America’s Public Health System – Part 1
The Rise and Stall of Our Once Great Public Health System
This is the first essay in Civic Way’s series on public health, an overview of America’s public health system, including its primary functions and history. In the next essay, we will confront the system’s major vulnerabilities. The author, Bob Melville, is the founder of Civic Way, a nonprofit dedicated to good government, and a management consultant with over 45 years of experience improving government agencies.
Highlights:
America’s public health system, which is designed to prevent the very illnesses, injuries and conditions that its health (medical) care system is funded to treat, has dramatically improved health outcomes
Despite the inherent efficiencies of public health, the US spends far more on treatment than prevention
As medical care providers like large hospital systems, insurers and pharmaceuticals get bigger, wealthier and more politically influential, public health agencies become more neglected
Starving an undernourished public health system to feed a bloated health care system—and failing to align the two systems—only increases aggregate health care costs
Without change, the US public health system will not likely protect us from the next pandemic
Public Health and Health Care are Not the Same
Until the Covid-19 pandemic, public health was little understood in the US. Overshadowed by the media’s focus on our health (i.e., medical) care system, including such issues as insurance coverage, rising hospital costs and obscene drug costs, America’s public health system was largely overlooked.
To understand the public health system, we must first distinguish it from the medical care system. In the US at least, they are two very different systems and, as outlined below, poorly aligned and integrated.
The public health system is about protecting our community (collective) health. Preventing illness and disease, tracking conditions that pose threats to the community at large and mitigating public health perils like pandemics. The medical care system is about treating individuals and helping them recover from illnesses or injuries. In the US, it is the medical care system that has received the most attention and money—by far.
The public health system is (or was) one of America’s greatest achievements. Its legacy is remarkable. The virtual elimination of once-menacing diseases, such as smallpox and polio. Falling maternal and infant mortality rates. Rising average life spans. Despite these triumphs, it has been America’s medical care system, with its celebrated hospitals, technology and innovations, that has seized the spotlight.
The Growing Prevention-Treatment Gap
There are many distinguishing factors between public health and medical care. One is their raison d'être. Public health agencies are largely governmental and tax-funded. While many medical care providers receive public funds, the medical care system is increasingly nongovernmental.
As a result, their fiscal motivations are markedly different. For public health agencies, there is little correlation between revenues and service. For most medical care providers, the opposite is true. This distinction—the prevention-treatment gap—heavily influences their respective investments, cultures and operations.
The prevention-treatment gap dominates our public health and medical care systems. A specialized surgeon, for instance, makes far more money than a public health officer. Filling hospital beds becomes fiscally more crucial than keeping people healthy. Since treatment is more lucrative than prevention, the fiscal incentives favor treatment over prevention. We should not be surprised when, as a nation, we spend far more on treating diseases than we do on programs that would have prevented them.
The public health-medical care gap is staggering. The US spends less than three percent of its health dollars on public health programs. And the gap is widening. From 2008 to 2019, per capita health care (medical) care spending in the US rose from $7,900 to $11,600. During the same time period, per capita state and local public health spending fell from $80 to $56. The US also spends more on health (medical) care to treat chronic conditions—and less on disease prevention—than other industrialized nations.
This structural imbalance between public and individual health care is inexorable. Many medical care providers—large hospital systems, insurers, pharmaceuticals, among others—keep getting bigger, wealthier and more politically influential. Public health leaders more diminished. After enacting the Affordable Care Act, for example, the US invested billions in modernizing electronic medical data, but precious little in public health data, leaving the public health data system outmoded and inefficient.
In the final analysis, the structural imbalance costs us dearly. Starving an undernourished public health system to feed a bloated health care system only increases aggregate health care costs. Still, until the pandemic, most media outlets acted as if the public health system didn’t matter. The so-called health care debate, for instance, raged for decades around such issues as costs and insurance coverage, yet largely ignored the obvious efficiencies that could be realized by shifting resources from treatment to prevention—public health programs.
Reconnecting with Public Health
One of life’s pleasures is reconnecting. With family, friends, places and memories. Perhaps it is time for us to get reacquainted with one of our most faithful and noble institutions—the US public health system.
What do we need to know about our public health system?
While public health service capacities vary widely from one agency to the next, there is a generally accepted set of essential public health services. There are several broad services that provide a model framework for the most effective public health programs, including:
Surveillance – monitor and assess community health assets, needs, status and causal factors
Mitigation – investigate, diagnose and address public health hazards and problems
Policy – create, advocate and implement laws, regulations and policies that improve public health
Resources – maintain a strong organizational infrastructure and a diverse, skilled public health workforce
Collaboration – strengthen, support and mobilize civic partnerships to improve health
Equity – promote equitable access to individual health services and care
Communications – inform people about health conditions, factors and improvement strategies
Communities with sufficient resources to provide this broad range of services are more likely to preserve—if not enhance—their collective health.
What are some examples of the services offered by robust public health programs? Data-driven surveillance systems that alert people to potential public health threats, such as infectious diseases, foodborne illnesses, environmental toxins and natural disasters. Inspections to prevent food, water, sanitation and chemical hazards. Childhood disease vaccination programs. Maternal and family health education. Chronic disease prevention. Emergency preparedness and mitigation.
Unlike the medical care system, the public health system’s primary focus is on prevention and community. Virtually every public health service, with the exception of emergency-related services, is designed to prevent illness or injury before they occur. To minimize the diseases, illnesses and injuries that would otherwise require more costly and invasive medical treatment. To free public resources for other needs.
Public health systems—properly organized and supported—keep us out of the hospital. A friend indeed.
Pay Me Now or Pay Me Later
We know that investing in public health can save us far more in medical care. We also are learning that addressing other factors can improve public health and reduce the need for medical care. Diet, exercise and other personal habits, for example, have a huge impact on chronic illness.
Perhaps the most intriguing emerging public health issue is its link to social ills. The body of evidence demonstrating the links between social factors and health is too credible to ignore. What are these factors? Neighborhood, housing, water, sanitation, food, education and economic security, to name a few. To public health experts, these are known as Social Determinants of Health (SDOH).
Let’s examine just one factor, food insecurity. The US Department of Agriculture (USDA) defines food insecurity as limited or uncertain access to adequate food. Using this definition, the USDA estimates that over ten percent of US households are food insecure (even more for households with children). Food insecurity and the resulting nutritional deficiencies are associated with poor health outcomes, especially among children. Higher risks of birth defects, anemia, mental illness and hospitalization. The pandemic only made it worse.
In recent years, racism has been recognized as a public health crisis. In June 2020, the New England Journal of Medicine stated that racism promotes brain disease, “accelerates aging, and impedes vascular and renal function.” The American Public Health Association and American Medical Association also regard racism as a public health crisis. Over 50 US local governments have passed laws deeming racism a public health crisis. The pandemic has further exposed the vulnerability of minority communities.
Public health leaders continue to find new ways to improve public health. The question is whether we will equip—or even allow—public health agencies to apply this knowledge. To pursue innovative, collaborative initiatives. To help us make healthier choices. To reduce medical care costs. To protect us from ourselves.
Public Health’s Rich Legacy
The US began building its public health system as early as the 18th Century with colonial quarantine laws. While the federal government’s public health role came later, local governments launched public health efforts early in the 19th century. In 1805, in response to a yellow fever outbreak, New York City created the nation’s first board of health. It had to survive Tammany Hall’s corruption, but the City’s public health agency ultimately provided a model for other cities to emulate.
By the early 20th Century, today’s public health system began to take shape. The 1918 flu pandemic revealed the need for an effective national public health system. In 1921, Congress passed the Sheppard-Towner Act, making the US Public Health Service responsible for distributing federal funds to state governments for public health. In turn, states took on a broader role in overseeing local public health services.
During the second half of the 20th Century, federal, state and local public health agencies expanded to meet new demands. The 1957 H2N2 flu pandemic. Polio and smallpox vaccinations. HIV/AIDS prevention and treatment. Confronting Sexually Transmitted Diseases (STDs). Upgrading public water systems to limit typhoid and cholera. Food safety inspections.
Since 2000, public health agencies have stepped up to combat one threat after another. Post 9/11 biomedical hazards. SARS from 2002 through 2004. The 2009-10 H1N1 flu outbreak. MERS during the 2010s. Zika in 2015-16. Periodic Ebola outbreaks beginning in 2014. Opioid overdoses during the last decade.
As new threats arose, old threats resurfaced. In 2018, the US had 115,000 syphilis cases, 580,000 gonorrhea cases and 1.7 million chlamydia cases, the highest number ever recorded. In 2019, the US had the most measles cases since 1992. The Covid-19 pandemic has necessitated the largest national immunization program since the mid-20thCentury polio vaccinations.
During the last century, the US’ public health efforts—coupled with new antibiotics and public water and sanitation improvements—exceeded the most optimistic expectations. Immunization programs virtually eradicated grave diseases like polio and smallpox and significantly curbed others like measles, diphtheria and rubella. Public health agencies found ways to control other diseases like typhoid, tuberculosis, cholera and yellow fever. Fortified foods virtually wiped out rickets and goiters.
By the time the Covid-19 pandemic arrived in early 2020, our public health system seemed to have many diseases on the run. Our average life expectancy grew dramatically. Our maternal mortality, infant mortality and percent of total deaths attributable to children under the age of five plummeted. While not every group has benefitted equally, our public health system has made the US a much safer and healthier place to live.
Public Health at a Crossroads
Despite its successes—or perhaps because of them—the US public health system is at a crossroads. After years of political neglect and funding cuts, it faced an uncertain future even before the pandemic. Indifferent political leadership. Growing public complacency. Competing funding priorities. Jurisdictional barriers.
The pandemic has brought new—and, in some ways, more daunting—challenges. Shameful political demagoguery. Reckless legislative interference. Media-fueled public skepticism and hostility. Threats against public health workers followed by waves of departures. Unless we chart a new course, America’s public health system may be too weak to combat the next pandemic.