Our public health system needs an overhaul — Congress can start here


Two years and numerous variants into the COVID-19 pandemic, our national response continues to be defined by mixed messages and unforced errors. Try as we might, that isn’t going to change until and unless we overhaul our public health infrastructure. 

The fact is, our current patchwork of federal institutions — namely the Centers for Disease Control and Prevention, the Food and Drug Administration and the National Institutes of Health — was simply not designed for a crisis like this one. And the lack of coordination among them has manifested in dangerous ways, from conflicting public guidelines to direct interagency conflicts

The booster shot rollout last fall was a prime example. For weeks, experts at the CDC and FDA debated which groups should get a third shot, wasting valuable time and causing widespread confusion. We’ve seen similar confusion around rapid tests. The CDC long failed to forcefully explain the value of treating these tests as public health tools, useful for screening at the population level; the FDA, meanwhile, has ignored the public health use case altogether and has been painfully slow to approve tests, leading to major shortages. Making matters worse, the CDC recently issued confounding guidelines for when COVID patients could leave isolation — guidelines that seemed to have been shaped in part by the agency’s wariness to recommend the widespread use of tests that were in such short supply. 

This dysfunction has not only stymied our response to the novel coronavirus; it has eroded public faith in our health institutions — and in science as a whole. Recent polls show that less than half of Americans trust what the CDC has said about the virus — and our beliefs are largely shaped by ideology, rather than evidence. 

That’s terrifying. Between new and reemerging infectious diseases to the myriad impacts of climate change, we know the next crisis isn’t a matter of if, but when. And we must redesign our public health apparatus to restore public confidence and meet the many global health threats we will face in the coming decades. 

Fortunately, we don’t have to start from scratch. We have a blueprint in the Goldwater-Nichols Act of 1986

Prior to this historic bipartisan legislation, the U.S. military was mired in many of the same issues we’re now facing in public health: inter-and-intra-service rivalries, infighting and poor delineation of responsibilities. While by no means perfect, the Goldwater-Nichols Act greatly streamlined the military chain of command. It fostered cooperation at the strategic and operational levels. And it fundamentally transformed our defense establishment for the better. 

It is time to do the same for public health. 

Such legislation should create clear lines of authority within public health institutions at both the state and national levels. It should bridge communication and execution gaps across agencies with overlapping mandates and establish the responsibilities of the private and social sectors in relation to them. And just as critically, it should establish broad new investments in public health across the board. 

The act could transform, in particular, the now-strained relationship between the CDC and the FDA. For instance, the CDC could provide input on what makes rapid tests most useful from a public health perspective, and the FDA could streamline its standards for reviewing tests used in this way. The CDC could also take the lead in guiding the FDA on how rapid tests would be used in real-life scenarios, whether for public health in general or for individual diagnostic purposes. 

Better cooperation could also vastly improve the rollout of future booster shots, should they prove necessary. The agencies should work together to review the epidemiological and clinical data, hold joint public hearings and send out clear and uniform messaging about which groups of Americans should get another round of boosters, and at what intervals, to avoid a repeat of our experience last fall. 

Of course, bipartisan legislation of this magnitude — or of any kind — is a taller order today than it was in 1986. But it’s by no means impossible. Look no further than our recent infrastructure bill for a trillion-dollar example that consensus can still be reached on the issues that matter most. We can increase buy-in across the aisle by focusing on efficient governance and unified messaging. 

No one in this country has been untouched by the pandemic. And while many Americans have been disheartened by our national response, there is broad, crosscutting support for a substantial increase in public health spending. We can turn that will into a transformative moment. 

But we must do it now — before the next presidential election cycle derails any hope of bipartisan cooperation, and before complacency sets in once again and we lose the urgency to act. If we succeed, we can meet the next crisis that inevitably comes our way with coordination in place of confusion and swift action in place of delays. 

If we fail, the price will be precious lives. 

Michelle A. Williams is dean of the faculty at the Harvard T.H. Chan School of Public Health, and Angelopoulos Professor in Public Health and International Development at the Harvard Chan School and Harvard Kennedy School. Richard J. Tofel is the former president of ProPublica and a distinguished visiting fellow at the Harvard T.H. Chan School of Public Health.

Tags Centers for Disease Control and Prevention Food and Drug Administration Government agencies Health Public Health Emergency of International Concern U.S. federal government response to the COVID-19 pandemic

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