Reflecting on the Past to Divine a Better Future for Public Health
Public health has undergone definition and redefinition in the US since the Union’s conception two centuries ago. There are plenty of definitions to go around. My favorite, hands down, comes from a CEA Winslow, the founder of the Yale School of Public Health and an eminent public health researcher in the last century. One hundred years ago this January, he published a letter in Science Magazine, “The Untilled Fields of Public Health,” wherein he reflects on a conversation he had with two students wanting to think about a future career in public health, and what that might mean for the field going forward. So, to Winslow, what is public health?
Public health is the science and the art of preventing disease, prolonging life and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventative treatment of disease, and the development of social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health. ~ Winslow
What appeals to me so much about this definition is that he recognizes that public health represents the levers by which society can improve population health. Public health isn’t about merely remediating that which is already ill, but, at its core, prevention. In what feels like week 13 of April, in the 15th month of 2020, that central premise — prevention — sounds pretty good right about now.
COVID-19 is taxing the economy, health care systems, and public health systems across the US. It has laid bare the chronic underinvestment from federal and state policy makers in core public health infrastructure. It also has left many in the field wondering, where do we go from here?
Let’s parse that a bit.
Sometimes I liken public health to firefighting. While both groups do prevention, you really only hear about them when something’s on fire, whether that’s a house fire or an infectious disease outbreak. It’s pretty clear that we are in the midst of the Great Chicago Fire.
I won’t belabor excellent analysis and reporting that has been done by scholars and media alike. To reopen the country, it is clear there needs to be improved testing both to identify active infections and those who have recovered, sufficient protective supplies for health care workers, a decreased positive test rate, strong social distancing measures, and substantial social support to help folks weather the response. Each day makes clearer to me that to make this happen, we likely need a congressional commission or board like we had in World War I and World War II, with comparable, congressionally enabled powers akin to the Defense Production Act. Fundamentally, we need to have a group that can, through evidence-based decision making, commandeer supplies and supply chains and distribute the needed supplies to states and localities, as opposed to blocking states or otherwise outbidding them for those resources. After we can establish good testing capacity and do large-scale, technology-assisted, contact tracing and maintain some social distancing, we will hopefully soon make it to one or more vaccines. Then, if we’re lucky, the recovery begins. While preparedness experts constantly talk about the challenges associated with recovery — the incredible costs and the time it takes — it’s not something that’s been widely talked about yet in the media, other than to say that the recovery might “take years.” That’s true. But there’s a lot more, too. Perhaps the subject for a future post? For now, it might be worth focusing our attention more on the “public health” recovery that must happen.
Establishing a Sustained and Sustainable Governmental Public Health System
For a few years now, the CDC has published its funding profiles online. These represent outlays to states and localities, as well as private organizations, to support public health efforts. As I often do, I have found it useful when thinking about the future to look at the historical data to see where and how Congress has empowered CDC to spend these dollars. There are a few things that become clear looking at these data. First, they are just incredibly messy. I’ve tried to clean it up a little bit for you, dear reader, but there’s still plenty more tidying that could be done. It might seem this is more of a “semantic” issue, but I’d argue it’s actually more foundational. The programs, and organization of the programs, change in small and large ways constantly in these data. It’s really hard to make comparisons year to year, which makes it hard to identify gaps and opportunities. The second thing that these data tell us are that Congress just hasn’t substantially invested in government public health in at least the past decade. We see pretty substantial blips when there was Ebola or there was Zika, but otherwise we’re not even keeping up with inflation for most of these programs. Because the CDC is one of the primary funders of public health in the country to states and local health departments, it’s easy to see how a lack of federal investment has helped to drive the underfunding of state and local public health — especially during and immediately after the Great Recession.
It’s easy to point at these numbers and complain. But what could reasonably be done going forward? Enter an extremely timely report from Trust for America’s Health (TFAH).
Source: Author analysis of CDC Funding Profiles. Note that the Profiles excluded Vaccines for Children spending in 2014-2017.
Recommendations for Funding Public Health from Trust for America’s Health
Last week, TFAH released the latest in its public health finance series, this one entitled, “The Impact of Chronic Underfunding on America’s Public Health System: Trends, Risks, and Recommendations, 2020.” In it, TFAH makes a coherent argument that while substantial, perhaps frankly incredible levels of funding might be needed for governmental public health in the near term to respond to COVID-19, there are extremely pressing needs in other areas to shore up deficiencies in the government public health system. Deficiencies that aren’t just infectious disease control. To ascertain this, they look at federal and state investment in governmental public health and shine a light illuminating the harsh reality that many states only nominally invest their dollars into public health — often relying on federal funds to do the heavy lifting.
In a federalist system such as ours, it’s unreasonable to expect that the federal government can or should solve all problems states have. However, it must be the equalizer for meeting basic needs of its citizenry. This is why it is practical for the federal government to be such a large payer in the health care space. Without it, differences, disparities, and inequities would be even more profound across the states. It seems like public health is now in that same boat. States are investing differentially and have relied on the federal government to pick up the slack. But CDC and other federal agencies have not been empowered or financially resourced to do that. This has got to change. TFAH offers a set of concrete ideas for how it might change, and I’ll leave you with those. The COVID-19 response is cracking the foundations of our multi-payer health care system. But so far, we’re only seeing a bending of the public health system. Investment and flexibility both are needed.
Trust for America’s Health Recommendations for Policy Actions
Substantially Increase Funding to Strengthen the Public Health Infrastructure and Workforce
- Invest in cross-cutting public health foundational capabilities.
- Modernize surveillance and data.
- Recruit and retain the public health workforce.
- Provide full-year funding for federal agencies.
- Restore and grow the Prevention and Public Health Fund.
Safeguard and Improve Americans’ Health
- Invest in community prevention of chronic disease
- Prevent substance misuse and suicide epidemics.
- Support the growing population of older Americans.
Improve Emergency Preparedness
- Strengthen public health emergency preparedness, including within the health care system.
- Finance standing response funds for emergencies.
- Prevent infectious disease outbreaks.
- Slow the spread of antimicrobial resistance.
- Prepare for the impact of climate change, including weather-related emergencies.
Make Funding Investments in Ways that Address Community-Wide Social Determinants of Health and Health Equity
- Address community-wide social determinants of health.
- Focus funding on populations at elevated risk due to the impact of racism, poverty, and systemic discrimination and disinvestment.
- Increase funding for programs focused on reducing disparities, including REACH and Good Health and Wellness in Indian Country.
Source: Trust for America’s Health
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