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Public-health funding today keeps the doctor away

Sep 12,2022 - Last updated at Sep 12,2022

FAIRFIELD COUNTY, CONNECTICUT  —  With COVID-19 still an ever-present threat and monkeypox cases rising alongside existing chronic epidemics, building strong, responsive public-health systems has never been more important. In addition to improving data management (which I addressed in a previous commentary), we also need sustained investment and training in the public-health workforce.

Public health has always suffered from chronic underfunding, partly because the social and economic benefits of investing in preventive care are difficult to quantify or invisible to the untrained eye. Successes in containing disease outbreaks or reducing mortality rates often go unnoticed. Unfortunately, it often takes a massive failure of prevention to get policymakers and the public to recognise the need for greater preparedness.

Americans spend significantly more on medical costs than do people in other similar wealthy countries, yet still have lower life expectancy, higher rates of chronic disease and maternal mortality, and fewer doctors per capita. America’s underinvestment in public health is a major reason. Researchers developing cancer treatments have far greater access to funding than those working on cancer prevention.

You know you have a flawed system when you can’t mobilise investments that will pay for themselves, which is precisely what most outlays for public health will do. According to a systematic review of 52 interventions published in 2017 in the Journal of Epidemiology and Community Health, health-protection programmes (including vaccinations) saved an average of $34 for every $1 spent on them.

Despite this massive return on investment, a 2020 investigation by Kaiser Health News and the Associated Press found that per capita funding for state public-health departments in the United States dropped by 16 per cent between 2010 and 2019, while spending for local health departments fell by 18 per cent. Many health departments thus were already in dire shape when COVID-19 arrived.

While Congress invested heavily in public health during the pandemic, federal funding is still following a familiar boom-and-bust cycle. The federal government will spend money to address a specific crisis, but it will not sustain anywhere close to the same level of funding after the emergency ends. Local and state health departments are left to bootstrap their operations until the next crisis, for which they will not have had the resources to prepare.

We are now entering a new bust phase, with many local health departments approaching a COVID-19 funding cliff. Emergency funding has been spent or is expiring, even though core public-health services such as testing, reporting, and vaccinating are still needed to address a high caseload. Public-health departments need to provide these services in addition to all the other functions they are charged with, including but not limited to managing water safety, issuing death certificates, tracking sexually transmitted diseases, and preparing for other infectious-disease outbreaks.

A lack of consistent and predictable funding also means that health departments are unable to recruit, retain and invest in a skilled workforce. Emergency funds for personnel sometimes remain unspent, because local public-health departments are wary of hiring people who will then become permanent fixtures on their payrolls after the additional funding runs out. Owing to these staffing limitations, public-health agencies will instead simply shift personnel from one agenda to another. For example, some public-health departments are now being forced to divert staff working on syphilis and chlamydia in order to conduct outreach, contact tracing, and vaccine campaigns for monkeypox.

These staffing issues, together with an environment of political pressure, harassment, and personal threats from the public, have led to an exodus of public-health officials in recent years, following a similar exodus of physicians and other frontline workers during the pandemic. A bad problem is fueling a worse one.

In a major new report, the Commonwealth Fund Commission on a National Public Health System recommends that Congress provide an additional $4.5 billion annually for guaranteed, not discretionary, federal funding for public health. That would cover the difference between what the US currently spends on public-health personnel ($19 per capita) and what it needs to spend ($32 per capita). But this figure is primarily based on personnel; it almost certainly needs to be higher to cover core infrastructure such as material, equipment, and training.

Moreover, the Commonwealth Fund also recommends that the US Department of Health and Human Services establish a national continuing-education and training system, in coordination with schools and public-health programs, and together with state, local, tribal and territorial health authorities. The report also advocates public-health training in other departments (such as those focused on education, housing, and criminal justice) to encourage collaboration and address issues like the social determinants of health.

Public-health funding often competes with many other demands on government budgets. But by investing in robust staffing and infrastructure, we can significantly reduce the amount of money we spend on treating preventable diseases, ultimately freeing up funds for other purposes. More importantly, we can develop systems that are well prepared to control outbreaks of emerging diseases and address ongoing chronic illnesses, giving all citizens a chance to benefit from longer, healthier lives.


William A. Haseltine, a scientist, biotech entrepreneur, and infectious disease expert, is chair and president of the global health think tank ACCESS Health International. Copyright: Project Syndicate, 2022.

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