News & Views — Public Health Funding: It’s Not Just About Vaccines

Many of the complaints leveled at government responses during the COVID-19 pandemic were directed at public health agencies, and, more personally, at local, state and federal public health officials. A recent report from Trust from America’s Health, The Impact of Chronic Underfunding on America’s Public Health System: Trends, Risks, and Recommendations Report 2023, described the critical connection between public health funding and COVID-19 responses; however, the current social and political climate also played an important role. As described in the 1988 Institute of Medicine (IOM) Report, The Future of Public Health, “The task of the public health agency has been not only to define objectives for the health care system based on facts about illness and health, but also to find means to implement health goals within a social structure” (p. 70).

The evolution of public health

Public health was born in the 1800s out of a reckoning that diseases were societal issues that could not be escaped (IOM Committee for the Study of The Future of Public Health, 1988, p. 59). Prior to that time, the rich, who could isolate themselves at their country estates, believed that common killers of the day, like the plague, were only issues for the poor and immoral. Indeed, members of the working class were at greater risk of untoward outcomes, with more than 5 of 10 dying before their fifth birthday. However, urbanization brought to bear the realities of infectious diseases, leading to losses among almost all families. Early public health efforts centered on improved sanitation as critical to addressing the horrors of disease, particularly as the biology of how diseases spread was not yet firmly established.

As populational surveys were conducted in places like London, Massachusetts and New York City, the notion of local interventions to monitor and address sanitation and health-related issues started to evolve. Due to political tensions in the U.S., many of these ideas were not translated into action until after the Civil War. However, the earliest of these reports, particularly the one completed in Massachusetts by Lemuel Shattuck, became the basis for public health agencies, which were born at the local and state, not the federal, level. By the end of the century, many states and larger cities had public health departments. Except for the Marine Hospital System and the development of the National Hygienic Laboratory in 1887, federal public health involvement didn’t take hold until early in the 20th century with the Food and Drug Act in 1906 and the renaming of the Marine Hospital System in 1912 to become the U.S. Public Health Service. The latter of which also included expanded authority for the Surgeon General who was the head of that system at the time. However, it wasn’t until passage of the Sheppard-Towner Act of 1922, a program for maternal and child health, that federal funds were used for personal health services (IOM Committee for the Study of The Future of Public Health, 1988, p. 67).

Scientific understanding was evolving in parallel, increasingly offering solutions that ultimately became the basis for public health interventions. For example, Pasteur’s and Koch’s contributions in the 1860s and 1870s led to germ theory, and as bacteria were identified to cause diseases, public health efforts expanded beyond community-based interventions, like sanitation, to include those aimed at individual health. As described in The Future of Public Health, “Scientific measures were seen as replacing earlier social, sanitary, moral, and religious reform measures to combat disease. Science was seen as a more effective means of achieving the same desirable social goals” (p. 64). The result was an expansion of public health efforts to include diagnostic laboratories, clinical care and health education. And health departments “gained stature as a source of scientific knowledge in health” (p. 65).

Public health entities have led the way with successes like the Clean Air Act of 1963; the Safe Drinking Water Act of 1974; the Supplemental Nutrition Assistance Program (SNAP); the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); and ongoing campaigns against infectious and non-infectious agents alike — promoting vaccines, denouncing tobacco, and encouraging physical activity, among others (Trust for America’s Health, 2023).

However, over time, the costs associated with public health activities caused a shift in support. By the late 1960s and early 1970s, this took the form of health maintenance organizations and the National Health Planning and Resources Development Act of 1974, which established guidelines for, and agencies to oversee, health planning. Throughout the late 20th century, social and political tendencies toward fiscal conservatism led to greater emphasis on state-based efforts, tighter federal budgets, and the advent of consolidated funding programs, like block grants. Over decades, ongoing fiscal conservatism led to underfunding as costs and needs increased, but budgets did not.

Fast forward to COVID-19, and the results quickly become prescient. “The COVID-19 crisis highlighted the need for robust investment in public health infrastructure, research, surveillance, and rapid-response capabilities to better prepare for and mitigate the impact of future public health emergencies” (Trust for America’s Health 2023, p. 4).

Two critical needs at this point in time

While the report from Trust for America’s Health offered a significant level of detail related to the current situation, it highlighted two tangible shortcomings of today’s public health environment that demonstrate why, as a society, we could expect only limited success during COVID-19. Even at the start of the pandemic, public health agencies at all levels were suffering from:

1. A lack of data modernization
2. A workforce shortage

Lack of data modernization – The data management systems in use by public health agencies at the start of COVID-19 weakened their collective ability to collect and evaluate data in real time. “The Data: Elemental to Health” campaign has identified five data management programs that require modernization. These include electronic case reporting, laboratory information management systems, syndromic surveillance, electronic vital records, and a national notifiable disease surveillance system. Modernization efforts also require cross-system compatibility and state-level integration.

Workforce shortage – A 2021 analysis of the public health workforce by the de Beaumont Foundation and the Public Health National Center for Innovations, “Staffing Up: Workforce Levels Needed to Provide Basic Public Health Services for All Americans,” found that over the last decade, local and state public health departments lost 15% of their staff. To meet minimum public health needs, they would need to hire an additional 80,000 full-time employees (54,000 at local health departments and 26,000 at state health departments). These numbers become even more dire when looking at population size, where rural America (areas covering less than 25,000 residents) require a 230% increase in their workforce to meet minimum needs. A more recent survey comparing public health staffing between 2017 and 2021 found that almost half of local and state public health staff left their positions (Leider et al., 2023).

Both issues remain in our post-COVID-19 environment. Both are complex to resolve, but both offer tangible ways to begin a public health recovery — should a societal demand require such.

Where from here?

The evolution of public health demonstrates how the values of a society directly affect the potential impact public health agencies and professionals can have. We are living at a time during which scientific understanding has been devalued by many and self-centric values rule the day. As long as we live in a society in which individual freedoms and personal opinions are the priority, our public health agencies will only be able to protect us so much — even those of us with a country estate at which to retire.

Resources

• The Impact of Chronic Underfunding on America’s Public Health System: Trends, Risks, and Recommendations Report 2023
• The Future of Public Health
• A Closer Look: The History and Authority of the FDA
• The Data: Elemental to Health
• Staffing Up: Workforce Levels Needed to Provide Basic Public Health Services for All Americans
• The Exodus of State and Local Public Health Employees: Separations Started Before and Continued throughout COVID-19, Leider and colleagues 2023.