Since 1898, public health nurses in Georgia have been making a difference in their communities by preventing infectious diseases, treating chronic illnesses and promoting healthy behavior.

They improve the health and safety of their communities "through their clinical practices, emergency preparedness, community collaborations and population-based health services," said Carole Jakeway, RN, MPH, chief nurse for the Georgia Department of Human Resources Division of Public Health.

Nurses are the backbone of public health, but that backbone is suffering serious stresses because of low salaries and funding, increased demand for services and changing demographics.

"I get e-mails almost every week from public health department managers telling me that they've lost more nurses," Jakeway said. "Even in rural areas, nurses are leaving for $18,000 to $26,000 salary differences."

Aside from nurses' going to higher-paying jobs, Georgia lost 233 public health nurse positions from 2003 to 2006, because of inadequate funding and budget cuts, according to a 2006 Georgia House of Representatives Study Committee on Public Health report.

The number of public health nurses serving Georgia's 159 counties dropped from 1,700 in 1990 to 1,556 in 2005. In the same period, the state's population increased from 6.4 million to 9 million.

"I can't remember a more challenging time in public health," said Marcia Massengill, nurse manager for the Clarke County Health Department in Athens. "The problems are multidimensional, and we need all the help we can get."

Massengill, who has been a public health nurse for 30 years, said that trying to serve the public with dwindling resources is difficult.

"We have three clinics in Clarke County, including one teen clinic in Athens. We had to drop a DFACS [Department of Family and Children Services] clinic and a second teen clinic due to staffing and funding shortages. We play musical chairs trying to staff the remaining ones," she said.

It's bittersweet when Massengill loses a nurse, as she did recently to a new Veterans Affairs clinic. She's glad that the nurse is making twice her former salary — "the bottom line is that we all have bills to pay" — but she is concerned for the department and the community.

"When people call about an opening and we tell them the salary, we hear silence or laughter," Massengill said.

Under the Georgia Merit System, the annual starting salary for a public health nurse is $31,474 (the lowest in the Southeast). New nursing school graduates hired at hospitals make $40,000 to $45,000 or more. Public health nurse managers make $51,173, compared with the Georgia market average of $83,040 for nurse managers.

Doing more with less

Barrow County Health Department nurse manager Susan Kristal supervises a licensed practical nurse who has 28 years' experience but makes only $800 a year more than her son, a hospital orderly.

"There's something wrong with that. Our salaries are not even in the competitive realm, and there's no real career track, either," said Kristal, RN. "I stay because I want to give people education and hope and because I get to see results. But these days, I have to re-evaluate why I stay pretty often."

Public health nurses are struggling to do more with fewer resources, as demand grows for their services. Inflation, population growth and changes in Medicaid and indigent health funding are squeezing already-small budgets.

"The population has changed, and we're seeing an influx of patients from different cultures. We're coping with more language barriers, more infectious and chronic diseases — and more people are uninsured," Kristal said.

Her department recently provided a breast exam for a woman who had been downsized from her job. The patient had started a small business but couldn't yet afford health insurance. The screening detected cancer in its early stages.

"We're the safety net for many people," Kristal said.

The Clarke County Women, Infants, Children clinic used to treat walk-in patients, but high demand for services forced the staff to turn many people away. The clinic now uses a same-day appointment system to manage the flow of patients.

"We're trying to be creative, but we still can't see everyone who calls," Massengill said.

Programs such as Children First, which sent nurses to visit struggling new moms, have been cut, even though nurses believed that the early intervention helped prevent some child abuse and neglect.

Public health nurses direct community initiatives for growing health concerns, such as diabetes, hepatitis, obesity and tuberculosis, and they also counsel clients.

"People think it's a 9-to-5 job, but it's not, really, because everyone wants a little piece of you." Kristal said. "There's no shortage of public health needs — just a shortage of resources and time."

Her department, working with other community groups, has started a task force to raise awareness about the high teen pregnancy rates in her county and about the economic and health risks for teenage mothers and their babies. From 2000 to 2004, Barrow County's teen pregnancy rate was 63 out of every 1,000 girls ages 15 to 19, higher than the rates in Georgia (57 out of 1,000) and in the United States (42 out of 1,000).

The task force's goal is to provide prevention-oriented school and community-based programs to give teens the tools to make healthy decisions, with the hope of reducing teen pregnancies, improving high school graduation rates and achieving a healthier community.

Since Sept. 11, 2001, the role of public health nurses has grown to include emergency preparedness for biological and chemical terrorism.

"In hurricanes, tornadoes, biological and chemical terrorism, mass casualty incidents and pandemic flu, public health nurses are critical," Jakeway said. "Trained to be experts, they know their communities [and] the leadership network and are skilled at bringing people to the table."

The Georgia House study committee report found that the shortage of nurses and a lack of public health infrastructure are putting Georgia's emergency-response ability at risk.

Public health nurses have always been advocates for others in the community, but now they have decided it's time to advocate for themselves. Jakeway encourages nurses to let local and state officials know what challenges public health nurses face.

"We really need to educate people about all that public health nurses do," Massengill said.

Wearing many hats

Public health nurses have many roles. They perform physicals and gynecological exams and dispense medications for tuberculosis and HIV patients. They immunize children and run free screenings to identify those at risk for heart attacks or strokes. They teach diabetics how to manage their diets. They stay prepared for mass health emergencies.

With the training they get in community health, public health nurses often have more autonomy and responsibility than other registered nurses. Because of their specialized training, "it takes a year to get new nurses oriented to public health — to teach all the skills and competencies — so replacing an experienced nurse is very costly," Jakeway said.

"We're fortunate to have many dedicated nurses who love what they do," Kristal said. "Individually, the changes we see may seem small, but they can have a really big impact on a community — like when someone tells me that he's listened and quit smoking, or when you teach a new mom about breastfeeding and proper nutrition, or when a 17-year-old with an STD [sexually transmitted disease] asks you how to have a healthy relationship. That's when you know you're getting somewhere.

"It makes me proud of public health when I think of all we do. People trust the care and information that they get here, but I'm concerned, too. It leaves a vacuum when nurses retire or leave for better pay. If we can't replace them with bright, young people, we're in trouble."

The House Study Committee report recommended increased salaries, the development of a progressive career track for nurses and tuition support, including service-cancelable loan programs for public health nurses.

"I'm hopeful and optimistic, because the Legislature is keenly interested in these issues," Jakeway said.

BY THE NUMBERS

In 2006, public health nurses in Georgia:

- Collected 10,621 specimens for tuberculosis laboratory cultures.

- Screened 8,116 contacts of tuberculosis cases and started 1,062 patients on preventive medication.

- Educated 2,390 health care providers and 3,550 citizens about tuberculosis prevention and treatment.

-Tested 111,667 people for HIV and treated 9,500 people infected with HIV.

- Administered approximately 610,500 immunizations.

- Gave 273,541 flu shots.

- Screened 3,658 children for chronic medical conditions; 24,500 people for hypertension; 2,100 people for diabetes mellitus; 16,385 people for breast cancer; and more than 120,000 women for cervical cancer.

Sources: Senate Resolution 354 and House Resolution 333, which commended and thanked public health nurses for their contributions to the health and well-being of Georgians.