Download PDF Winter Issue of The Bridge on Complex Unifiable Systems December 15, 2020 Volume 50 Issue 4 The articles in this issue are a first step toward exploring the notion of unifiability, not merely as an engineering ethos but also as a broader cultural responsibility. Public Health: Designing for Effectiveness Thursday, December 17, 2020 Author: Karen DeSalvo Public health is what society does to create the conditions in which everyone can be healthy. The US public health community and its partners have been striving for years to articulate the structural and mission challenges of the country’s public health system. But the covid-19 pandemic has thrust these challenges to the forefront in a way that the community’s more deliberative efforts have not. A series of major policy decisions, chronic underresourcing of the US public health infrastructure, and political actions that put individual over community created a crisis in public health infrastructure concurrent with the SARS-CoV-2 crisis. In this historic moment, the US public health system is called to stand up, but it is stumbling. It should not be a surprise that the system has incomplete capacity and capabilities to meet the acute and chronic demands during this pandemic. Despite the US economy’s longest expansion in its history, spending on public health infrastructure has failed to return to prerecession levels. Funding seems a perpetual concern. During the last great pandemic, caused by an influenza virus in 1918, the US medical establishment was only beginning to emerge as a separate professional practice. Since then, with the advent of a formalized medical infrastructure, coupled with the marvels of therapeutics such as antibiotics, treatment for acute myocardial infarction, and therapy to prolong and even save life for those with cancer, medicine has taken center stage in thinking about ways to address health. There are calls for better coordination between medicine and public health, but such coordination would take not only willingness but likely also shared accountability or other significant external pressure. I experienced these issues firsthand in a different catastrophe. Role of Public Health vs. Medicine When Hurricane Katrina struck New Orleans in 2005, I saw how important it is for medicine and public health to collaborate and coordinate—and what happens when they do not. At the time, I was on the faculty at Tulane School of Medicine and only vaguely aware of the city’s health department and its role. But it soon became clear to me that public health tools and expertise would be needed to bring back the community. Only the public health sector could handle foundational needs such as the restoration of potable water, a public health laboratory for communicable and other diseases, and ongoing population surveillance for environmental exposures from the flood waters. These and other essential functions of public health complement medical care for acute and chronic disease. My admiration of the role of public health following Katrina was a major reason I later went into public service as health commissioner for the City of New Orleans. Covid-19 has similarly highlighted that medicine alone is insufficient to improve the public’s health, particularly in the absence of the right tools. Early reassurances to the public that the healthcare system would be able to provide life-saving treatments like ventilators if people got sick became questionable and made it apparent to the public that treatment is an insufficient approach to communicable disease. There is a clear need for help from the public health system to leverage authorities to require public health measures like masks and social distancing or to do effective contact tracing to mitigate new outbreaks. Evolution of the US Public Health System The history of the US public health system reflects the concurrent development of national and local structures aimed at addressing communicable disease outbreaks at the local level. At the national level, the US Public Health -Service emerged in the late 18th century principally as a means of protecting US ports from the import of infectious diseases on ships. Local public health efforts got a much later start with the establishment in 1911 of the first county-level health department in Yakima, -Washington, following a typhoid outbreak. The success of local informal public health action led to a groundswell of support, including from the business commu-nity, for the formal establishment of a county-level health department. This model was soon adopted across the nation, leading to the current decentralized, locally funded public health system. The Centers for Disease Control and Prevention is the country’s national “brand” for public health, but has no real authority to promote and protect public health at the local level. Rather, its role is to convene and to provide grant funding, epidemiologic insights, and communication tools for state and local public health officials who have the actual authority. Challenges and Ways Forward Government and local public health agencies were struggling to keep up with the expectations of addressing the public’s health in the 21st century even before the covid-19 pandemic. Their efforts during this pandemic have been nothing short of heroic with staff working long hours daily for months. But the workforce is too small for the needs, whether for surveillance, contact tracing, or laboratory capacity. And with shrinking state and local budgets due to the covid-19-related financial crisis, layoffs were announced. Leaders of state and local health departments resigned because of personal death threats. And roles and responsibilities of public health at the national, state, and local levels—from surveillance to testing and contact tracing—were stripped. The challenges facing US public health are not insurmountable if we—the public and policymakers—are willing to ask and address difficult questions about the current paradigm to protect and promote the public’s health. And do so with urgency given the crisis the system is facing. Medicine should become a vocal, durable, and visible partner in the efforts of public health to strengthen and modernize. And it should rally to support rational and reasoned public health requests to increase funding, update infrastructure, and modernize data and digital infrastructure. Through alignment and allyship, medicine and public health can resume their vital partnership and reduce unnecessary complexity in the system to address and improve the health of the public both during a pandemic and every day. About the Author:Karen DeSalvo (NAM) is chief health officer at Google Health.