To the Editor:
Despite the huge burden of chronic disease in the United States — four of every five
deaths and $325 billion in health care costs and lost worker productivity per year
(1) — the number of epidemiologists who work on chronic disease at state health departments
remains less than half the number who work on infectious disease and less than one-third
the combined number who work on infectious disease and bioterrorism (2). The percentage
of state and territorial health departments that reported having "full/almost full
or substantial" capacity in epidemiology and surveillance for chronic disease did
not improve between 2001 (52%) and 2004 (48%) (3). The Council of State and Territorial
Epidemiologists (CSTE) recommends that every state have a minimum of five full-time
chronic disease epidemiologists (CDEs), at least one of whom should have a doctoral
degree (4).
To obtain detailed information about chronic disease epidemiology capacity, including
workforce, at state health departments, CSTE conducted a national assessment in March
2003. States were asked to report the number of people who spent at least 50% of their
time at the health department doing work related to chronic disease epidemiology,
as well as the training (academic degrees) and years of chronic disease epidemiology
experience for each of those people. In the survey, chronic disease epidemiology was
described as
[…analyzing and interpreting…] data related to chronic diseases or risk factors for
chronic diseases. At the very least, chronic disease epidemiologists combine data
from different sources, such as vital statistics and population estimates, to calculate
rates. Commonly they calculate rates at one or across several points in time for groups
of persons (e.g., rates by sex, rates by health district). Depending upon their duties
and skills, [Behavioral Risk Factor Surveillance System] coordinators, cancer registry
workers, people in data analyst positions, and others may be considered chronic disease
epidemiologists. If they calculate and interpret rates, they may be counted as chronic
disease epidemiologists.
States were asked to include CDEs who worked at the health department even if they
received their paycheck from another organization (e.g., an academic institution).
Responses were received from 47 states (including the District of Columbia) during
April through July 2003. One state is excluded from the analysis because of missing
information about the educational background of chronic disease epidemiology staff.
Among the 46 states included in the analysis, 25 (54%) had five or more full-time
CDEs, as recommended by CSTE; 40 (87%) had at least one doctoral-level CDE; and 24
(52%) had both (Table).
Our analysis indicates that, despite the large public health burden of chronic diseases,
as of 2003 only about half of states had the minimum chronic disease epidemiologic
workforce recommended by CSTE. As the U.S. population continues to age, states will
need even more CDEs to maintain adequate surveillance and plan data-based interventions
to control high-prevalence chronic conditions such as heart disease, stroke, cancer,
diabetes, chronic respiratory diseases, and arthritis, as well as risk factors such
as smoking, physical inactivity, poor nutrition, and obesity.
State agencies can use the CSTE recommendations and the results of this survey to
customize their approach to developing capacity for chronic disease epidemiology.
For example, the 16 states that have a doctoral-level CDE but fewer than five total
CDEs might focus their workforce development efforts on hiring junior-level epidemiologists.
Every state should have an epidemiology job series in its personnel system (4) to
facilitate the hiring of chronic disease and other types of epidemiologists. Results
of this capacity survey can also help CSTE and the Centers for Disease Control and
Prevention (CDC) identify states that are highest priority for technical assistance
and capacity-building support.
Workforce, although critical, is not the only component of chronic disease epidemiology
capacity. Other components of capacity that have been suggested include 1) access
to data and consultants, 2) data analysis, 3) data interpretation, 4) information
dissemination, and 5) outreach and partnership (4). To improve chronic disease epidemiology
capacity in state health departments, CDC and CSTE should
Develop capacity-building strategies to address specific gaps in either workforce
or other components of capacity in state public health agencies.
Develop minimum standards for routine analysis of chronic disease data.
Identify factors that foster a productive chronic disease epidemiologic unit in state
public health agencies.
Identify elements of the 2003 survey that are most likely to be useful for ongoing
surveillance of capacity for chronic disease epidemiology.
Additional previously published recommendations for increasing capacity should be
given serious consideration as well. These include the following:
Identify funding to support CDEs in states with the greatest need.
Foster, support, and encourage collaboration among state health agencies and academic
organizations in teaching, research, and special joint state and academic projects.
Develop a national educational effort targeted at state health officials, agency or
bureau directors, and program administrators to enhance understanding and awareness
of the role of epidemiologists and chronic disease programs in states (5).
Our study is subject to at least three limitations. First, it may overestimate the
chronic disease epidemiology workforce because all epidemiologists who work at least
50% of their time at the health department doing work related to chronic disease epidemiology
were considered to be full-time employees. Therefore, the true number of chronic disease
epidemiologists in some health departments may actually be lower than what is reported
here. Second, five states were excluded from the analysis because of nonresponse or
missing data. Third, some states, especially those with large populations or an excessive
burden of chronic disease, may require more than the minimum workforce recommended
by CSTE.
Although techniques for assessing and characterizing capacity for chronic disease
epidemiology should be refined, some steps to increase workforce have been undertaken.
Since 1991 the chronic disease State-based Epidemiology for Public Health Program
Support (STEPPS) activity at CDC has provided staff or salary support to 30 states
for chronic disease epidemiology positions. Of the 23 states that no longer receive
support from STEPPS, at least 16 (70%) have made the successful transition to one
or more chronic disease epidemiology positions that are supported independently by
the state. More recent capacity-building activities include the CSTE/CDC Applied Epidemiology
Fellowship Program (6), which places trainees under the supervision of experienced
CDEs at state health departments, and a mentoring program, which pairs CDEs in states
that have limited capacity with more experienced epidemiologists for a period of 6
to 12 months. Both of these activities met with early success but had limited implementation
because of limited funding.
Our study did not examine factors that may be associated with the epidemiology capacity
in state health departments. We intend to conduct such analysis in the future, which
will consider factors such as workforce, competencies, access to key data sets and
software, and academic linkages.