“For all people in the United States, where one lives should not determine one’s level of public health protection; public health deficiencies anywhere jeopardize the health and security of the nation. Disasters, natural and man-made, can happen anywhere; disease outbreaks do not recognize political boundaries; and the costs of poor health outcomes that can be prevented by public health intervention are borne nationally through expenditures in the publicly funded health care systems. To effectively respond to emergencies such as pandemics or natural disasters and to address pervasive health challenges such as diabetes and heart disease, federal, state, local, territorial, and tribal officials need a predictable minimum capacity in every part of the country.”

The above three sentences appeared in a remarkable statement from a group called the Public Health Leadership Forum. The article—“Developing a Financing System to Support Public Health Infrastructure”—appeared in the American Journal of Public Health in October of last year (before we knew about COVID 19).

I discuss this article at length in this issue of Nygaard Notes.

This article is about the financial support our public health system needs in order to do its job.

“In the United States, governments at all levels (federal, state, and local) have a specific responsibility to strive to create the conditions in which people can be as healthy as possible. For governments to play their role within the public health system, policy makers must provide the political and financial support needed for strong and effective governmental public health agencies.”

The above quote is from a remarkable 2003 book put out by the National Academy of Medicine, called “The Future of the Public’s Health in the 21st Century.” Taking seriously that bit about government’s “responsibility” to “provide the political and financial support needed”, a group of public health advocates published a noteworthy article this past October in the American Journal of Public Health (AJPH) entitled “Developing a Financing System to Support Public Health Infrastructure.”

The Building Blocks

The very first paragraph of the AJPH article grabbed my attention: “All people in the United States deserve the same level of public health protection, making it crucial that every health department across the country has a core set of foundational capabilities.”

What do they mean by “foundational capabilities?” They basically mean that, to be able to protect the public’s health, every part of a public health system has to be able to do certain things. These skills and capacities “are the building blocks for provision of the more visible services of public health,” such as “immunization and smoking cessation programs, emergency preparedness, and food safety.”

A public health system, the authors say, should be able to: assess the health of the population; be prepared to deal with threats to the public’s health; have clear policies in place for dealing with emergencies of all kinds; translate public health science into appropriate policy and regulation; harness community resources and people to advance a community’s health; lead people to consensus and action around public health “with a particular focus on advancing health equity in communities,” and; operate in an efficient and accountable manner.”

13 Bucks Apiece

The current pandemic has made it abundantly clear that the U.S. system of public health falls short in a number of these foundational capabilities. Lack of funding is a big reason why. The AJPH article notes that “Federal funding for local public health comes mainly through the Centers for Disease Control and Prevention (CDC)… This CDC funding has lost its purchasing power over the years…”

Indeed, as the Trust for America’s Health pointed out in a report last year, “Funding for public health programs via the CDC budget decreased by 10 percent over the last decade while public health risks grew.” Roll Call Magazine reports that, “since the Great Recession, frontline state and local health departments have lost more than 56,000 positions due to funding cuts.”

How much would we have to spend to have the kind of public health system that most of us want? Not much. The AJPH article—published long before the current pandemic began—addresses this question, stating that “Current research indicates an annual cost of $32 per person to support the foundational public health capabilities needed to promote and protect health for everyone across the nation. Yet national investment in public health capabilities is currently about $19 per person, leaving a $13-per-person gap in annual spending.” For the system as a whole, “the total cost of foundational capabilities is about $9.5 billion, with a total gap of approximately $4.5 billion per year.” Roll Call sums it up: “We need an additional $4.5 billion a year to close the gap between what we currently spend on public health and what we would need to ensure that all communities across our nation are served by a strong public health system. $13 apiece!

And, in case that isn’t persuasive enough, The Trust for America’s Health tells us that “a 2017 systematic review of the return on investment of public health interventions in high-income countries found a median return of 14 to 1.” That’s right: Every dollar spent today on public health means we’ll spend $14 less tomorrow to treat the people who didn’t need to get sick in the first place.

There’s a history here: “The Prevention and Public Health Fund, created in the Affordable Care Act as a mandatory funding stream ‘to provide for expanded and sustained national investment in prevention and public health programs to improve health…’ has been critical in softening the blow of some of the budget cuts.” However, a proposal to create “a core Public Health Infrastructure Fund”—which would have gone a long way toward funding public health infrastructure at all levels—“was not in the Senate version that became law.” In the years since, “Congress has been slowly chipping away at funding for the agency’s public health programs.”

The authors state simply that “A new, permanent, and stable mandatory funding source, providing an additional $4.5 billion a year, is needed to establish and maintain foundational public health capabilities to ensure public health protection for individuals through state, territorial, tribal, and local governmental public health.” This would be the Public Health Infrastructure Fund that we should have gotten as a part of Obamacare.

Principles guiding the fund would include things like this: “Financing of foundational public health capabilities is a governmental responsibility and should be assured through sustainable, dedicated revenue streams.” And this: “Investment of funds should promote equity in health outcomes for all people in America, both within and among communities.”

In their conclusion, the authors of the AJPH article make clear that their proposal is not simply about money, and that “transitioning to an emphasis on foundational capabilities reflects a significant transformation of the US public health system. This level of disruptive change will take time and requires dedicated, reliable resources to assist jurisdictions in making the transition. A Public Health Infrastructure Fund, or similar mechanism, is needed to address the $4.5 billion shortfall, finance foundational capabilities adequately, and fulfill the government’s responsibility to create the conditions in which people can be as healthy as possible.”

The needed $4.5 billion is equal to 6/10 of one percent of the current U.S. military budget.

Public health workers talk about what they call the Social Determinants of Health, which are defined as “the conditions in which people are born, grow, live, work and age that shape health.” The Kaiser Family Foundation points out that “Addressing social determinants of health is not only important for improving overall health, but also for reducing health disparities that are often rooted in social and economic disadvantages.” That’s the beauty of Public Health: It focuses on conditions, which leads us to look at how people are living, which leads us to look at social justice as fundamental to the health of a community. When the shameful health disparities in the US have been eliminated, we will have achieved what public health folks call “Health Equity.”

One group in particular takes seriously the social justice aspect of public health: Human Impact Partners.   HIP sees itself as “part of a movement to change the field of public health to be more accountable to health equity and the social determinants of health—and especially to the social justice movements that are organizing their way towards healthier and more equitable communities.”

HIP’s mission is “To transform the policies and places people need to live healthy lives by increasing the consideration of health and equity in decision-making.” They do this through a combination of Research, Capacity Building, Advocacy, and what they call “Field Building: We mobilize the public health community to contribute its power—knowledge, skills, and resources—and engage in social justice movements to advance health equity.”

For an inspirational look at how to bring an anti-racist perspective into the current crisis, check out HIP’s booklet called “A COVID-19 Response & Recovery Health Equity Policy Platform.”

The introduction to the 10-page platform is so inspirational (and short) that I present it here in its entirety. The emphasis is in the original:

“Decades of underinvestment in our public infrastructure and neoliberal policies that gutted protections for working people, our healthcare, and our wider safety net are vividly exposing their consequences. People of color—most harshly Black, Latinx, and Native people—are disproportionately experiencing the consequences of these conditions.

“In this context, directly impacted communities are naming and working towards transformative solutions around areas including the criminal legal system, housing security, economic security, and healthcare access.

“Public health needs to act on solutions led by directly impacted communities

“Below is a cross-sector policy platform, that if implemented, would challenge the conditions that create inequities in health outcomes. HIP did not generate these ideas—they come directly from grassroots organizations, and their members, who are leading the work. As public health workers, we need to do everything possible to aid in putting these policies in place to support people during this pandemic and beyond.

“Now—as ever—is the time to set aside concerns of objectivity and politics, and use our power to change the unjust systems that have perpetually harmed the health of communities across the US.”

What follows then is a detailed list of over 50 specific policy recommendations in the four areas mentioned above: Economic Security; Housing Security; Criminal Legal System, and Healthcare Access.” Each grouping includes a list of concrete “Ways for public health to take action” on the recommended items.

For reasons of space, I will only mention one of HIP’s projects. It’s called Public Health Awakened, and here’s how they describe themselves:

“Public Health Awakened is a national network of public health professionals organizing for health, equity, and justice. We work with social justice movements on strategic and collective action to create a world in which everyone can thrive and to resist the threats faced by communities of color and low-income communities. We are calling on public health nonprofits, government agencies, academics, and others to courageously step up and use our power—our evidence, expertise, voice, and resources—to protect and promote people’s lives and communities.”

PHA envisions a future where: People live in healthy and equitable communities; A spirit of activism and advocacy is normalized within public health; Social justice organizations recognize public health as a partner in their movements; Public health and equity advocates have a home from which to take action; The narrative about what public health is and the value we bring has changed.

In order to create this vision, PHA says, they are: Creating a more explicit social justice identity for public health professionals; Shifting the public debate by lifting up the collective voice of public health, and; Building a community of social justice oriented public health professionals

The PHA folks think like I do (and I don’t often say that!) Check out this one-page link to see what I mean: Fact Sheet: Tax Policies Impact Health

For a better understanding of the relationship between public health and antiracism (or social justice generally) check out Human Impact Partners. They say it plain.