, and 90 (8%) were non-Hispanic and another race. From November 2020 to July and August 2021, the share of adults who believed harassing or threatening public health officials because of business closures was justified rose from 20% (n = 218) to 25% (n = 276) (P = .046) and 15% (n = 163) to 21% (n = 232) (P = .01), respectively. In multivariable regression analysis, respondents who trusted science not much or not at all were more likely to view threatening public health officials as justified compared with who trusted science a lot (November 2020: 35% [95% CI, 21%-49%] vs 7% [95% CI, 4%-9%]; P < .001; July and August 2021: 47% [95% CI, 33%-61%] vs 15% [95% CI, 11%-19%]; P < .001). There were increases in negative views toward public health officials between November 2020 and July and August 2021, among those earning $75 000 or more annually (threatening justified: 7 [95% CI, 1-14] percentage points; P = .03), those with some college education (threatening justified: 6 [95% CI, 2-11] percentage points; P = .003), those identifying as politically independent (harassing justified: 9 [95% CI, 3-14] percentage points; P = .01), and those trusting science a lot (threatening justified: 8 [95% CI, 4-13] percentage points; P < .001). Conclusions and relevance: While antagonism toward public health officials was concentrated among those doubting science and groups most negatively affected by the pandemic (eg, those with lower income and less education), the findings of this study suggest that there has been a shift toward such beliefs within more economically advantaged subgroups and those more trusting of science. Restoring public trust in public health officials will require nuanced engagement with diverse groups.
Objectives. To characterize the experience and impact of pandemic-related workplace violence in the form of harassment and threats against public health officials. Methods. We used a mixed methods approach, combining media content and a national survey of local health departments (LHDs) in the United States, to identify harassment against public health officials from March 2020 to January 2021. We compared media-portrayed experiences, survey-reported experiences, and publicly reported position departures. Results. At least 1499 harassment experiences were identified by LHD survey respondents, representing 57% of responding departments. We also identified 222 position departures by public health officials nationally, 36% alongside reports of harassment. Public health officials described experiencing structural and political undermining of their professional duties, marginalization of their expertise, social villainization, and disillusionment. Many affected leaders remain in their positions. Conclusions. Interventions to reduce undermining, ostracizing, and intimidating acts against health officials are needed for a sustainable public health system. We recommend training leaders to respond to political conflict, improving colleague support networks, providing trauma-informed worker support, investing in long-term public health staffing and infrastructure, and establishing workplace violence reporting systems and legal protections. (Am J Public Health. Published online ahead of print March 17, 2022: e1–e11. )
Rising stress and burnout in public health
  • De Beaumont Foundation
De Beaumont Foundation. Rising stress and burnout in public health. March 2022. Accessed June 22, 2022.
Public health officials are quitting or getting fired in throes of pandemic. Kaiser Health News
  • M R Smith
  • L Weber
Smith MR, Weber L. Public health officials are quitting or getting fired in throes of pandemic. Kaiser Health News. August 11, 2020. Accessed June 22, 2022.