Opinion | Is it time for a national public health system?

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Since the early months of the covid-19 pandemic, it has become clear that the US public health system is in need of major improvements. Now, a blue-ribbon commission assembled by the Commonwealth Fund has issued a report with a rather provocative conclusion: The United States needs a national public health system.

To better understand the rationale, I spoke with three committee members. Former New York State Health Commissioner Nirav R. Shah explained to me that there is a fundamental problem with public health in America that long predates the pandemic: “It is disorganized, under-resourced, poorly coordinated and disconnected from the health care delivery system . “

He’s right. There are nearly 3,000 local health departments with many different options. Depending on where someone lives, they may be served by a well-funded city or county health agency that provides many safety services, or one with a handful of staff and a shoestring budget. The result is evident in the disparities seen during the pandemic: some areas quickly set up large vaccine clinics and free testing sites; others struggled with the basics of contact tracing.

The Commonwealth Fund Commission wants to set a national standard for health department capabilities and help them achieve it through new funding. That last part, to me, is the most important part of their proposal: a federal government commitment to sustainable and reliable funding for local public health.

When I served as Baltimore’s health commissioner, my biggest challenge was understaffing. The same people who worked on the opioid epidemic and maternal and child health were called upon to respond to weather emergencies and disease outbreaks. Each crisis was like robbing Peter to pay Paul, with each new problem diverting attention from existing priorities.

Over the past decade, state and local health departments have lost 15 percent of their essential staff, largely due to budget cuts. A one-time subsidy like Congress’s bailout is not a long-term solution. “Millions of dollars in pandemic funds are unspent because they come with a fiscal gap,” Shah explained. “If you hire people this year, what will happen to them next year?”

That is why the commission is looking for approximately $8 billion from Congress each year, most of which is directed at local labor shortages. The rest will pay for a revamped data system that links public health agencies and hospitals. Julie Gerberding, another committee member, told me that could make a big difference in the early days of COVID-19.

“If we had real-time information exchange, we might have found hotspots much earlier,” she said. “We may have seen outbreaks in meat processing plants and that the average age of ICU admission is going up; we could have focused our efforts earlier on workplaces and nursing homes.”

Commission members are quick to point out what a national public health system is not. Gerberding, who served as director of the Centers for Disease Control and Prevention during the George W. Bush administration, is clear that the proposal is not to federalize public health, but to set standards. “Our goal is to make sure there are basic public health protections for everyone, no matter where they live.” She is careful to say that while better national coordination is needed, local and state control is paramount.

I think this distinction is really important. Local health departments need to be better funded so they can respond to emerging crises without having to pull staff away from other day-to-day duties. Federal agencies could also be better coordinated with each other (another issue the report addresses).

But public health in the United States will not operate with top-down control. City and county health officials know their communities best and should be empowered to make local decisions. There is also a real danger that the federal government will gain too much power. Just think what could happen if a president who, for example, promotes anti-vaccine conspiracy theories, has more control over public health policies.

Is the Commonwealth Fund proposal realistic? If Congress can’t get its act together to allocate $10 billion for boosters and antiviral pills, what are the chances it will agree to a new annual line item? Committee chairwoman Margaret Hamburg, who was New York City’s health commissioner and then head of the Food and Drug Administration, was unfazed. “Trillions of dollars were lost because of the pandemic,” she told me. “The amount we’re asking for is so small compared to what the lack of a coordinated public health response is costing us.”

In other words, the United States cannot afford to no to reform its underfunded and outdated public health system. I hope policymakers will read this report and use it as a blueprint for taking concrete, practical action to protect our nation’s health.

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