Renewing America Series: Public Health as a Public Good—What's at Stake?

The COVID-19 pandemic amplified health disparities and renewed conversations about the limitations of current public health systems after decades of disinvestment. Panelists explore the idea of reframing public health as a public good to drive investment, modernization, and encourage better coordination across health systems.

With its Renewing America initiative, CFR is evaluating nine critical domestic issues that shape the ability of the United States to navigate a demanding, competitive, and dangerous world.

FREIRE: Welcome to today’s Council on Foreign Relations meeting, “Public Health as a Public Good—What’s at Stake?” This meeting is part of CFR’s Renewing America Series, an initiative evaluating nine critical domestic issues that shape the ability of the United States to navigate a demanding, competitive, and dangerous world. I’m Maria Freire, former president of the Foundation for the National Institutes of Health. And I have the honor of presiding over this discussion today.

Joining us are David Cutler, the Otto Eckstein Professor of Applied Economics at the Department of Economics at Harvard University; Linda Fried, who’s the dean and the DeLamar Professor of Public Health and professor of epidemiology at Columbia University’s Mailman School of Public Health; and Margaret “Peggy” Hamburg, former foreign secretary at the National Academy of Medicine, former health commissioner of New York City, and former commissioner for the Food and Drug Administration. Peggy is a member of the CFR Independent Task Force on Preparing for the Next Pandemic. Welcome, everybody, and thank you for joining us this afternoon.

Linda, I’m going to hand the floor over to you first. Help us understand what we mean by “public health.”

FRIED: Thanks, Maria. And good afternoon to everybody.

So I’m going to speak as a physician who spent a lot of her life in clinical practice. And to say that we know that medical care matters hugely, but when we’re talking about public health, talking about what medical care needs to succeed. Public health has been defined formally by the U.S. National Academy of Medicine as what we together, as a society, do to assure the conditions in which everyone has the chance, the full opportunity, to be healthy. That means that you, your family, your friends, your neighbors can live healthily longer, and be able to enjoy the fruits of life. That’s the goal of public health. I would say you could summarize it in saying that public health’s mission is to raise the floor and the ceiling of health for everyone through preventing disease and investing in the conditions of our society and our communities that promote health.

We know a lot now how to do that based on science, evidence, and experience. But I think the critical point is that we do this in the United States through the U.S. public health system, a system at local, state and federal levels, comprised of over 3,000 community local public health departments, fifty-one state and territorial departments, and the U.S. CDC. And we do it through the Food and Drug Administration, and many other governmental entities. Through those the shared responsibility of the U.S. public health system is to join—for them to be our vehicle to join together to solve the problems that no one clinician could solve for their patient, and no one can solve for themselves—like, say, for drinkable water, like conditions of safe and healthy food, and affordable food, like the ability to prevent the spread of infections—which 100 years ago was one of the first learnings of public health, that we could only do that successfully, ultimately, together. And many other things that we’ve learned since then about how to prevent a whole host of the major disease and illnesses that affect health.

FREIRE: Linda, thank you. From your words, it’s important to emphasize the fact that public health is not only pandemic preparedness. And I think that’s a very important message. It is much bigger, much broader than that.

FRIED: Right. Well, you could add, I think accurately, that what we’ve learned over the last hundred years, since this country really started public health, is that the conditions of our world, of our communities, of the resources we have access to, are very much the dominant shapers of whether people can be healthy, whether they get what we are now calling underlying conditions, like heart disease or stroke, and whether they are able to have the food they need, and so many other things. Whether we are addicted to opioids, whether we are in a position where there is a lot of mental ill health in our communities. These are issues which, of course, require clinical treatment, but also are open to approaches in our communities that can prevent or mitigate those illnesses.

FREIRE: Thank you, Linda. One of the—one of the key factors, I guess, you pointed out—and I’d like David to pick up on that—is that public health, and certainly the gains in public health, have had enormous economic impacts. So, David, from your perch as an economist, help us understand how we frame this issue.

CUTLER: Yeah. So Linda is right, these are—public health measures are public goods. The two classic examples of public health are defense and health—public health, in particular. And there are things where no individual person will pay for much on their own, because a lot of the benefits go to others. So when you think—economists sort of differentiate between public goods, which are goods that everybody benefits from, and private goods, which are goods that only the person who consumes it benefits from. And so cleaning the air, or providing information about how to make things safer or healthier are things that everybody benefits from. And so the market is always going to underprovide it.

And we sort of observe that historically. It’s been very difficult to get, you know, people to pay for stuff that benefits everyone else. And that’s exactly the situation we find ourselves in in terms of public goods. So the way to evaluate them is not so much how much does the market give of them, because we know that the market will under-provide them. You know, for certain big-ticket items very few people will pay for them on their own. The real way to evaluate them is to say in society as a whole when we put money in, what do we get out for it? So are we getting return out for it that’s commensurate with the dollars that we put in?

The literature in public health is very, very clear, that a large share of the improvements in health over time are due to public health efforts. Not the only source of improvements over time but it’s certainly a large share, going back to things like clean water, and sanitation facilities, through things like information about the harms of smoking and how to make cars safer, and how to make society safer, to how to immunize people, and dealing with pandemics, and so on. So to me, there’s no economic case at all—there’s really no economic debate at all that we should be having about whether public health is worth it. That is, any measure of the gains in terms of improved health are going to be infinitely greater than what we spend on it.

To put it another way, almost every study finds that public health measures are more important than individual medical care at improving health, and yet we spend probably about thirty times more on individual medical care measures than we do on public health per person in terms of where we direct our resources. So I don’t think there’s any economic case at all that we should be spending more. I think it’s really an issue about kind of the practicalities, like where should we spend it and how should we go about doing it, and how should we make sure that the money is always there, and stuff like that. But just kind of economically it’s one of those examples of something—you sort of teach it as an example of something that—where the market is going to get it wrong on its own and where you really need the government to be involved.

FREIRE: Well, that’s a—that’s a nice way of introducing Peggy, because, Peggy, you’ve been at that crossroads, right where the rubber meets the road. So Linda makes the case of the importance of public health, the gains we have had, and the importance to keep the momentum. And I want to talk a little bit about marginalized parts of society as well in obtaining these goods. David says it’s a no-brainer that investment in public health is well documented. But you have been at the crossroads, and you are at the crossroads of policy and politics and public health. So help us understand a little bit how the rubber—and what happens when the rubber meets the road.

HAMBURG: Well, thank you. And I’m so delighted to be doing this panel with my friends and distinguished colleagues, and such an important topic at a really critical time. You know, public health has long been a vital part of our overall approach to health, but it has been underappreciated, underfunded and, you know, one of the reasons for that is that when public health is doing its job properly, as Linda noted, it’s all about prevention. It’s about stopping problems from happening. It’s reducing risks. It’s about preventing disease and promoting health. You know, when I was health commissioner in New York City, you know, I certainly experienced firsthand the longstanding challenge of public health working at the intersection of a whole suite of complex issues and domains of activity. Certainly at the intersection of law, of economics, of social issue and values, and, of course, politics.

And there are many reasons why public health has struggled in that context, because it does deal with issues that don’t align always with political agendas. It takes a long view. It’s investing in the health of communities. It is addressing issues that, you know, may come up against strongly held ideologies or social values—reproductive health, gun violence, addiction. It is a form of government that requires both the putting forward of guidance and the enforcement of that. And so, you know, it comes up against ideologies about what is the appropriate role of government. And it, of course, is very much linked also to trust in government and government advice. So the ability of public health to communicate clearly what it does and what needs to be done is also very, very important.

I had the unusual experience of working in New York City three years for Mayor Dinkins and three years for Mayor Giuliani. Very different in their political orientations, but the truth is I did my job the same way in terms of the core public health functions that we needed to provide. In presenting to the mayors, I spoke somewhat differently, I’ll confess. With Mayor Dinkins I focused on addressing needs of underserved populations as a top priority, with Mayor Giuliani it was public safety. But those are all integral parts of public health. And it helped them as leaders understand the mission and the activities of the health department and, I think, you know, to be supportive.

But, you know, one of the great challenges for public health, especially today, is to really explain what it is and what it does. And we are, sadly, in a moment when public health is probably more politicized than it’s ever been. Some would say it’s weaponized, but in terms of partisanship and ideology. And we have to, you know, really work together to support these core functions and remove it from the, you know, political firestorm.

FREIRE: I want to—I want to pick up on a lot of these themes because clearly, we have—do we need—let me rephrase it. Do we need to retool public health and the education that you’re talking about, Peggy? Do we need to do something different? David, you’ve mad ethe case that the economic argument is well understood, and yet we seem to be having this conversation every five years. And nothing seems to be moving forward. Peggy, you said a little bit earlier you thought that perhaps the pandemic might help crystalize some of these thinkings, but I’m not sure. So throwing it back to you, David, and then to you, Linda. What do we need to do? How do we retool for what’s ahead? How do we change the equation? David.

CUTLER: So let me start off with a couple of thoughts, and then I’m sure Linda—I’m incredibly curious to hear Linda’s response to it. One is, I think having some consensus around what would be the most important steps we can take now would be very helpful. So, for example, prior to, let’s say, the Affordable Care Act in medical care, there was a very long series of discussions people had about the best way to insure people. And there was a lot of back and forth, and people had their different views.

But in the end, there sort of came to be a kind of general sense, like, you could go this way, you could go this way, you could this way, and here what they would involve. And then it was just a question of if there was a politician who was willing to do it and there was a Congress that was willing to go along. You know, a president that was willing to propose it and a Congress that was willing to go along. And so that—it had been kind of worked out what the agenda looked like, so you didn’t have to spend a lot of time at that moment when you were ready thinking about the agenda.

I remember, it was at least true as of a decade ago or so, there wasn’t a similar agenda on the public health end. So there was not a similar here’s what you would do to address the major public health issues in the country. Here’s how you’d go about doing it. Here’s what it would mean, and so on. And it may be that it’s out there, but that’s, I think, the first—the first issue.

I think the second issue is we have a sort of different approach to thinking about public health funding than we do even just about, say, medical care funding, where medical care funding is kind of on autopilot. And, you know, the default is that we’ll keep doing what we’re doing, unless we decide to do something different. And public health is a little bit different, which is that we are always thinking about reauthorizing. And so it’s almost like the base—what is the default differs a lot. And those defaults can matter an enormous amount in terms of whether what you’re doing is doing a lot, or whether what you’re doing is not enough.

And so thinking about changing the default where even to some—say something like, you know, I was mentioning earlier that we spend, you know, anywhere from thirty-plus times more on medical care than on public health. So maybe our default should be that we spend one-tenth as much—you know, only ten times more on medical care than we do on public health, or whatever it is. That that—that changing, therefore, what that default is I think can have a very big impact so that it’s not always, you know, justifying things by pulling from something else. It’s sort of, this is what we’ll do, because we’ve decided that this is an appropriate thing to do.

The third think I think is important is to link some of the public health issues to some of—to economic issues. And one of the things that struck me about COVID—and even though we don’t want to pigeonhole this in terms of pandemic disease—but in COVID one of the things we learned is that the economy is much more sensitive to health impairment than we’d guessed. So a century ago when we had the great flu there was a recession which was very short-lived. And the reason is people needed stuff, and so they had to go back to work, and they had to buy stuff, and so on.

And now, a lot more spending is discretionary. It’s sort of do I need to go out to get that coffee? Or do I need to go to that business meeting? Or do I need to go, you know, to that evening out, or whatever it is? And in many cases, people decided the answer is no. And so the way that I think about it is that the economy is more of a luxury economy than it used to be. And if you’re in a luxury economy, anything that increases the prices of it—like, for example, the potential to make you sick—can have an enormous impact on the economy. And I think that’s something that we haven’t quite appreciated as much.

And that means that efforts like public health efforts that allow people to remain at work are actually even more valuable than they used to be, because the economy will unemploy them more rapidly than it used to be because they’re sort of in a luxury realm, not in the essential realm. And particularly for a lot of low-wage workers, for a lot of women in the labor force, the economy is fairly quick to unemploy them. So thinking about how we make that clear so that when—so that we think about public health measures in terms of our health, but also as an employment policy, would be—will be helpful in terms of moving this forward.

FREIRE: That’s very interesting. I think we’ve seen the great resignation, and we’ve seen a great movement of people in their choice of work that we hadn’t seen before. And of course, there were people from low economic levels that had a very hard time during this pandemic. They had no option. They had to go work.

Linda, tell me—give me your perspective. Now, we’ve gotten the economist perspective. Let’s look at the health perspective. And, Peggy, I’m going to rope you in and bring you back and say: OK, I like this idea of making this argument. Who do we talk to? So, Linda, you first.

FRIED: Oh, I’ll start with where David was, because I think the economic argument is quite tight. And certainly, COVID made it clear that health and the economy are not separable. (Laughs.) That the state of health of a population is critically important to the state of the economy. And we certainly have known that in terms of worker productivity, but here we’re talking about the whole economy. But if we’re talking about how to appreciate and how to actually reinvest in public health as a public good that is foundational to the wellbeing of a society, then I think it’s useful to reflect on what’s been accomplished so that we know what we’re valuing and what we need.

So three statistics. In the first hundred years of public health, due to vaccines, public health is responsible for preventing 103 million cases of smallpox, polio, measles, mumps, rubella, hepatitis A, diphtheria since 1924, including twenty-four million in the last decade. And we count on that in terms of our state of health. Public health has been responsible for a two-thirds decline in deaths from cardiovascular disease since the 1950s. And public health has been responsible from twenty-five to thirty increased years of our life expectancy. So in the U.S. we’ve gone from—in a hundred years—a life expectancy of forty-seven at birth to almost eighty. Those are just three statistics, but they’re profoundly important.

And we take for granted, as we take for granted many of the successes of public health, that this new state of existence, with much lower rates of death from chronic diseases, much lower rates of infectious diseases, et cetera, is somehow normalcy. But it requires continued investment. And then we have learned so much since the U.S. started taking this for granted. So around the 1960s, the U.S. started disinvesting in public health. It’s disinvested tremendously. And many of the challenges of this pandemic is a result of antiquated data systems, health departments with a skeletal workforce, who are not trained in public health in the main, and low pay. And expecting them to carry the weight not only of maintaining the advances we’ve had in these and a hundred other problems, but somehow responding to incoming threats that we never saw before, and incoming opportunities.

So long past when we started defunding public health, we learned that half of chronic diseases are preventable. But we don’t have a public health system and workforce resourced to accomplish what we could deliver to the American public. We learned since then how to advance prevention of many conditions that we are plagued with. The U.S. health status has declined to the bottom of peer nations in the last thirty years, and much of that is attributed to our disinvestment in public health. So these are the issues of the present. And then there are the issues of what’s coming in. How do we protect all of us from the health impacts of climate change, wildfires, extreme hurricanes, et cetera?

These are things we need a public health system to lead on. How do we create health across the longer lives that we’ve now created? We need a public health system that can create the conditions and the programs and the policies that can have—enable everybody to have an opportunity to be healthy through those longer lives. And the list goes on and on of problems we never had until the 21^st century. So we desperately, I think, need this public good of public health in a large way to bring the return on investment that David’s talking about for the incoming challenges, as well as the longstanding ones. And we need to perhaps take the opportunity of having really frayed the public health system over the last bunch of systems to reimagine and redesign it as a really effective way to deliver health to everyone in every community for the problems of our present and future.

FREIRE: Well, I mean, my goodness, that’s an agenda. (Laughs.) It’s sort of reinvigorating something that we took for granted. And I think we’re now seeing the result of that in many different ways.

Peggy, I want to turn to you before we open this session for Q&A, because what David has said and what Linda has said is very, very important. Do you think we need a public health plan? Is there such a thing as a public health plan? Do we need an education campaign? Where do we go from here?

HAMBURG: Well, I think that David and Linda have laid in compelling and stark ways why public health matters, the economic benefits, and the health benefits. But I think we have to recognize that we are at a critical juncture, and at the moment the public and policymakers may not be quite so convinced. During COVID they have seen a public health system really flailing in this country, and not able to fully step up to the tasks of, you know, what is, you know, one of the most catastrophic threats to health, certainly in our generation but, you know, of the century. And the fact that public health has not, you know, risen to the task as adequately as we would have hoped and wished, you know, partly reflects what Linda said, that it’s been underfunded for a very long period of time and the infrastructure, you know, has been inadequate. And under these circumstances, you know, too weak.

In addition, you know, we have seen political leaders, you know, not galvanizing the expertise and resources of public health in the most constructive ways, and often, in fact, undermining public health’s capacities. And then, you know, certainly we have to acknowledge there have been failures in communication that have undermined trust and confidence, and a lack of understanding on the part of the public also bout, you know, how actions will unfold in the face of uncertainty and addressing a novel virus, and related pandemic that is going to bring changing circumstances, and thus changing public health actions.

But one thing that is absolutely clear is that this is a time for us to really assess where we are and where we need to be, to really do some of the reform that needs to be done to the basic public health system, to modernize public health, and, as David was saying, to adequately invest now and for the future. One of the things about public health that we’ve seen during this pandemic that makes it challenging is that it is a distributed responsibility. We have national public health agencies, like the Centers for Disease Control. But the real bread and butter of public health happens at the state and local level. And many of the authorities are state and local. But it does mean that there are different policies. And we need a national system to really integrate many important components of public health.

We also have fragmentation that leads to, I think, less than efficient use of resources. When you have, you know, tiny local health departments, they can’t really have the workforce and the other resources to adequately do the job. So we need to look at how can we create an integrated system of public health that recognizes the importance of state authorities and autonomy, but is linked into a national system. We also have to dramatically upgrade our systems for data collection and dissemination. And we suffered greatly, and continue to, in that regard. We need to find ways for public health to better integrate with our health care system. They’ve too often been stovepiped separate systems, and they need to be a continuum. We need to be able to share data across those systems. And we need to be able to integrate the community-based prevention strategies with the hospital care.

And we really have a sort of unique moment right now to take this on and address public health reform. But we need to make sure when we do that that we adequately educate the public and policymakers, that we systematically look at what’s needed, what we’ve learned from COVID and beyond, what are the challenges of the future and how do we need to retool for that. And importantly, you know, we really need to be very clear about why this matters for people, the economy, our security, and the future.

FREIRE: Very well-said, Peggy. And you’re absolutely right. There’s been an enormous disconnect. I know that we have focused on the United States, and this is part of this particular CFR initiative. But we are also all aware that public health is—doesn’t have geographic boundaries. So before anybody in the Q&A session reminds us of this, I think we’re all very cognizant of the fact that what happens here will happen elsewhere. And we’ve seen it, of course, during this terrible pandemic.

It is time to invite the members and guests to join us for the conversation if you have any questions. I want to remind everybody that this meeting is on the record, and the operator will tell you how to queue in for questions. So, Operator, if you would let me know if there are questions. And in the meantime, we’re going to still continue the conversation.

I’d like—I’d like this notion of a default, fundamental, basic amount of money for public health pegged to whatever indicator we want to do it. Linda, do you think that would—that would help? I mean, money is, of course, a big problem. But I would imagine it’s not the only issue, right? So.

FRIED: I think consistency and stability of the ability to maintain functions is critical to being able to take the long view, which is public health’s responsibility. If you’re preventing disease and investing in everyone’s health, you have to be consistent and keep going in that to create the conditions that are good for people. If you don’t know if you’re reauthorized in a year or what resources you’ll have in a year to keep going, it, first of all, makes it very hard to recruit the best people, it makes it difficult to retain them, and you cannot build programs of well-trained people that are intended to actually have long-term effects. So I think David’s proposal is foundational to success.

Then you have to have the infrastructure and systems that those people can depend on. And as Peggy said and I think I said, the disinvestment since the 1960s has meant that we—the U.S. public health system does not have modern data systems that are interoperable, you can communicate, can track data in real time, and can be useful. And that—these kinds of deficits really need to be corrected. And then there are the issues of how to deploy the science we know could work and have a well-trained workforce who can take responsibility for getting it done.

FREIRE: We have—we have some hands raised. So I’m going to ask the operator to please announce the first question. Thank you, Linda.

OPERATOR: Thank you.

(Gives queuing instructions.)

We’ll take the first question from Jay Markowitz.

Q: Hi. Thanks so much for doing this call.

I can’t help but think about how perverse the incentives are to invest in the private sector, on companies that treat disease rather than prevent it. I work at ARCH Venture Capital, which is—its business is to create companies. And I would love to create the kind of companies in the private sector that address this public health problem, but the environment is so skewed to creating companies that treat disease and against treating companies—and against creating companies focused on preventing disease. I’m curious what solutions the panelists might have on how to create the right set of incentives to get the private sector to invest in companies that do things like prevent pandemics, prevent cardiovascular disease, prevent cancer, when all of the incentives and all of the economic payment models are geared towards paying for diseases after they’ve already occurred. Thank you.

FREIRE: Well, Jay, I think you’ve just identified the next conversation for the next conversation—(laughs)—because I think we’ve been battling this issue and we’ve been seeing this problem with things like AMR, you know, when you have a disincentive or not the right incentives—economic incentives for private investment. So, yes, David, I’m going to call on you.

CUTLER: Well, just one thing to add that I don’t know if it’ll be helpful but it’s a recent economic trend, and something called social impact bonds. I don’t know if anyone has heard of those. But those are things, like, let’s say you’ve got a social program that you think will save money for the government. The government may not have the money to pay for it up front, but you’re hopeful that down the road it will. So what you do is, in essence, the government finances it by issuing bonds, the way it often does. It borrows money, it issues bonds. But the bonds only pay off if you’ve achieved savings on your target relative to what you thought.

So you could think about—let’s take cardiovascular disease. Let’s say you’ve got either Medicare or Medicaid. And you sort of say, well, look, I’ve got something which is going to lower your Medicaid spending on heart disease, or I’m going to lower your Medicaid spending on nursing homes, or whatever it is. You say, OK, fine. So here’s what our baseline is. If you come in below that, then we’ll know that you’ve saved us money and we’ll pay out the bond on the basis of how much of that you’ve come in. So if we don’t save any money, we’re not going to pay out, means the government won’t pay a thing. But if we save a lot of money, then you as a bondholder can get a very big return, and you as a company can get a very big return.

So it’s kind of a way of saying, look, if you believe it’ll save money, put your money up, and then let—and then we, as a government, can then pay you back based on it actually doing that. And so that—and that’s not too dissimilar from what a lot of businesses do. They borrow money and then if it is successful, they’re able to pay it back. If it’s not successful, they’re not able to pay it back. So that’s one possibility that I hope we can use more for things that are like this, speculative but with a potentially high return. So someone could make a lot of money, or if it fails they don’t—the government isn’t out anything.

FREIRE: Go ahead, Peggy.

HAMBURG: Oh, OK. Well, I was just going to say, you know, I think, you know, one of the things COVID has really shown us that when you can develop public-private partnerships, you can often be much more effective at really aligning, you know, resources—science and technology and economic investments—to address unmet public health and medical care needs. And I hope that coming out of COVID we can continue to think about those kinds of models for problems that are not, you know, catastrophic pandemic threats, but very, very serious unmet public health and medical care needs that burden individuals and families and, you know, in fact damage our economy, and certainly challenge us in terms of our futures.

And, you know, I think that it may not be that companies are going to rush to invest in products to address certain public health needs, because it’s not going to have the payoff for—that a blockbuster drug will have. But I think that we can create contexts where we can create, you know, the ecosystem to make it in the interest of everyone to be working together to address important public health problems. Certainly, during COVID we’ve also seen that one area that for a long time the pharma industry didn’t see as that attractive in terms of return on investment, vaccines, you know, in fact can be.

And when you look at some of the cutting-edge tools in the life sciences today and where there are big prospects for biopharma, a lot really does have to do with early detection, with trying to prevent the full-fledged consequences of disease—whether it’s, you know, cancer diagnostics for early warning of risk or, you know, genome editing. You know, there certainly is a desire amongst the public and consumers and opportunities in science and technology today to address problems with more of a focus on prevention and early detection. And, you know, sort of thinking about how public health and health care, you know, fit together, I think there are opportunities, you know, to engage the biopharma industry more aggressively.

FREIRE: I think the notion of public-private partnerships is very important.

Linda, a couple of sentences, because we have several hands raised.

FRIED: So I think it’s important to see this as a both/and proposition. We need to define the elements that are a governmental public health system has to provide, and then the opportunities for the private sector to, in partnership or in addition, to be able to bring value in terms of prevention.

FREIRE: Thank you.

Yes. Operator, would you give us the next question, please?

OPERATOR: We’ll take our next question from Laurie Garrett.

FREIRE: Hi, Laurie. The floor is yours.

Q: Hello. Thank you very much. It’s great to see all of you.

My question is a little tricky. I can’t think of any time in my four decades in public health and emerging disease threats, pandemics, where the trust was as deeply divided and where public health was as deeply hated, with fires whipped up by political leadership in a particular party. I can’t recall—I mean, it seems like every major past initiative we had bipartisan support at the front and center for response. Now we have direct targeting, with death rates higher in counties that voted for Trump than in counties that voted by Biden, as tracked by multiple agencies. And we have elected coroners, which 38 percent of all death certificates signed in America—we have elected coroners who are actually refusing to sign that people died of COVID in several counties across America, for political reasons. How do we get past this? How do we get out of this moment where there’s actual death threats against public health workers, where our army of public health volunteers and fighters is quitting out of fear?

FREIRE: Well, Laurie, this—yes, it is a tricky question, and with not very many simple answers. But this pandemic has helped shine a light on many issues, and this is a very troubling issue. Certainly, I think it had to do with education. But I’m going to hand it over to the dean for her to take the first crack. And then I’m going to ask David for your thoughts. And, Peggy, you’ve addressed this a little bit earlier in your remarks. But, again, let’s be pithy because we have a lot of questions.

Linda.

Q: Yeah.

I’m going to start with what probably sounds naïve, which is that it’s really critical for people to understand how much of what we take for granted in terms of health in this country is due to our investments—our wise investments in public health over the course of the last hundred years. And that there’s some things that a successful society can accomplish only together. I mean, human beings have known that since the beginning of humanity. There are some things we have to do together. And public health is the enactment of that in terms of creating health. We have to understand that. And we need leadership to be able to articulate it, as well as everybody understand that it matters to them.

FREIRE: Well, I think that’s a very—the leadership—(laughs)—just sums it up, right? So unless David or Peggy, you want to say something short and to the point, I have more hands than time.

HAMBURG: Well, I just would—I would have to say, I mean, Laurie, as always, put her finger on the—you know, the pulsing hart of the problem. And it’s horrifying and terrifying, and just enormously discouraging to see where we are in this country, and in other places in the world, in terms of this divisiveness with public health now caught in this terrible position. But I think that, you know, it’s a broader set of issues about how can we find, you know, the sort of places where we can have thoughtful, considered discussions and make informed decisions for the betterment of all. But we have to keep trying. I think we have to, as a public health community, come together in ways that we haven’t before to, you know, really address the problems that do exist within public health, so that we can strengthen public health.

We have to work with policymakers. We have to continue to educate the public and demonstrate value and trustworthiness. I mean, I think that’s a part of the problem. And I think we have to sort of take encouragement where we can find it, which isn’t always that great these days. (Laughs.) But Linda can tell us if I’m correct, but I think that actually interest in public health applications to schools of public health are increasing. So while there are many, many people in public health who are just discouraged, and want out, and feel attacked in ways they never have before, and we can document that that is true, that there also is, you know, a sense that public health matters and that it is important to pursue careers in public health. So I would take some encouragement from that as well.

CUTLER: Marie, I’ll just—maybe I can give two quick comments from other areas of economic policy. One is, I would say, start with some small victories. So don’t try and convince people to do everything at once. Find one thing on which you can do something and make progress on it and show that you can make progress. So, you know, we’ve done that with the Earned Income Tax Credit in economic policy, or macro policy, or whatever it is. So find things we can do small.

And then the second piece of advice is build broad bases of support. So for example, one of the things about the Affordable Care Act that was important, many cases expanded access to Medicaid afterward and they came in over time, is because hospital executives would come in and say: Look, you may or may not want to do this, but this is really important for us. And local officials would come in and say: This would really be important for us. And I think you could build up some of the same types of medical constituencies that say, look, we can’t handle a huge HIV problem because of opioids, or whatever else it is. So you’ve got to find a way to do something about this, or else we’re going to be in big trouble here. And sort of building the broad constituency can help you sometimes if the narrow issue has become too toxic.

FREIRE: I like the notion of small victories. Let’s go to the next question, please.

OPERATOR: We’ll take the next question from Rob Shepardson.

FREIRE: Rob, the floor is yours.

OPERATOR: Rob, please accept the unmute now button.

All right. We’ll try a different question. We’ll take our next question from Tom Bollyky.

Q: Great. What a wonderful event. So thank you for organizing it.

I was actually going to ask the flipside of Laurie’s great question, which is fishing for some good news here on public health. And what I wondered, are there positive examples emerging, investments that have occurred during the pandemic? Obviously, there was an announcement of $7 billion as part of the American Rescue Plan. Is that providing any durable benefits for local public health? Any reorganization examples, or innovations that we should be looking to model elsewhere? Positive stories emerging on how people have responded to rebuilding public health in response to this crisis?

FREIRE: Well, I’m going to—Linda, since I didn’t give you a chance to answer the previous question, this is the flipside of the coin. So any thoughts of what has gone right? You’re on mute.

FRIED: One thought of what’s gone right is that we’re having this session, and many other people are doing it as well. And I think it’s—one of the challenges for public health always is that nobody knows they didn’t get the disease, and so there is not a native constituency for a public good like this. And so I think the upswell, not just in students wanting to study public health because it really, really, really matters, but an upswell from the public in recognizing that this matter is what is critical for the long term. And I feel like there has been not just this session but many conversations to recognize the disaster that we have wreaked in the pandemic because of long-term disinvestment.

FREIRE: I think one of the lessons that I’ve seen from the pandemic, you touched on it, Peggy, earlier, which is linking the public and the private sector to face a common goal. It’s a shame that it has to come when we are faced with such a drastic circumstance, but I wonder if there are lessons that can be learned here, either through that bonds that you were talking about, David, or the issues that you were addressing, Peggy, including education and bridging the gap. So what do you think have been good lessons learned, Peggy?

HAMBURG: Well, I don’t know if we’ve learned this lesson or not, but as we come out of COVID I hope one of the lessons that we have learned and will act on, especially if there are significant additional resources that can be invested in public health, is that you want to build systems that are put to use every day, that routinely are in place and, you know, benefit health, and benefit the economy, and that we can point to as making a difference, not just assume people will appreciate the fact that public health is, in fact, protecting their health, and preventing disease, and reducing critical risk factors. But we also want to have systems that, you know, can be scaled up, in the case of the need to respond to emergencies.

And I think, you know, we have to move away—and we saw with COVID response, I think, you know, how unhelpful fragmented systems are. We really need to take this moment to really create a much more integrated system, and really better define the national role in our public health system. But also, the critical partnerships and linkages of public health with so many other domains of activity. And, I think, you know, public health has always been—I think this is important; we haven’t really touched on it—you know, also concerned about equity, about making health available to all. And during COVID we’ve seen how much underlying poor health and lack of access to certain critical services matters even more in an emergency. And I think that we have an opportunity to really recommit to health equity and reducing disparities in health as we, hopefully, improve health for all.

FREIRE: Thank you, Peggy. David, any thoughts on what’s gone right side of the equation?

CUTLER: So without specific reference to COVID-19, just a couple things. One is, I think it’s probably worth stressing over and over again the enormous impact of public health on the reduction in tobacco use, which has been one of the greatest achievements of the public health system over the past sixty or seventy years, and how much that’s meant to Americans that they’re no longer spending a lot of money and losing years to that. So that’s, I think, really important. The area where in some sense I think that people are the most caught up, where I’d love to see us be able to bring some rationality and sensibility to it, is school-based public health policy. Where people are very confused about is what’s safe for my child, and what’s safe for the teachers, and so on.

And I think that confusion is making it very difficult for people. And, you know, is school going to be open next week? And what am I going to do if school is closed next week? And how am I going to handle the job, and stuff like that. And so I think that that’s a real issue. Like, if I were going to say what issues could I address and try to straighten out in people’s minds, I think that would be number one. And then just to pick up on one thing that both Linda and Peggy have made, which is, you know, Congress recently passed an infrastructure bill. And for the first time really we’ve recognized that infrastructure is more than just roads and bridges. It also involves electronics and broadband, and so on.

And in coming back to the idea of small victories and victories that matter, we should show that we can take some of that and use that to improve public health measures, and medical care measures, by making information flow and all those other things. And then we can tell people, see, look, you did this. You paid for this. And this is what we’ve gotten out of it. And you can—and this is progress. And you can see this progress here. You know, whether it’s knowing more about who’s really sick in school and how to manage schools, or whether it’s more about, you know, where hotspots in the community, where the next opioid epidemic is going on. You know, the same way we can show that policing, while it went too far, reduced crime, maybe we can show that public health measures with the right information can reduce disease, and that can then generate a lot more support in the kind of one step at a time method.

FREIRE: That’s very—(laughs)—well, that’s very important, David. It strikes me that part of the small victories are—if we just had daycare, you know, that we could trust. Or what’s happened in the last couple years is that we’ve seen surrogates for public health, right? The schools have been surrogates for public health practitioners, universities having to give tests to students. That would have normally been part of the public health mobilization. But anyway, lessons to be learned.

We have time for one more question. Do we have any questions in the queue?

OPERATOR: We do. We’ll take our last question from Thomas Novotny.

Q: Thanks for this session. And thanks to David for pointing out the successes that we’ve had with tobacco control. I was going to bring that up.

But the other thing that I wanted to mention is that I think we need to beef up the federal workforce in a big way. We have, you know, the Epidemic Intelligence Service, which is the sort of frontline training, postdoctoral fellowship that CDC uses to staff up. And that, I think, can be improve—or, expanded. But also, at the same time to use the staffing and experience to reach out to agencies, whether it’s at the state or local health department levels, or even actually academia as well. So that the whole sort of philosophy of public health practice and public service can be connected, you know, through state and local health departments, but also into the academic public health programs. So I’m sure Linda can relate to that.

And I think the other thing that I just want to mention is that in choosing our leaders for CDC and HHS even, that we need to really pay attention to people who have practiced public health, rather than academic researchers. I think, you know, we need people who can communicate, you know, to the public in a rational way, with confidence that they’re representing the agency, the organization. And I don’t think we’ve had that in recent public health efforts. So anyway, I think beefing up public services is really one of the things we should look for.

FREIRE: Thank you very much. That’s certainly an important thing to do. We have one minute, so I’m going to go very quickly around. You know, Peggy, give you the floor first, and then quickly to Linda, and David you’re going to be bringing up the rear.

HAMBURG: Well, my comment really was partly a reaction to what my old friend Tom Novotny was talking about, about the importance of public service. I think that’s right. But I think it’s also important to recognize that public health will be most successful when we have many different kinds of partners. It’s not just government officials. It’s engaging institutions in the community. It’s engaging the private sector. It’s engaging, you know, obviously workplace safety and thinking about risk factors that go beyond the traditional ways that we think about health, including, you know, violence and injury. You know, smoking used to be in that domain, but—in terms of people not thinking of it as a threat to health, that obviously is the leading cause of preventable disease in this country and around the world. And we need to be recognizing that public health needs to be sort of embedded in all policies and programs.

FREIRE: Well said. Linda, real quick, before they get very cross with me.

FRIED: Well, I second what Peggy just said. Public health is an all-of-society proposition that we have to do together. But we do need to empower it as a public good to deliver the foundations through our—through a 21^st century public health system.

FREIRE: Thank you, Linda. David.

CUTLER: I’ll just say it helps to be both modest, in the sense of not claiming too much, and forceful, as the case may be. So in economic policy, there have been eras where we have gotten it spectacularly wrong, and then economists look like total idiots, which is deservedly so. And then we go back and we rethink it, and we say: What did we do wrong? And let’s come up with some better ideas moving forward. And then you try and convince people of that and move forward. And I think we were in an era where public health was kind of quiet, and it’s now down in the doldrums. And now we need to think about what do we need to do to move forward. And we need to come up with something, and then we need to aggressively push it. Recognizing mistakes that were made, but not saying therefore that dooms us. So keep going with what you think is scientifically right. And if you believe it, then you can convince people of it.

FREIRE: Well, thank you very much. Thank you to everyone that’s joined today’s virtual meeting. And thank you to these terrific speakers. A lot of food for thought. A lot of things that—lessons learned.

So this video and the transcript of today’s meeting will be posted on the CFR website. So thank you again and goodbye.

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