Providing for the Common Defense and Promoting the General Welfare by Strengthening the Nation's Public Health System : Journal of Public Health Management and Practice

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Providing for the Common Defense and Promoting the General Welfare by Strengthening the Nation's Public Health System

Lakey, David MD

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Journal of Public Health Management and Practice 29(Supplement 1):p S4-S6, January/February 2023. | DOI: 10.1097/PHH.0000000000001669
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The last several years have been some of the most trying for the public health workforce in a century. We are 2½ years and 6 surges into the COVID-19 (SARS-CoV2) pandemic. Meanwhile, the World Health Organization declared monkeypox a Global Public Health Emergency, polio has recurred in New York, and Ebola outbreaks are occurring again in Africa. Because of abundant and rapid global travel, the large and dense cities in which we live, and human encroachment into previously uninhabited areas, we should not expect that outbreaks such as these will cease.

The workforce that protects us from these and other threats is at a tipping point. In the United States, public health workers were pushed by the pandemic to make tough decisions to protect the public's health and save lives while also being pressed to minimize the economic impact of these decisions. A “pressure cooker” situation developed in many communities, and public servants received the brunt of the anger and frustration that had been simmering across the nation. As a consequence of the lifesaving decisions they had to make, several senior officials were harassed to the point that they had to leave governmental public health to protect themselves and their families.1

Improving the public health system has never been more important. The COVID-19 pandemic has reversed the trend of increasing life expectancy we have seen in the United States. It compounded the burden of drug overdoses and chronic diseases, especially those secondary to obesity and diabetes, taking years of life from Americans.2 Our nation's health outcomes are especially sobering and unacceptable as the disparities and inequalities of health by race, ethnicity, and rurality are exposed. Black mothers are 2½ times as likely to die during childbirth as White mothers, and Black babies are twice as likely to die in their first year of life as White babies (10.8 vs 4.6 per 1000). American Indians/Alaskan Natives have the highest rate of diabetes among any racial and ethnic group (14.5%), and Black and Hispanic Americans have a 60% higher rate of diabetes (12.1% and 11.8%, respectively) than White Americans (7.4%).3 As many have noted, zip code is now more important than genetic code in determining a person's ability to live a long and healthy life in the United States.

The visceral reaction to lifesaving public intervention during a global pandemic was surprising. However, the role of government officials in protecting the health of its citizens is an essential and well-established role of government. How old? We know from the Old Testament writings (Leviticus Chapter 13) more than 2500 years ago that strict rules were used to ensure individuals with skin lesions, which may indicate leprosy or other infectious diseases, were isolated outside their communities and only allowed back once a priest (the health authority) declared that the lesions were not infectious. In the 14th century, due to repeat outbreaks of plague, the concept of isolating people for 40 days was developed to limit its spread, resulting in the term quarantino, what we now refer to as quarantine.4

The inherent need for strong governmental public health is even found in, or at least consistent with, the preamble to our nation's Constitution. How can citizens possibly have “domestic tranquility” or “secure the blessing of liberty” with an unmitigated contagion? Doesn't the work of public health “provide for the common defense” against deadly pathogens, which in fact kill many more people than wars do? By definition, public health works to promote the general welfare by combatting chronic illness and increasing access to health care and helps establish justice by confronting and addressing health disparities. Strong and effective governmental public health is essential to having a healthy populace, a strong economy, and a functional and stable society. Indeed, it is noble work, and people look to leaders in government to fulfill that role in their most dire times.

As science and our understanding of germ theory advanced, society was able to develop better and more precise tools for infectious disease control, including vaccines and antibiotics. However, as these diseases became less common, many people forgot how devastating vaccine-preventable diseases such as pertussis and measles are. Physicians of my generation saw devastating diseases such as Haemophilus influenzae meningitis almost disappear in a few years as effective vaccines became available and state mandates ensured that these tools were used. But this success has resulted in complacency and a lack of appreciation of the essential role of strong public health systems in protecting health.

Unfortunately, governmental public health has been neglected in our nation as society became enamored with modern health care. Although the United States spends more money on medical care than any other industrialized nation, our outcomes are mediocre at best, and we have underinvested in the preventive strategies that actually keep people healthy in the first place. In fact, only 3% of our health care spending goes into public health. Increasingly, health care organizations are realizing that they will need to address social drivers of health if they are ever going to really improve population health and reduce the cost of health care.5

A critical challenge for health departments across the nation is consistent funding. Chronic disease programs to eliminate tobacco use, obesity, and diabetes consistently struggle. Data systems lag behind and are not integrated into health records and across state, local, and national systems the way they need to be to provide optimal health responses. Federal funding is frequently provided only after a major outbreak such as H1N1, Ebola, or COVID-19 and frequently disappears soon after the event resolves. This roller coaster of intermittent and emergency-based funding leaves health departments unable to sustainably invest in the people and resources they need to operate effectively.6

Should we be surprised, then, that at the beginning of the SARS-CoV2 pandemic the nation's public health institutions were not ready to respond the way they needed to? When local health departments are reliant upon fax machines to obtain critical health information, how do we expect them to respond effectively? When health departments are chronically understaffed and underresourced, why do we expect them to withstand the onslaught of emergency response activities and media attention needed to prevent further spread of the disease?

The Commonwealth Fund recently commissioned a critical effort to evaluate our nation's public health system.7 As this report noted, our public health efforts are underfunded and not organized for success, resulting in uncoordinated efforts at the federal, state, and local levels. Furthermore, this system is not funded at the level needed to protect and promote the nation's health, while expectations of health departments must improve if significant new funds are to be secured. The report also notes that health care systems must be leveraged and collaborations between traditional public health agencies and health care delivery systems improved so that we do not continue the silos between public health and health care. Finally, the report notes the public health enterprise faces a critical crisis in trust, which must be solved.

I had the tremendous privilege of working for a little over 8 years in one of the nation's largest state health departments. I learned firsthand the dedication, passion, and commitment that public health employees bring to work each and every day. I also learned that these employees did not always have the tools and resources they needed to protect and promote the public's health the way they knew they needed to.

This is why the work described in this issue of this journal is so important. The Public Health Workforce Interests and Needs Survey (PH WINS) provides us with the data we need to build and sustain our governmental public health workforce. PH WINS provides a snapshot of the public health workforce and provides individual employees with the opportunity to share their experiences and needs to best serve the public. We need to hear what the workforce is telling us through this critical survey and work together to address issues that they—the experts—believe to be important.

The cornerstone to solving all these issues is educating, recruiting, training, and maintaining the right public health workforce for this next century. This workforce must be ready to meet the challenges it will undoubtedly confront. Civil servants in public health must be able to combine technical skills with the program management, fiscal management, and interpersonal skills needed to build and implement public health programs while listening to and working effectively with the communities they serve. This workforce must better match the diversity of our nation in order to rebuild trust and credibility with their communities. People seeking these careers need to know that they will be able to provide for their families, that their careers will be fulfilling and challenging, that they can advance in their careers, that they will be able to make real differences in the lives of the people they serve, and that their public service will be honored and respected. Otherwise, we will again be caught flat-footed when the next pandemic hits and our nation will continue to experience poor health outcomes and significant health disparities.


1. Krisberg K. Threatened, harassed, doxxed: public health workers forge on—security teams protecting health officers. Nations Health. 2021;51(8):1–13.
2. Arias E, Tejada-Vera B, Ahmad F, Kochanek KD. Provisional Life Expectancy Estimates for 2020. Vital Statistics Rapid Release. Atlanta, GA: Centers for Disease Control and Prevention; 2021. Report No. 15.
3. Petersen EE, Davis NL, Goodman D, et al. Racial/ethnic disparities in pregnancy-related deaths—United States, 2007-2016. MMWR Morb Mortal Wkly Rep. 2019;68(35):762–765.
4. Mackowiak PA, Sehdev PS. The origin of quarantine. Clin Infect Dis. 2002;35(9):1071–1072.
5. Bipartisan Policy Center. Bridging health and health care. Published September 2021. Accessed October 4, 2022.
6. Trust for America's Health. The impact of chronic underfunding on America's public health system: trends, risks, and recommendations, 2022. Accessed October 4, 2022.
7. The Commonwealth Fund Commission on a National Public Health System. Meeting America's public health challenges: recommendations for building a national public health system that addresses ongoing and future health crises, advances equity, and earns trust. Published June 2022. Accessed October 4, 2022.
© 2022 The Author. Published by Wolters Kluwer Health, Inc.