Public Health Departments Must Be Center of US SDoH Strategy

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This entry is part 1 of 1 in the series JPHMP Thought Leaders

A few weeks ago, I was thrilled to see the White House draw attention to social determinants of health (SDoH) in their new report The US Playbook to Address Social Determinants of Health, written by experts in the Office of Science and Technology Policy. Every day, I see the harm of social factors on health while working in a tribal public health department. I hoped the White House would use the report to outline plans to support public health departments like mine.

But the playbook misses the mark. Though I appreciate the interest on SDOH, the report overlooks the essential role of public health departments in addressing SDOH and sends a worrying sign that our public health system will be forgotten (again) post-emergency. A successful, national SDOH strategy must leverage the ongoing work, expertise, and experience of public health departments by increasing our funding, as proposed in several bills currently in Congress.

How do public health departments address SDOH? The CDC published pieces (here and here) explaining how. They recommend health departments position themselves between healthcare organizations and community/social service entities. Departments can use their data gathering and analysis skills to identify needs and then convene multi-sectoral partnerships to work towards solutions.

This role is described in the 10 essential public health services, the gold standard of departments and the basis for their accreditation. The ten include ‘assessing and monitoring population health,’ ‘investigating root causes of health hazards,’ and ‘strengthening, supporting, and mobilizing communities and partnerships.’

Public health departments are currently delivering these services nationwide. According to the Public Health Accreditation Board, 90% of the US population are eligible for services from an accredited department. Though the COVID pandemic highlighted systemic issues, our public health departments continue to do lifesaving work, day in and day out.

Thus, it was disheartening to see the White House relabel this core work of public health departments in their playbook. They describe three pillars of action that sound very much like the 10 essential services: expanding data sharing and gathering (i.e. assessing population health), supporting flexible funding to address social needs (i.e. investigating root causes of health hazards), and developing backbone organizations (i.e. mobilizing communities and partnerships). Their overarching strategy is to build multisector partnerships and facilitate data sharing to better connect healthcare and social services – the exact area where the CDC tells public health departments to work.

But the 53-page playbook only mentions public health departments, or authorities, four times, three of which are in passing. The only mention relating to their action pillars is for public health departments to play a role in developing community backbone organizations, along with five other types of organizations.

Instead of public health departments, the playbook’s pillars emphasize other types of entities. The federal government is responsible for the first pillar dealing with data requirements for health research funding. State Medicaid agencies lead the second pillar because they can increase flexible funding options for social needs by submitting Medicaid 1115 waivers. Finally, the focus of the third pillar is community-based organizations that can become backbone organizations with support from new and expanded grant programs.

The timing of this report adds further concern. While there were numerous calls for strengthening our public health system just a few months ago, we may be watching public health be forgotten in real-time. Congress has lacked the political will for a national commission to review the response, let alone pass major reforms. Trust for America’s Health, one of the leading public health advocacy organizations, warns of a return to boom-and-bust cyclical funding in their 2023 annual report.

There are many precedents, from SARS, swine flu, and even HIV/AIDS, where public health faded into the background post-emergency. After one such example, the bioterrorism attacks in the early aughts, renowned health historians Elizabeth Fee and Richard Brown noted the déjà vu in the “periodic rediscovery of the deficiencies and unfulfilled promise of U.S. public health.” They wrote of the repeated failure to “sustain progress in any coherent manner” for our public health system. Public health supporters must be vigilant that the new normal does not include the old ways of forgetting public health.

History does not have to repeat itself. Stronger public health departments, which could simultaneously address SDOH and prepare for the next pandemic, are possible if current Congressional proposals are passed. One example is the Social Determinants of Health Act of 2023, which would give $100 million in grants to public health departments to address SDOH in specific, prioritized communities. Another option is Senator Patty Murray’s Public Health Infrastructure Saves Lives Act, which would create $4.5 billion in new funding for core activities of public health departments, including the activities described in the playbook.

I am grateful that the White House is paying attention to SDoH yet concerned that their plans ignore public health departments. Addressing SDoH is a core public health objective and public health departments must be integral to our national SDOH strategy. We must stop cycling attention in public health from urgency and apathy. Fee and Brown wrote more than twenty years ago, “If we do not wish to repeat past mistakes, we should learn lessons from the past to guide us in the future,” which is still relevant today. I hope we finally can.

This post is part of the JPHMP Thought Leaders series. Want to write a post for us? Learn more here.

About the Author

Eric Coles
Dr. Eric Coles, DrPH is a Public Health Officer at the Tule River Indian Health Center, Inc. He is also a co-founder of the National Alliance of Public Health Students and Alums (NAPHSA), which advocates for people with public health degrees. He graduated in 2020 with his Doctor of Public Health.
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