Sometimes we don’t value what we can’t see. It’s why I have to remind patients to keep taking their blood pressure medication even through they “don’t feel a difference.” Trust me, you will if you don’t keep it under control. Public health is much like continuing to take your medication; the work it does is often unseen because it prevents bad outcomes and therefore, doesn’t get the value or appreciation it deserves.
While many Americans likely believe that we are the healthiest nation in the world, we actually have the lowest life expectancy at birth among comparable countries – 78.6 years vs. 82.3 years. And compared to other high-income countries, we trail in nearly all health metrics. Nearly 50% of Americans have a preventable, chronic medical condition yet we only 3% of our health care spending is on prevention and public health programs.
What is the mission of our public health system? The Institute of Medicine articulated it as the, “fulfillment of society’s interests in assuring the conditions in which people can be healthy.” This is a broad, sweeping statement but one that we should have be a strong interest in achieving – and that can only happen when we have both an understanding of what public health is (and isn’t) and adequately fund that work. Because we know that access to health care services isn’t enough.
What is public health?
Public health is the science of protecting and improving the health of people and their communities. It is different from medicine, which emphasizes improvements in the health of individuals. On the other hand, public health is concerned with populations – from your local neighborhood or county to a single country or an entire region of the world. Public health is not a new concept, it’s been around for a long time as I wrote about in this post (500 BCE!). And it has a big job to do – while doctors treat illness and injury, public health works to prevent people from getting sick or injured in the first place.
Some public health work in your community could be childhood immunization programs, cancer screenings, tobacco cessation programs, workplace safety inspections, and work that keeps the air safe to breathe and water safe to drink. This work is happening all around you and you likely don’t even notice. Because the work of public health is *prevention* – so if something never happens and you didn’t even know that something could happen, how do you know to value the work of public health?
Here’s just one example for you: public health is responsible for newborn screenings, which detect rare diseases in newborns to improve early access to intervention. If your child is not found to have a rare disease, you probably think no further. But if your newborn does screen positive, then you’re likely grateful to know this information now, when treatment could be possible.
Who does the work of public health?
The government plays a significant role in the work of public health – often through local, state, territorial, and tribal health agencies. In some states, local health agencies have a lot of independence in their work, while in others the state health agency dictates local actions. The variety in state and local agency structure and function is one of the reasons why coordination can be so challenging within and between health agencies. At the federal level, there are many agencies within the Department of Health and Human Services that have public health functions – the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), the Food and Drug Administration (FDA), and the Occupational Health and Safety Administration (OSHA), to name a few. Outside of the government, public health happens at advocacy organizations like Families USA and Planned Parenthood, in health care organizations like hospitals and nursing homes, and in academia. Public health professionals can conduct research, educate on healthy lifestyles, advocate for policy change, and track epidemics and outbreaks.
One quick note on who doesn’t do the work of public health – most physicians. Yes, I know that physicians have been all over the news in the last year and half discussing the pandemic and its few public health successes and many failures. But it’s important to know that most of the time public health professionals are not physicians and that physicians are not public health professionals. There are some of us with training in both (you’ll see a MD, MPH or DO, MPH after their name or perhaps a PhD) but it’s still rare. Medical school does a very poor job training students to understand and value public health.
Since the 2008 recession, more than 35,000 jobs in state and local public health have vanished. And one survey before the pandemic showed that nearly 50% of the current public health workforce wanted to leave their job. While there have been increasing numbers of applicants to public health graduate programs, we cannot rebuild this workforce overnight without a significant investment. Which leads me to…
How do we fund public health?
We spend about 90% of our $4 TRILLION annual health care costs on common preventable chronic conditions – heart disease, high blood pressure, diabetes, etc. You’d think there would be a clamoring for investment before that point – but no, we only spend about 3% of that on public health. Even when the research shows that increasing our investment in public health by just 10% is estimated to lead to a 6.9% decrease in infant deaths and a 3.2% decrease in cardiovascular deaths. Every $1 spent on public health saves $5.60 in health spending.
In 2017, the CDC’s budget was a little more than $7 billion – that comes out to around $21 per person. Most of that money is distributed to states and localities, but there is wide variation. Missouri got about $6 per person while Alaska gets to be a big spender with around $112. It’s been over a decade without an increase in the CDC’s budget. The ACA tried by creating the Prevention and Public Health Fund, the first mandatory funding stream dedicated to public health with a planned $15 billion. But in 2012 – just 2 years after it was created – Congress passed the first of multiple bills that moved billions from the fund to non-public health activities. Over time, $6.25 billion was used to stall Medicare physician fee cuts and the Tax Cuts and Jobs Act in 2017 cut $750 million to fund the Children’s Health Insurance Program. And on top of all of that, in 2013, sequestration (across the board spending cuts) dealt a major blow to the fund – a 5% decrease in the overall CDC budget, $160 million decrease in funding for local, county, and state public health assistance, $25 million decrease in funding for global infectious disease work (including the National Stockpile), and $13 million less for emerging infectious disease work.
In the last year and a half, legislators have bolstered the government public health response through five supplemental funding bills with the specific purpose of responding to the pandemic, but it is not enough to rebuild our system as needed.
One of the big challenges of public health work is that the funding streams encourage work to remain siloed. In other words, funding for public health work often trickles down from the federal government with a specific focus or for a specific program, making it nearly impossible to re-distribute or to tackle broad, systems based projects. We have seen the consequences of underfunding and undervaluing public health work in the last year and a half.
So what can we do to improve public health?
First, you’re reading this post so you’ve (hopefully) gained a little knowledge into what public health is, who does this work, and how we do (or don’t) fund it. Second, we cannot simply value public health while we are in a crisis. Third, be a registered and engaged voter. This is more than just filling out your primary and general election ballots. It’s calling or emailing your members of Congress, as well as state and local officials, on behalf of issues that impact you and your communities – including adequately funding public health. You elected them, they work on your behalf so tell them what’s important. You can also send a note of thanks if they support a measure you like or oppose a measure you similarly dislike.
Health is shaped by social determinants – the conditions into which we are born, grow, live, and work. Differences in income are strongly associated with poor health through issues of access to quality housing, education, health care services, and employment opportunities. There are also significant disparities and health inequities related to race and ethnicity which persist regardless of income. Large populations of marginalized communities – those experiencing homelessness, the incarcerated, tribal populations, undocumented immigrants – also experience severe disparities in health care, mental health, poverty, and an added layer of social stigma. And then further compounding the rampant inequities laid out very briefly here, we have the mismatch of health care needs and access to care.
Government has played a significant role in creating and exacerbating these disparities and inequities and should play an equal if not greater role in correcting them. The Biden Administration recently released it’s budget blueprint, which is a step in the right direction for public health investment with increases in funding for data modernization, public health workforce and infrastructure, preparation for future pandemics, climate change, addressing social determinants of health, the opioid epidemic, and injury and violence prevention. The Presidential budget is simply a marker of administration priorities and does not have the force of law – it is up to Congress to draft and approve the annual budget, which is currently ongoing.
As a country, we (through the officials that we elect) have made it clear that what we value is medical care. And it’s not that medical care isn’t important, but we need to work to shift the health conversation from it’s stagnant emphasis on cost control, innovation, efficiency, and access to include recognition of the impact of public health in each of those domains. As you can see by the broad policy buckets that we consider to be social determinants of health, there are many opportunities for different parts of the government to invest in and value the health of individuals AND communities.
Featured image from Portland State University.