An illustration of a white butterfly and its shadow.

Turning Crisis Into Change

The U.S. needs a national public health system. Here’s why—and how to create it.

By Dean Ellen J. MacKenzie

In late March 2020—when the radical shift to pandemic life had just begun and so much was unknown—Anthony Fauci was asked how bad things could get. He rightly balked at making predictions when so much was in flux, but ultimately he said the U.S. could see 200,000 deaths. At the time, it was a staggering number, almost unthinkable.

Now we know it wasn’t even close.

With more than a million people lost to COVID-19 and one of the world’s highest per-capita death rates, the U.S. has learned grim truths about the inadequacy of our local, state, and federal health efforts. They are understaffed and under-resourced and lack the coordination to adequately meet our day-to-day needs—let alone address a crisis.

But the pandemic opens a window for change.

How will we apply the lessons learned from this devastating experience?

That was a question facing the Commonwealth Fund Commission on a National Public Health System. I served on the Commission this spring, with Vice Dean Joshua Sharfstein serving as one of the lead staff. The Commission brought together a group of nonpartisan public health leaders to examine weaknesses in our public health system and articulate a vision for the future.

The challenges are great. The U.S. has no centralized public health authority, so most matters are addressed at the state, local, or municipal level by a loose patchwork of about 3,000 health departments. Public health workers made heroic efforts when COVID-19 hit but lacked strong data systems, a resilient network of laboratories, a robust workforce, and effective communications strategies. Compounding these challenges was all that was wrong before the pandemic hit: our high rates of chronic illness, our health inequities, our lack of planning, and our lack of investment in prevention. These issues left large segments of our population especially vulnerable.

It is past time to act. Building on two decades of reports and meetings with experts, stakeholders, and government officials, the Commission made several detailed, concrete recommendations:

The federal government should lead a strong, capable national public health system. A new position, such as an undersecretary for public health, should lead a national effort to strengthen our infrastructure—including data systems, workforce, laboratories, and procurement—and promote coordination among our nation’s scattered public health departments.

Congress should provide stable funding matched with clear expectations for states, localities, tribes, and territories to protect the health of their populations. Beyond funding emergency responses, the federal government should support health departments to develop and maintain core capabilities to protect their communities. In exchange, the departments should meet basic standards through a revised accreditation process.

Health care systems should work closely with public health agencies in normal times and during emergencies. The U.S. Department of Health and Human Services should lead a comprehensive initiative to share health care data for public health purposes, with authority to establish and enforce standards for data collection. Health systems, hospitals, and community health centers should be expected to contribute.

The public health system should earn the public’s trust. Ethics, integrity, and transparency are key. We should bring community representation into federal efforts, share decision-making with communities, work with community-based organizations—and modernize communications to fight misinformation.

These are ambitious but attainable goals. The changes proposed by the Commission would cost an estimated $8 billion a year, which is little compared to the trillions we lost due to our weak response to COVID-19.

But even with a plan and a reasonable price tag, the next part of the challenge will be great: turning ideas into action.

Big changes are hard, but not out of reach—we have made them before.

In the late 1990s, Johns Hopkins led the Pew Environmental Health Commission to investigate how to strengthen public health’s response to environmental threats. Shelley Hearne, who is now director of the School’s Lerner Center for Public Health Advocacy, was the Commission’s executive director. Through reports, outreach, and stakeholder engagement, that Commission persuaded Congress to create and fund the CDC’s Environmental Public Health Tracking Program. The result is a dynamic nationwide data system that empowers public health officials to prevent and respond to environmental health threats, trace the geographic spread of pollutants, and more. It’s made a difference across the country by reducing asthma, advancing emergency response and heat wave preparedness, and improving drinking water supplies.

The key lesson from the Pew Commission, according to Hearne, is the importance of generating political will to invest in and implement expert recommendations. That is what is needed now.

We must put the ideas from the Commonwealth Fund Commission in the hands of decision-makers and the people who influence them. We must share them with members of Congress (Democrats and Republicans), partner with public health leaders in their districts, and reach out to constituents who are active at the grassroots level. We must work with communities, explaining not just what we want to do but how it will affect and benefit them.

We cannot let divisive national politics preempt action that will safeguard our country. It will always be difficult to advance policy on core issues like infrastructure, but we can do it with strong outreach, clear and transparent communication, and a commitment to remembering all that our country lost.

The only thing worse than the heartbreak of the current pandemic would be enduring the same pain in the next one.