We can’t combat the COVID-19 pandemic without public health investment

There was a time, not so long ago, when facing a global pandemic that threatened the health and lives of millions of Americans, the United States would have had the will and the wherewithal to mount an effective and expert response, guided and led by a federal agency that was the envy of the world.

The U.S. Centers for Disease Control and Prevention and the state and local departments of health in all 50 states would have led a coordinated all-out campaign, mobilizing national health agencies and marshaling resources to manage and ultimately end the pandemic here and around the world — just as happened in the last decade in the face of emerging threats from Ebola and Zika.

Troublingly, that is not so today.

As we deal with the worst outbreak of a viral disease to hit America’s shores in at least a century, the CDC — indeed, the entire public health infrastructure in this nation — is a shadow of its former self, lacking the infrastructure or the resources to coordinate a national response to this pandemic effectively.

In the absence of aggressive federal leadership, around the country, former directors of the CDC and the U.S. Agency for International Development (USAID) are now striking out independently. They are leading philanthropic initiatives for the funding and creation of programs to increase coronavirus testing and tracing steps critical to stem the tide of the pandemic and allow our battered economy to begin to reopen.

In essence, during the most severe public health crisis in recent memory, we are relying almost solely on voluntary initiatives — well-intended and evidence-based, to be sure — in the hopes that they might accomplish an end-run around federal leadership that is sorely lacking.

The emerging informal confederation includes a myriad of institutions and organizations, businesses, academic institutions, including my own. We are offering our expert assistance to our state and local health departments and to governors and mayors to enable them to meet their mandate to protect the health of the public. All of us are profoundly aware of the duplication of effort, lack of coordination, and the potential for confusion and contradiction that mark such splintered responses. 

Nowhere is the potential for confusion more in evidence than on the issue of widespread testing. As the Rockefeller Foundation recently concluded, that goal has been hobbled by “uncertainty over financing and payment; lack of coordination of local, state and national purchases; uneven distribution of test kits; severe shortages of reagents; regulatory barriers; and a severe lack of staffing.” 

There is some small ray of hope that perhaps this groundswell of action by various experts and agencies might at long last propel the federal government to enact its powers through the Defense Production Act to increase test production and distribution to the level that America needs. 

The efforts and initiatives of the confederated volunteers will, hopefully, mitigate the worst of the suffering in the short term in the absence of effective federal leadership. However, they are unlikely to leave us with the public health system we need to protect us. We need to do more, and now. This is certainly not the last pandemic we will face.

And if our halting national response to this crisis has shown us anything, it’s that we need to build a 21st-century public health system that can effectively protect Americans, including investments to urgently expand the public health workforce as soon as possible so that we can conduct effective surveillance and contact tracing for this pandemic. 

Public health interventions by our federal, state and local health departments have led to a healthier population over the last century, through a range of approaches that protect and promote health, including the prevention of diseases; public awareness campaigns; and the promotion of safer food and water and cleaner air. Research attributes 25 of the 30 increased years of life that Americans enjoy, compared to a century ago, to public health.

The nonpartisan organization Trust for America’s Health (TAH) reported that, in developed countries, the return on investment in public health approaches is 14 to 1. At least one recent poll of U.S. voters found that 89 percent of respondents believe that public health plays an important role in the health of their community.

However, even in so-called normal times, the U.S. invests only 2.5 percent of all health spending in our country into public health: a mere $274 per person per year in 2017.

The U.S. has stripped its public health system of the ability to invest in the kind of pandemic preparedness we now need. Between 2003-19, the CDC’s funding for state and local preparedness was cut by a third. Though there were modest increases during both the Ebola and Zika outbreaks of the last decade, those were one-time supplemental infusions, and their effectiveness was undermined by often-inadequate outlays and recurrent delays in funding. 

It has been estimated that there is a $4.5 billion gap between current funding and what is needed to build a strong public health infrastructure nationwide. Moreover, the underfunded system is bleeding seasoned professionals at an alarming rate and has been for years. A full decade ago, the Association of Schools of Public Health warned that this critical workforce was short, approximately 250,000 public health professionals necessary to deliver what our communities need.

Despite the proliferation of dangerous health threats to Americans over the last 30 years, such as opioid abuse and obesity, which have led to recent declines in life expectancy for Americans under the age of 50, there have been minimal changes in governmental public health activities. 

As this pandemic has painfully illustrated, we are reaping what we have not sown. We desperately need to use this moment to restore America’s public health infrastructure to its former greatness, not to vilify our public health leaders and institutions. If we are to recover from this crisis, we should be aiming our investments to build health as the foundation of a resilient America. 

Linda P. Fried, M.D., is the dean and DeLamar professor of Public Health, Columbia University Mailman School of Public Health.