Solving America’s public health crisis means addressing historic inequities
What is “public health” and why does it matter?
The COVID-19 pandemic has provided painful, if illuminating, answers to those questions over the past 14 months. At its most basic, public health’s most critical charge is to prevent sickness and illness by keeping people healthy in the first place. With nearly 600,000 Americans dead and millions more infected — and people of color and lower-income people bearing disproportionate impact on both counts — our public health system has clearly failed.
More accurately, we have failed our public health system, allowing it to atrophy over time by denying it the funding, attention and respect it deserves. Public health officials and their mission have traditionally and deservedly enjoyed bipartisan support, but the politicization of the pandemic has demonized the very people who have worked tirelessly to keep us safe. Through it all, we have suffered from a failure of imagination, unable or unwilling to understand how health and well-being are the responsibility of most every facet of government.
Public health naturally takes center stage during a pandemic, but we are paying a high price for our past neglect. Anyone who has been unable to stay home to care for a sick loved one, because doing so would mean lost income, has suffered because of our failure to provide universal paid sick and family leave. Anyone whose child never saw the inside of a classroom because the school district didn’t have the means to keep everyone safe sees how we have failed to connect health and education. Anyone who still can’t get to a vaccination site or a doctor’s office understands how transit access can impact the health of individuals and their communities.
As two people who have worked in public health for decades at the federal and local levels, we have seen how the United States only prioritizes public health during emergencies and how we define public health too narrowly. The pandemic’s disproportionate impact on Black and Brown people is the latest entry to a long list of disparities, from the nation’s abysmal maternal mortality rate to food insecurity to the dearth of safe and affordable housing. This requires a shift to a proactive approach that puts public health on solid ground, with sustainable and equitable funding — even during periods of calm — and expands the mandate of public health to confront the biggest health threat of our time: racism itself.
This work will take significant investments, require new thinking and come with the understanding that generations of inequities will require generations of work. We must engage with communities most affected by racism, ensuring that public health departments reflect the communities they serve and that the perspectives of people who have the lived experience of inequity are driving decisions. We will need to retool data systems that form the backbone of public health science so that data can be collected, analyzed and broken down by age, race, ethnicity, gender, disability, neighborhood and other factors. A modern data system could have saved lives during this pandemic by allowing us to provide the support and resources in the communities of greatest need. That same system could identify disparities that reflect our society’s gravest inequities and, in many cases, reveal patterns of structural racism.
Americans clearly see the need for a more robust public health infrastructure, according to a new national poll by the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health. Nearly three-quarters of people believe public health programs are vital to the nation’s health, and they support substantial increases in federal funding to help health departments and agencies carry out their missions. The American Rescue Plan Act included billions of additional federal dollars for public health, including $7 billion to rebuild the public health workforce — a necessary infusion, but a mere down payment on what is needed.
We entered this pandemic facing a massive structural deficit in our nation’s public health needs. Of the $3.8 trillion spent on healthcare in the U.S. in 2019, less than 3 percent was dedicated to public health and prevention. Rather than fortify our public health spending during periods following emergencies, too often we have reduced it. For instance, the Centers for Disease Control and Prevention’s budget for public health preparedness and response programs, when adjusted for inflation, has been halved since 2003. This has happened during a span that includes the current pandemic; outbreaks of other viruses like Ebola and Zika; the opioid epidemic; Hurricanes Katrina, Sandy and Harvey; and the unprecedented California wildfires. A top to bottom review of and recommitment to public health and its needs is long overdue.
Finally, policymakers must go beyond merely documenting health disparities and instead proactively address their root causes. Public health decision-makers and planners should be at every table, from housing to education to food access to the environment and beyond. At the federal level, that means a fundamental shift in our understanding of the mission of agencies and departments. The Department of Housing and Urban Development is a public health agency because its work can help ensure that the redlining scars of our past can give way to adequate and safe housing in communities of opportunity in the future. The Department of Agriculture is a public health agency because millions of families lack access to healthy, affordable food. The Department of Education is a public health agency because education is tied to better-paying jobs and longer, healthier lives. And the Department of Labor is a public health agency because if the minimum wage is not a living wage, families will continue to lack the resources for a healthy life. Every federal agency has a public health mission and mandate.
We will not create a healthier, sustainable and more equitable system until income and skin color are no longer determining factors in how well and how long people live. If this pandemic is not the nation’s wake-up call to the need for a long-term response to our dire public health needs, we can’t imagine what will be.
Richard Besser, president and CEO of the Robert Wood Johnson Foundation, worked at the Centers for Disease Control and Prevention for more than a decade, including as acting director at the dawn of the H1N1 pandemic in 2009. Follow him on Twitter: @DrRichBesser. Julie Morita, executive vice president of RWJF, was a commissioner for the Chicago Department of Public Health and served on the Biden Transition COVID-19 Advisory Board in a personal capacity. Follow her on Twitter: @DrJulieMorita
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