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Iowa and South Carolina Redesign Their Public Health Agencies

May 19, 2023

No one needs to point out that the nation’s public health system does not always function well, and the same can be said for environmental health. States are learning that cutting budgets and resources lead to subpar services and outreach to the public. It also leads to staff burnout.

Close to one half of the public health workforce has left the profession since 2017, with the resignations accelerating during the COVID-19 pandemic. According to the Association of State and Territorial Health Officials (ASTHO), 46% of state and local public health employees left their positions between 2017 and 2021. A majority of these employees (77%) had less than 5 years of experience.

Congress recognized this problem by providing $3.2 billion in federal funding to fix the exodus of employees from the state and local public health workforce. 

Dr. Michael Fraser, CEO of ASTHO responded saying “we need to make public health departments thrive and good places to work, but $3.2 billion won’t correct this problem.” 

Dr. Anne Zink, director of public health in Alaska expressed similar sentiments when she said, “Public health has become reluctant to talk about their profession. They don’t have the basic tools to make public health work. Burnout comes from working in a system that does not support its workforce.”

States are beginning to recognize that public health is not meeting its goals and missions. One state, Iowa, is seeking to remedy this situation by combining its public health agencies. South Carolina n the other hand,  is trying a solution that divides its main public health agency. Both efforts impact the environmental health programs in these states.

South Carolina 

South Carolina is one of three states that still combine environmental regulation and healthcare under one agency—the South Carolina Department of Health and Environmental Control (DHEC). DHEC is one of South Carolina’s largest agencies, employing more than 3,500 full-time workers. The department does everything from restaurant inspections and running county health departments to monitoring shellfish beds. Lawmakers have complained that the agency has become too powerful and ineffective. For the second year in a row, South Carolina senators voted to break up DHEC.

The agency had not done itself any favors, say sources close to DHEC. The former director cut staff and resources, which lead to a backlog of unmet services including the inspection and permitting of onsite wastewater.

The legislation would create a Department of Public Health and a Department of Environmental Services overseen by directors appointed by the governor. The board of health would be abolished.

The environmental control functions of DHEC would transition to the Department of Environmental Services, which would also take over the current Water Resources Division within the Department of Natural Resources. Food safety would be overseen by the Department of Agriculture, which lacks epidemiology staff and does not have a food safety laboratory. The Department of Agriculture also lacks a public health mission.    

From the legislature, the overall attitude is that DHEC does not operate well. “I think right now DHEC is spread thin. They've got not only the state, but the federal government piling on new responsibilities, and then they're not getting the funding or the staffing to carry out those missions,” said sources close to the legislature. The question remains, however, if these moves without additional staff or resources will improve services.


Iowa is choosing another approach that combines human services, public health, and aging services into one mega department: the new Iowa Department of Health and Human Services (DHHS). Environmental health, however, is being reassigned to the Department of Inspections and Appeals (DIA).

In summer 2022, the state combined the Department of Public Health (DPH) and the Department of Human Services (DHS) in an effort to be more efficient and responsive to the public. Then in May 2023, the DPH and DHS announced a new agency—the Department of Health and Human Services (DHHS). The new department will employ 5,484 state workers; however, only 462 employees have been assigned to public health and fewer than 50 to environmental health.

DHHS was developed through 2 years of work on the realignment effort between the former agencies to create their new mission, vision, and guiding principles. DHHS will oversee more than $2 billion in state funding, which is greater than one quarter of the state’s budget. Millions of Iowans will be impacted by the services offered.

Public health in Iowa has long had trouble responding to needs and requests due to a lack of resources. This was amplified during the COVID-19 pandemic. Governor Kim Reynolds was not pleased with the pandemic response from the Iowa Board of Health. This new bill eliminates the board with the secretary of the new agency being appointed and reporting directly to the state governor.

The Legislative Fiscal Office says the new agency will eliminate 110 positions and reduce overall expenditures by $6.4 million, with $4.4 million coming from federal sources.
Environmental health will primarily be reassigned to DIA and most services will be delegated throughout the 99 county public health agencies with limited support and oversight from the state. Food safety will stay with the state for most counties; 23 counties will handle food safety within their jurisdictions.

Senator Zach Wahls, who leads the Democratic minority party in the Iowa Senate, said he wants to be certain that the state does not lose focus from its public health department, especially on the heels of the COVID-19 pandemic. “I think, given how substantial the human service portion is going to be of the newly merged DHHS, making sure that we don’t lose sight of the public health mission that is continuing to be front and center,” he stated.

Similar to South Carolina, this restructuring in Iowa does not come with additional resources for environmental health and public health programs.

For more information, contact Government Affairs Director Doug Farquhar.