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Recommendations for Building a National Public Health System

The public health system in the US has long been neglected, and COVID-19 threw the consequences into stark relief. 

A report from the Commonwealth Fund explored some critical issues within our public health system. Findings confirmed that challenges with leadership, communication, testing, and more need urgent solutions to better serve the American public’s health and to anticipate and respond to future threats. 

In this Q&A, adapted from the August 5 episode of Public Health On Call, Stephanie Desmon talks with Margaret Hamburg, MD, former president of the American Association for the Advancement of Science, former Commissioner of the U.S. Food and Drug Administration, and the leader of the report, about how investments in public health and building a stronger national public health system will make an enduring difference in the future. 


      Public Health On Call

      This article was adapted from the August 5 episode of Public Health On Call Podcast.



      What was the purpose of the report?

      There have been concerns about how to strengthen our public health system for many years. But the COVID-19 experience put into stark relief many of the challenges of having a fragmented, sometimes haphazard, national public health system. 

      We felt this was the time to take a deeper dive and see if we could propose a framework for real action that could provide people with a stronger public health safety net and system. We can and must do better. 

      What were the main findings? 

      We focused on four domains of activity. We approached them with the perspective: “How could the federal government provide more leadership, coordination, and support?” If we want a system that isn't a patchwork, we need federal leadership, with commitment and sustainability. 

      The first area of focus had to do with the federal government, particularly the Department of Health and Human Services (HHS)—how it’s organized, resourced, and equipped with the right authorities to lead the system. We called on HHS to create a new position—an undersecretary for public health—that could be a focal point for all of the public health agencies of HHS … and coordinate with other components of the federal government that have important roles and activities that bear on public health.

      The second area of focus was on recognizing that we can do better to support state, local, tribal, and territorial health agencies and public health departments in having the infrastructure they need to be able to meet a set of basic standards, and to support greater coordination, communication, and collaboration. 

      The third area of focus had to do with the importance of creating a system for health in this country that's a continuum—that includes both public health and its critical activities and institutions, but also the healthcare delivery system. 

      We need to make sure that we can bring the health care system closer to public health, in terms of hospitals, health systems, and clinics. There are many mechanisms that we can build on from the COVID-19 experience. 

      The last area of focus was the need for public health to earn public trust and confidence. Sadly, I think during COVID-19, public health agencies and leaders have been questioned in ways that they never were before. Public health agencies, as polls demonstrate, have lost the trust and confidence that they once had. We need to rebuild that. 

      With Congress cutting funding for COVID testing, treatment, and vaccination, are we headed in the wrong direction?

      It's so unfortunate that when there's a crisis, people mobilize, new resources are identified and made available—and then people become complacent. We can't afford to do that. We've done that too many times. If COVID-19 isn't the wake up call that prevents us from hitting the snooze button, I don't know what will be. 

      It is important to recognize that COVID-19 may not be the worst infectious disease threat that we will face in our lifetimes, or over the course of the future. It's also important to recognize that the investments that we're talking about are nothing compared to the costs of a pandemic like COVID-19, where we spent trillions of dollars responding.

      The investments that we're really talking about in this report, and that are so crucial to strengthen our public health system, are investments that will matter every day to people everywhere in this country. They will help to reduce preventable disease and to make a more productive workforce. We're talking about investments that are essential for health, quality of life, productivity, and preparedness, should we face another catastrophic threat.

      Do you see the political will to change this focus and to fully support public health?

      I have to be a realist about this. Public health has never had a really powerful voice. Many of us that have worked in public health talk about being the “poor step sister” within the world of health, let alone in other domains. 

      We must make the case that public health is vital to every American. Public health is essential to keep our populations healthy and productive, to continue to grow our economy, to public safety and our national and international security. 

      Part of what our commission hoped to do was to be able to not only lay out a compelling case, but to also put forward some real actionable steps in the near term, and identify areas where we need Congress's help to act.

      Do you think this fractured system cost lives in the COVID pandemic? 

      I think we could and should have as a nation responded better to COVID-19. We should have mobilized more swiftly. We should have galvanized a set of activities and policies that were slow to be put in place. All of that took a toll. 

      But many of the problems revealed during COVID-19 about our fractured public health system were not new. We've seen them in other much smaller infectious disease outbreaks. We see them in some of our critical health statistics in terms of preventable or modifiable chronic diseases like heart disease and obesity. We see it in the growing toll of addiction and overdose deaths—in shockingly high maternal mortality rates. We rank below 60 other countries, in terms of life expectancy, yet we are the wealthiest and with a highly sophisticated health system.

      Where do we go from here?

      I think we have to continue to demonstrate why public health matters. We have to highlight programs and policies that work well, that demonstrate value and return on investment. Frankly, we have to work in a way that can do as much as possible in our modern era. De-politicize and prioritize public health, because done right, it will save lives.


      Stephanie Desmon is the co-host of the Public Health On Call podcast. She is the director of public relations and marketing for the Johns Hopkins Center for Communication Programs, the largest center at the Johns Hopkins Bloomberg School of Public Health.