The coronavirus pandemic has exposed crucial shortcomings in our public health system. Plenty of experts said a pandemic was coming, but that didn’t affect a response that included a lack of coordination, inadequate funding and a failure to be strategic.
There is no simple solution either to the immediate crisis or to the underlying concerns. But one way to improve the odds that we get the public health system we need, as opposed to the one we have, would be to add a secretary of Public Health Systems to the president’s cabinet.
True, we already have a designated national public health unit within the Department of Health and Human Services, the Centers for Disease Control and Prevention. The National Institutes of Health and the Food and Drug Administration are also part of H.H.S., as is the assistant secretary for preparedness and response. And don’t forget the Federal Emergency Management Agency in the Department of Homeland Security. Or the National Security Council, which created in 2016 a playbook (now discarded) for a strategic federal response to a pandemic.
In theory, these entities taken together should have put in place the measures needed to ensure an effective early warning system, an adequate strategic stockpile, needed hospital surge capacity and an intergovernmental compact with state and local agencies on who would do what.
And yet they didn’t.
So what explains our lack of readiness? Sure, there are always unexpected situations that complicate effective performance. No one would have predicted that the C.D.C. would contaminate coronavirus test kits. Or that we would have a president who would show such reluctance to heed the advice of public health scientists.
But organizational structure and formal accountability really do shape outcomes. And the current federal model follows the longstanding treatment of public health as a subsection of the traditional medical care system. The C.D.C., for example, with its $8 billion budget, is housed in a government entity that is focused above all on the $1.2 trillion insurance programs (Medicare and Medicaid) it administers. More generally, public health gets less than 3 percent of the $3.7 trillion in national health spending.
How did we get here? Ironically, the story begins with public health victories. Before the 1940s, medical care was rudimentary and largely lacked scientific expertise. Local and state governments, then charged with the task of protecting the health of their communities, focused attention on nonmedical determinants of health, using regulatory authority to ensure working sewage systems, safer food, chlorinated water, cleaner streets, better workplace conditions, improved housing and emergency preparedness. These interventions produced steep increases in life expectancy.
Following World War II, however, the federal role in health care grew enormously, arriving precisely when there were extraordinary advances in medical research and care. Federal policy came to be grounded in the assumption that clinical medicine can conquer all disease. This means more dollars for hospitals and for health insurance programs that offer access to the latest medical technologies and fewer dollars for public health and the nonmedical factors that affect health.
The bias against public health is also sustained by the complicated effort to demonstrate an immediate return on investment for the public health dollar, the reality that public health measures often require restrictions on individual liberty and the fact that public health is politically invisible until a crisis strikes.
We actually do have more than 3,000 local and state health departments, still the core of our public health system. These agencies prevent threats to health (providing immunizations and screenings), promote healthy living (eat better, stop smoking, be physically active), develop policies to protect community members (inspection of food services), diagnose and investigate health problems and help with emergency preparedness and disaster response.
But these agencies are inadequately funded and understaffed. Incredibly, by 2018, there were 56,000 fewer public health workers than there were a decade before. So when the coronavirus arrived, most local health departments were not properly resourced to conduct needed diagnostic tests, to isolate the infected, to determine who had contact with the infected and to provide support to vulnerable populations.
So this moment when public health and preparedness are highly visible is the perfect time for a steady national focus on how to create a public health system for the 21st century. Without a strong national voice, it is not likely to happen.
The current pandemic also illustrates the interdependence of public health and acute care, as demonstrated by the heroic workers now saving lives in hospital emergency rooms and I.C.U.s. But with an effective system of public health preparedness, we would have had less need for such a dramatic surge in acute care interventions.
Moreover, a cabinet agency is not an antidote for poor leadership. It’s unlikely that President Trump would pay more attention to a public health secretary than he has to Alex Azar, the secretary of H.H.S. Nor is a cabinet agency a substitute for the 3,000 local and state health departments that should remain the core of our public health system.
But just as the Sept. 11 attacks changed America (and the world), so too will Covid-19. We need thousands of additional public health workers, more and better public health labs, increased investment in data analytics and early warning systems, and more effective control over the supply and distribution of needed protective equipment. Our state and local health departments also need a dedicated federal partner that can supply them with data, listen to their concerns, channel funds effectively and create clearer lines of communication back and forth.
Most of all, we need a health system in which acute medical care is recognized as just one (very important) partner among the various sectors that shape our overall health.
It will take strong national leadership, billions of dollars and a 21st-century Marshall Plan to create the public health system we need. The new secretary of Public Health Systems should be the person who leads that effort.
Michael S. Sparer is the chairman of the department of health policy and management at Columbia’s School of Public Health.
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Source: NY times