The federal, state, and local agencies and departments that comprise the U.S. public health system are dedicated to disease prevention and health promotion. Public health workers track and predict emerging and persistent threats to societal health, respond to health risks and events, and promote health through education, intervention, and policymaking. In recent centuries, a wide range of public health interventions are largely responsible for the nation’s increased life expectancy, including those that have promoted clean air and water; improved sanitation and food safety; created safer environments that lead to fewer injuries; and increased the uptake of vaccinations that protect against infectious diseases.
Yet chronic underinvestment has long challenged the U.S. public health system, creating major infrastructure problems and weakening the system’s ability to address basic needs, respond to emerging threats, and sustain supports after initial crises wane. For example, funding tends to spike temporarily in response to major health threats, such as the spread of the Ebola and Zika viruses in 2013 and 2016, only to decline dramatically after the immediate danger subsides.
The lack of sufficient and sustained funding has created persistent gaps in the public health system—and these gaps have only worsened during the COVID-19 pandemic. Many public health workers, for example, have long lacked job supports and adequate compensation, and COVID-19 compounded these issues, leading to increased political polarization around health safety measures and workers under intense strain. Additionally, many public health agencies lack the technology and data systems necessary to carry out functions such as disease surveillance and risk identification.
Serious and sustained investments in public health are necessary
Investments in public health infrastructure must reflect the benefits produced. Increases in public health spending are linked to declines in mortality and reductions in low birth weight, foodborne illnesses, and rates of sexually transmitted diseases, to name a few.1 Investing in public health also saves money in the long term: Every $1 invested in public health yields improved health outcomes equivalent to as much as $88 in expenditures saved by county public health departments.2 And because the public health workforce is largely made up of women and people of color, investing in public health advances economic justice and equity by supporting a diverse workforce. Public health interventions are also effective at reducing racial health disparities by identifying and addressing the factors that influence health and reducing the burden of disease.
The increasing frequency and severity of public health threats—climate change chief among them—make these investments all the more urgent. Emerging infectious diseases, such as COVID-19, are also becoming more frequent, thereby overwhelming the health system, weakening the economy, and causing significant loss of life. Additionally, the growing threat of bioterrorism, such as the anthrax attacks of 2001, puts the nation’s security at risk and requires a robust public health response.3
How to build a strong public health system
A robust U.S. public health system depends on factors explored in-depth in the accompanying report and outlined below.
1. Sufficient and sustained funding
The federal government should prioritize stable, sustained investments in the public health system. Experts agree that $4.5 billion, or $32 per person, of new and permanent annual funding is needed to ensure equitable and sustained foundational public health services for all.4 States can also direct pandemic-era federal investments, such as funding from the American Rescue Plan Act (ARPA), to efforts that improve public health infrastructure.
The federal government should also replace siloed, disease-specific funding with comprehensive approaches to shoring up public health infrastructure. Funding appropriated to the Centers for Disease Control and Prevention (CDC) and the funding that flows from the CDC to state and local health departments must be flexible in order to address gaps in public health agencies’ capacity to detect and respond to emerging threats while also meeting existing demands to address infectious and chronic diseases and environmental hazards. The bipartisan PREVENT Pandemics Act of 2022 supports comprehensive funding for public health.5
2. Upgraded and expanded preparedness for future public health emergencies
The federal government must fund state efforts to upgrade and expand disease surveillance systems and lab capacity to identify unmet needs and emerging health threats, including climate change and environmental disasters. Improved lab capacity would help public health systems respond more quickly to biological and chemical terrorism, emerging infectious diseases, and other public health emergencies. The United States should continue to fund efforts such as the National Wastewater Surveillance System, which allows the public health system to track and identify how viruses evolve and mutate through wastewater treatment surveillance.6
3. Improved public health data
To reduce health disparities and improve health outcomes, state and federal governments must target resources and interventions to the communities and individuals disproportionately affected by health threats, which are often communities of color and disabled and LGBTQI+ people. Public health data must include detailed demographic characteristics such as race, ethnicity, disability status, sexual orientation, and gender identity so that decision-makers can identify these disparities. To close current gaps, states should include mandatory data entry fields for these demographic categories in information systems.
The federal government should also invest in modernizing public health data systems to make them more flexible, dynamic, and interoperable. Data must be transferable across the public health and health care systems that capture electronic case reporting and lab data. In addition, the CDC must be granted the authority to require standardized data collection within and across localities and to coordinate and compel data-sharing to provide a national understanding of health across the country. Timely, accurate data collection is essential to quickly identifying and responding to new health threats and trends. Federal efforts to modernize data systems and plan for emerging threats include the CDC’s Data Modernization Initiative7 and recently created Center for Forecasting and Outbreak Analytics.8 Both federal and state governments need sufficient, ongoing funding to ensure continued development in data capabilities and new technological advancements.
4. A diverse, well-trained, and supported workforce
State and federal governments must build a diverse and culturally competent public health workforce that is trained in strategic and systems thinking, data science, communication, and policy evaluation. This will ensure that the public health system is able to rapidly develop innovative approaches in surveillance and detection, risk communications, laboratory science, data systems, and disease containment. State and federal governments also must support diversity, equity, and inclusion in the public health workforce by investing in raising awareness and interest in related professions among underrepresented groups, expanding recruitment, and creating pipeline programs in underserved communities. Policymakers should also support new public health workforce initiatives such as the recently launched Public Health AmeriCorps, for which the ARPA allocated $400 million.9
In addition, federal and state policymakers should provide incentives for public health workers to join and remain in the public health workforce, such as loan repayment, salary bonuses, pay equity, and opportunities for job growth. Public health loan repayment programs such as the proposed Public Health Workforce Loan Repayment Act of 2021 would assist health departments with recruitment and retention by incentivizing a workforce whose salaries are currently not competitive with the private sector. 10 Additionally, providing professional development, training, and advancement opportunities, as well as improving workplace conditions, would help support and retain current workers.
Finally, public health agencies need to build strategic partnerships and training pathways that they can leverage during times of crisis to shore up the public health system’s surge capacity. By establishing partnerships with private organizations, local institutions, and professional associations, public health agencies can ramp up their capacity to respond quickly to health emergencies.
5. Consistent, clear communication with the public
Public health leaders need to develop, test, and disseminate consistent, clear messaging around what public health is and why it matters. The COVID-19 pandemic has highlighted the disastrous consequences of a lack of a national understanding about the critical role that public health systems play in preventing disease and promoting health and well-being. After the rampant confusion and misinformation of the past two years, leaders must restore public trust in public health officials. They can do so through storytellers and spokespersons who engage the public over news media, in community settings, and through other accessible channels.
State public health agencies also need to strengthen public and private partnerships to advocate for public health. Health care systems, community-based organizations that address social determinants of health, and policymakers play critical roles in ensuring community health and achieving equitable health outcomes.
6. Increased standardization of public health capabilities
Public health capabilities differ significantly across states and localities. State and local agencies need financial and technical support to standardize their public health offerings to ensure every community has access to an agency that provides fundamental services and capabilities. Policymakers can provide resources for increasing the number of public health agencies that meet national accreditation requirements. States can also use ARPA funding to improve equity across public health departments within their borders.
7. Renewed global public health efforts to address international risks
COVID-19 has starkly illustrated the importance of international preparedness and coordination to ensure health and safety within U.S. borders. It is also important, however, to bolster public health preparedness globally. The United States has already provided $19 billion in health and humanitarian assistance to assist COVID-19 response efforts around the world,11 but the transition to broader, institutionalized investments in global public health will require reliable, sustained funding and follow-through.
COVID-19 has highlighted the costs of the nation’s crumbling public health infrastructure to both health and economic well-being. While this has catalyzed action to improve the public health system, further action is needed. From increases in infectious diseases and biological threats, to the growing impact of climate change on health, to the continued burden of chronic illnesses, now is the time for policymakers to fully invest in sustainable public health infrastructure so that these threats to lives and livelihoods can be comprehensively addressed and prevented.