America’s Public Health System – Part 5

More Strategies for Rebuilding Our Public Health System

This is the last essay in Civic Way’s series on public health. In our last essay, we recommended several structural strategies for rebuilding the public health system. In this essay, we offer some additional strategies for improving it. 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 public agencies.

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Highlights:

• We should adopt a new legal and regulatory scheme, including clear public health agency powers, a coherent national tax system on unhealthy products, a national incentives system for encouraging healthy choices and a tougher enforcement regimen

• We must bolster our local public health agencies, repurpose local assets for public health and expand local programs that promote healthy lifestyles

• We should rebuild the public health workforce, partly through a concerted effort to grow community partnerships and partly through the recruitment and retention of government workers

• With federal leadership and funding, we must modernize the public health data infrastructure and revitalize public health communications to combat disinformation and increase public support

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Introduction

As we noted in our last essay, America’s public health system needs sweeping structural and financial reform. Such reforms are only the first step. To protect our families, friends and neighbors from future public health threats—pandemics, climate change, bioterrorism and others—we must do more. 

In this essay, we outline more strategies for reforming our public health system. Aligning public health laws and regulations with risks. Equipping local public health agencies to protect their communities. Recruiting public health workers and expanding community partnerships. Finally, upgrading public health information and communications capabilities.

Modernizing Public Health Laws and Regulations

In today’s political climate, it is easy to overlook our past victories. Not so long ago, smoking was prevalent, if not venerated. Some even touted the benefits of smoking. However, we overcame the fierce opposition of the powerful tobacco industry, changed public attitudes and passed new laws. Today, smoking is widely discouraged and, in many places, prohibited. And we are much better for it.

We must show the same resolve with other public health issues. We must design a new legal framework for fighting pandemics and preventing disease, illness and injury. We must enact public health laws and policies that will empower us to confront future challenges as a nation and community and encourage us to make healthy choices as individuals.

The new regime must be multi-dimensional. It should empower public health officers to protect the community, but it also must offer the rest of us ample incentives to live healthy lives as well as conspicuous disincentives to discourage unhealthy behavior. What are some examples of this approach?

First, we must empower public health officials to do their jobs, to protect us during pandemics and other existential crises. We grant our military leaders the latitude they need to protect us against foreign foes, why not do the same with public health leaders fighting invisible foes like viruses?

During emergencies, public agencies should possess sufficiently flexible personnel, contracting and procurement powers. Public health leaders should be empowered to issue protective orders and insulated from political interference and public abuse. And we should have tough criminal and civil sanctions for those threatening or trying to undermine public health workers.

Second, under Article I, Section 8 of the US Constitution, we should institute a coherent national system of taxes and fees on consumer items that increase our vulnerability to disease or illness (e.g., junk food, soda and cigarettes). The federal legislation also should authorize regional and local public health bodies to enact higher taxes (subject to the approval of their respective legislative bodies). Eliminating our patchwork tax model will reduce healthcare costs and provide a reliable funding source for our public health system.

Third, we should develop a national system of incentives for encouraging smarter choices by producers and consumers. For producers, we should stop subsidizing counterproductive business practices like growing unhealthy products and offer market incentives for producing healthy commodities. For consumers, we should subsidize healthy choice incentives (e.g., health insurance discounts and sales tax exemptions).

Fourth, we should ensure that all federal, state and local laws and regulations foster lower healthcare costs and better health outcomes. Ambitious production goals and rigorous certification standards for healthy foods. Strict air, water and sanitary laws. Good primary care access. Sensible ventilation and traffic control ordinances for business districts. Budgetary rules requiring elected officials to continually assess the public health impact of government social policies (e.g., economic opportunity, housing, childcare and paid leave).

Finally, the new legal framework should include clear regulatory disincentives and sanctions where appropriate. In the case of clear threats to the public health like cigarettes and environmental toxins, aggressive regulatory limits and bans should be continued or instituted. In addition, the regulatory system should include sufficient resources and mechanisms for enforcing health-driven regulations.

Rearming our Local Public Health Defense

Local public health agencies remain the first line of defense against health threats. Unfortunately, their sizes and capabilities vary considerably. Even the largest and most capable have suffered from neglect in recent years. To protect our health and lives, it will be imperative to rebuild and expand these agencies.

The CDC should lead the system, but the local agencies must implement it. An early national detection and response system. A broad testing network with free tests and quick results. An army of public health teams to quickly trace, test and isolate positive cases. The rapid, consistent dissemination of mandates, guidelines and other vital information. All of these require more capable and agile local public health agencies.

We should expand the local public health network to give all citizens easy, affordable access to primary care and public health services. To galvanize a shift from treatment to prevention, we should fund and coordinate primary care centers through local public health districts. We should repurpose and leverage fallow resources, including health assets (e.g., Covid-19 testing sites and 24-hour clinics) and civic assets (e.g., schools and libraries), to provide primary care and other vital public health services (e.g., blood-pressure tests).

Finally, local public health agencies should lead efforts to promote healthy lifestyles and prevent costly diseases. Using national research, local public health districts should increase their disease surveillance capabilities. They should more aggressively promote healthy choices and expand related services (e.g., free nutrition and exercise programs for vulnerable populations). Through their community partners, local public health districts can better win public support and materially reduce many determinants of poor health outcomes.

Rebuilding Public Health Partnerships and Workers

Restoring our public health system will require more people, not just more public health employees, but more community partners. Not just more public health workers, but more diverse and skilled workers, from the private and public sectors alike.

We must resist the impulse to rebuild the public health workforce simply by hiring more government employees. We will no doubt need more government personnel, but our first priority should be to expand community partnerships and expand the private sector public health workforce, especially in underserved communities. With foresight and funds, we can attain both goals.

To expand community-based public health partnerships, we should start by redefining the roles of the public and private sectors. Government’s primary public health role, especially at the local level, should be to lead, coordinate and galvanize public health work. It should steer rather than row. Instead of using community partners to fill in the gaps, government should delegate more of its direct service and implementation work to its community partners.

By controlling more public health funding for their respective service areas, local public health districts will be in a far stronger position to incentivize partnerships—with public health entities, other sectors (e.g., housing) and other actors (e.g., faith-based). They will define partner roles and duties, shape plans and programs and thereby improve community-based public health capacity and collaboration. And, by suggesting model governance, operating and performance standards, they will ultimately influence outcomes.

Even with more community partners, our local public health agencies will need more staff with the skills and diversity to serve their communities. And attaining this goal will require a whole host of measures. Modern civil service and human resource management systems. Competitive compensation and career retention incentives (e.g., loan relief). More comprehensive and frequent training. Relentless recruitment programs.

Building the next generation of public health leaders and practitioners—public and private—also will require some bold initiatives. An expanded Public Health AmeriCorps. Regional or multi-state public health corps for public health graduates. Multi-year public health internships for public universities (e.g., Historically Black Colleges). Community college public health associate degrees. Subsidized stipends and education bonuses. Such initiatives will amplify the societal value of public health professions.

Restoring Public Trust in Public Health

The last two years have been confounding. Perhaps the most mystifying and alarming development has been the demonization of the public health profession. We can lament this problem or we can fix it. Fixing it will entail two broad strategies—upgrading information systems and enriching communications.

Under federal leadership and standards (and with full federal funding), we should build a modern public health data infrastructure. A fully-integrated, digital collection and reporting system, one that seamlessly links all providers, agencies and partners, yet protects privacy and security. One that gives all public health agencies the data they need (when they need it) to detect risks, protect people and improve health outcomes. A uniform health dashboard would help focus our attention unifying healthcare and public health.

There are many ways to make this happen. One is to facilitate the real-time transfer of patient data from medical providers to public health agencies (sharing Electronic Health Records would help). Another path is to expedite the transmittal of self-reported data from individual patients to public health agencies (e.g., age, race, ethnicity, income and ZIP code). Other options include e-health passports, health sensors, personal mobile tracking technology and social media platforms.

The second stage entails revitalized public health communications. With federal leadership and funding, local public health agencies should conduct coordinated (and incessant) public health information campaigns to combat disinformation and win public support for proven self-help measures (e.g., masks).

These locally-led campaigns will have many parts. Trusted local voices to convey public health warnings and guidelines. Solid relationships with media outlets. Regular public health forums. Consistent, fact-based messaging. Effective exploitation of multiple media platforms. Tenacious public engagement, especially during public health emergencies. A reliable warning system for alerting citizens of new outbreaks.

Forging a New Public Health System

What we do about public health could prove to be one of the most fateful decisions we make this century. The pandemic has opened our eyes. It has shown us how our politics and governance can cripple our public health system. The next crisis could pose a far more daunting test.

We can meet this challenge if we recommit ourselves to our union and patriotism (and accept personal responsibility for unhealthy behavior). If we work together as Americans, without regard to political party or tribe, we can fundamentally reform our public health system.

A truly modern public health system—one structured and funded to meet the threats of the 21st Century—will protect us against future pandemics and other existential threats. It also will free us from the burdens of our healthcare system. By improving our collective health and preventing many diseases that ravage our nation, it will reduce the healthcare disparities and costs that threaten our future.

With a modern public health system, we can mount a defense against internal ills equal to the one we have built against foreign military threats. We will be armed to defeat the next invisible enemy. And, we can better fulfill Abraham Lincoln’s promise that our nation “shall not perish from the earth.”