Opinion: Use crisis to improve public health

Georgia’s State Capitol.
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Georgia’s State Capitol.

Georgia ranks 51 out of the states and D.C. in terms of the percent of citizens who have received at least one dose of vaccine. This is not surprising given that Georgia ranks 46th on 49 measures of access to health care, quality of care, health outcomes, and income-based health care disparities. The pandemic in Georgia has pointed out deficiencies in our state’s public health system that have persisted for years and given us an opportunity to make critically important improvements.

The state’s public health system is fixable. By acting positively, quickly, and transparently in three areas, Georgia can improve its performance in a wide range of problem areas, from infectious diseases to chronic diseases, to mental health and violence prevention.

To begin, let’s explain public health and health care and their relationship and differences.

Julie Rosenberg
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Julie Rosenberg

Credit: contributed

Credit: contributed

Healthcare is generally considered as the treatment provided to individuals, people who are sick and go to the doctor’s office, clinic, or hospital. Public health, on the other hand, has responsibility for protecting and improving the health of everyone and generally is concerned more with prevention than with treatment.

Mark Rosenberg, former president and CEO of the Task Force for Global Health, said his contacts inside the CDC “tell me that they never, ever have seen censorship as limiting and pervasive as it is right now.” SPECIAL
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Mark Rosenberg, former president and CEO of the Task Force for Global Health, said his contacts inside the CDC “tell me that they never, ever have seen censorship as limiting and pervasive as it is right now.” SPECIAL

The main provider of public health services is government at local, county, state, and national levels. Nonprofits, the health care delivery system, employers and business, the media, and academia also contribute in important ways. A landmark study by the Institute of Medicine in 1988, “The Future of Public Health,” identified three key functions of governmental public health agencies: assessment or problem identification; policy development and mobilization of resources; and assurance that the right services are delivered and that the identified problems have been solved.

There are three key ways we can improve public health in Georgia. We need to:

1.) Increase the resources

Investments in better information infrastructure, human resources, delivery capacity, and communications capacity will help Georgia pull ahead and begin to better protect its citizens. The Institute of Medicine study declared that “this nation has ... allowed the system of public health activities to fall into disarray.” Twenty years later the institute sounded the alarm again and said we had still failed to adequately invest in our public health system. It prompted policymakers, public health agencies, and educational institutions to increase investment in public health activities. On average, the U.S. spends less than 3 cents of every health dollar on public health — less than 3 cents to prevent 97 cents’ worth of care and treatment.

Georgia invests in public health only a fraction of what it should be and what other states invest. Georgia spent $22.58 per person on public health in 2018, less than half of what Alabama spent. Investment in the capacity to both develop and implement public health interventions may be the most important determinant of success. A recent study suggested that a good COVID-19 vaccine delivery system may be more important than the efficacy of the vaccine itself in ending the pandemic.

Further, better decisions require better information. This means better data collection and infrastructure systems. These can tell us where the highest burden of disease is and where to focus limited investments, who is most vulnerable and who is being served, so as to help improve equity. Better information systems can also allow for collaboration between public health and other sectors, or between Georgia and other states. Right now, just about every state has a different data collection system, and they do not work with one another. If someone goes to Alabama to get vaccinated, Georgia cannot track this. To be fair, Georgia is not the only state with this problem. In the U.S. there are more than 60 different data systems for immunizations alone. CDC could work with states to develop a common and shared comprehensive public health data system. But CDC is also under-resourced.

2.) Protect the science and accuracy of public health information from political interference

Because most public health measures are recommended and funded by the government, public health is inherently political, and decisions are often driven by organized interest groups, such as those advocating for change, or by politicians. That in itself is not a bad thing. Good politicians, political will, and supportive policies are essential ingredients for any public health system; they can bring the moral compass to science.

But government needs to make clear what the science tells us and assure that the very best evidence is used in decision-making and that public health is not a partisan issue. The transparency, honesty and integrity of science must be maintained. Public health leadership must stand up for public health goals and be honest with those they serve.

The downstream effects of allowing politics to interfere with evidence and public health messaging is that, on top of hurting public health, it erodes public trust in and understanding of science. In the face of rapidly changing knowledge and policies, effective communication from trusted sources is critical.

More immediate measures are needed to strengthen nonpartisan commitment for public health and to protect the scientific independence and voice of public health institutions.

3. Address equity and the most heavily burdened parts of the population

The Robert Wood Johnson Foundation has defined health equity to mean “everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.” And since public health, unlike healthcare in this country, is responsible for everyone in our state, it is well-positioned to work towards the goal of health equity.

Public health must prioritize and target populations with poor outcomes; focusing on those who lack access to care, have high unemployment rates or limited economic resources, high rates of uninsurance and underinsurance; cultural differences that may pose challenges, such as social, cultural, and linguistic barriers; low health literacy levels, and environmental challenges, which include unsafe streets, homelessness, incarceration and minimal or no spaces for physical activity or exercise. Racism has also been deemed a public health crisis and is a threat to good health outcomes.

Addressing equity and helping those who have been left behind in the past will also help restore trust in our public health system and in interventions such as vaccines. Georgia must tackle this issue head-on.

Building a strong public health infrastructure will not only help us address immediate needs but to also be better prepared for the long-haul. All of us will benefit because none of us is protected until we all are.

The pandemic has shown us where, why, and how we can do much better. The bad news about ranking 51st in a public health measure is that we are the very worst; but the good news is that there are 50 states from which we can learn to do much better.

Julie Rosenberg, MPH, is an assistant director at Ariadne Labs and deputy director of the Global Health Delivery Project at Harvard University. Mark Rosenberg, M.D., is president emeritus of The Task Force for Global Health and retired as assistant surgeon general after working 20 years at the CDC. He is also Julie Rosenberg’s father.