Finding a Way Forward for Public Health - Greater Investment, Greater Distrust

The thinking was that infectious diseases were behind us, a problem of the past and of impoverished places that were stuck in the past. Antibiotics, better sanitation, improved nutrition, a higher standard of living — they combined to push infectious diseases to the margins of health concerns. Twentieth century public health experts called it the epidemiologic transition, from a healthcare past dominated by diseases, such as tuberculosis, diphtheria and typhoid fever, to a healthcare present and future concerned with heart disease, cancer and diabetes.

“The most remarkable change in patterns of health during the (past) century has been the largely successful conquest of infectious diseases,” wrote Allan Brandt, Harvard medical historian, in “No Magic Bullet: A Social History of Venereal Disease in the United States Since 1880,” his highly regarded history of venereal disease that was first published in 1985.

When Ezekiel Emanuel, M.D., Ph.D., an oncologist and prominent health policy expert at the University of Pennsylvania in Philadelphia, was in medical school and residency in the 1980s, he was captivated by oncology because of the power of the science, the complicated ethical issues and the seriousness of the disease. Yes, the HIV/AIDS pandemic had started, but how about infectious disease? “It wasn’t the sexy area,” Emanuel says.

It has been said that time makes fools of us all. Certainly, the past two years have made that confidence about the decline and fall of infectious disease seem wildly wrongheaded. When government healthcare statisticians calculated the age-adjusted death rates for 2020, COVID-19 was the third leading cause in the U.S., trailing only heart disease and cancer. From 2019 to 2020, the age-adjusted death rate increased 16.8%, which is the largest single increase ever recorded. Life expectancy for the total population decreased by 1.8 years, which is the largest single year decrease in over 75 years.

Other mortality statistics are just as grim. Researchers at the Institute for Health Metrics and Evaluation at the University of Washington reported estimates of the excess mortality due to COVID-19 in March in the Lancet. Their figures show 824,000 reported COVID-19 deaths in the U.S. from Jan. 1, 2020, to Dec. 31, 2021. They also tabulated excess mortality. Worldwide, it was over three times greater than the number of reported COVID-19 deaths (18.2 million compared with 5.9 million). For the U.S., the researchers put the excess mortality at 1.13 million. Reasons for the difference between excess mortality and reported COVID-19 deaths include the possibility of undercounting COVID-19 deaths and knock-on effects of the pandemic, such as deaths from delays in healthcare or the widely documented worsening of mental health.

COVID-19 made it impossible to ignore the enormous disruptive power of an infectious disease. However, there were plenty of warnings before 2020. In 1992, the Institute of Medicine (now called the National Academy of Medicine) released “Emerging Infections: Microbial Threats to Health in the United States.” Two years later, journalist Laurie Garrett sounded the alarm with her book, “The Coming Plague: Newly Emerging Diseases in a World Out of Balance.” And the plagues — although not as infectious and lethal — did come. Novel diseases have punctuated the past two decades, including the West Nile virus (1999); severe acute respiratory syndrome (2003), which, like COVID-19, is caused by a coronavirus; H1N1 influenza (2009); Ebola (2014); and Zika (2009).

Ira Wilson, M.D., Sc.M., a professor and chair of the Department of Health Services, Policy and Practice at the Brown University School of Public Health in Providence, Rhode Island, notes there was a transition away from infectious diseases in the 20th century, but many of those diseases were bacterial and therefore were treatable with antibiotics. These novel 21st-century infectious diseases are viral and harbored by animals. Experts in these zoonotic diseases point to deforestation and other factors as bringing human beings into closer contact with many animals, Wilson explained. “The first transition had to do (with mostly) poverty and bacterial diseases, so people were less likely to die of infections. They died of other things,” he says. “This is a different or new transition. Humans are invading ecosystems that have evolved without them.”

Chutes and ladders

The epidemiological transition envisioned decades that often depicted the post-infectious disease problems of heart disease and cancers as “diseases of affluence.” That is another concept that is out of step with these times, notes Theo Vos, M.D., Ph.D., M.Sc., professor of health metrics sciences at the Institute for Health Metrics and Evaluation and a member of the senior management team. “Diseases of affluence are diseases of poverty in the U.S,.” Vos says. “That was maybe coined 30 (or) 40 years (ago). There are (more) rates of obesity, diabetes, heart disease and quite a few cancers among poorer people.”

So rather than a smooth glide path from infectious disease to so-called diseases of affluence, the 21st-century epidemiologic transition seems more like a game of chutes and ladders: progress here, regress there. How might the U.S. healthcare system respond and adjust to this era of viral disease outbreaks and uneven distribution of disease? There’s no end to the answers to those questions. And the questions have been posed in many different ways.

For decades, both providers and payers in the U.S. have been oriented toward dealing with acute episodes of disease and injuries, with perhaps some attention to a few chronic conditions. Public health, with its orientation toward prevention, has been way down on almost any list of healthcare priorities. Spending on public health shot up in 2020 because of the pandemic, but in 2019, it totaled $105 billion, according to the annual report on U.S. health expenditures that the CMS Office of the Actuary issued earlier this year. That is less than 3% of the $3.75 trillion the U.S. spent on healthcare that year and approximately 9% of the $1.19 trillion the country spent on hospital care.

Rodrigo Cerdá, M.D., M.P.H. medical director of Independence Blue Cross in Philadelphia and member of the Managed Healthcare Executive® editorial advisory board, says U.S. healthcare is skewed toward rescue care. “We pay people a lot of money to get Johnny out of the well over and over again, but we do not invest any money in building a little wall around the well so Johnny doesn’t fall in,” Cerdá says.

The scanty funding for public health came up during a panel discussion about COVID-19 in February, which was jointly sponsored by STAT and ProPublica. “There have been a lot of finger points that have gone toward the sector of public health,” said Umair Shah, M.D., M.P.H., secretary of health for Washington State. “ ‘Why couldn’t you have done this faster? Why weren’t those systems available? Why wasn’t the staffing to these levels? Why didn’t you have the right technologies?’ That all goes to this value system, where we have continued to value healthcare to the detriment of investment in public health.”

Emanuel describes the U.S. healthcare system as being “neither fish nor fowl,” but like Cerdá, he references money spent on acute care and, more specifically, that approximately one-third of healthcare spending is on hospital care. However, Emanuel also notes the pandemic-fueled uptake of telehealth and remote care and how that trend may push more money into managing chronic disease and improve outcomes as a result.

Burden-of-disease calculations

The Institute for Health Metrics and Evaluation was in the spotlight in 2020 during the early months of pandemic, when disease models projecting the number of deaths from COVID-19 flared up as hot news. However, the institute is known in health research and policy circles for its ambitious efforts to quantify the burden — how much early mortality and disability they cause — of disease and injuries.

Thousands of researchers are involved in creating its Global Burden of Diseases, Injuries, and Risk Factors (GBD) study, which quantifies those burdens on a country-by-country basis. The Bill & Melinda Gates Foundation funds the effort. Ideally, governments and international organizations use the GBD research to match healthcare resources to healthcare needs.

Vos says the institute’s researchers are working on finalizing the COVID-19 burden-of-disease numbers. As the third leading cause of death in the U.S., it won’t be small, although the fact that COVID-19 disproportionately affects older people is something of an offsetting factor. Vos says long COVID-19 may come in at about 30th in the ranking of disabling conditions, “so not way up there but not trivial.”

He doesn’t believe, though, the disease burden of COVID-19 and other recent disease outbreaks is so large as to merit a complete overhaul of U.S. healthcare system. “There are important things that have come out of this that we should learn from,” he says. “But there are still lots of people who will have problems with their eyes, have pain in their knees and so on. That’s not going to go away.”

Even so, there’s nothing like a public health crisis to stoke the appetite for more spending on public health. Federal spending on public health skyrocketed from $13.3 billion in 2019 to $128.2 billion in 2020, according to the CMS Office of the Actuary. The initial version of the now-stalled Build Back Better Act included $51 billion for public health infrastructure and pandemic preparedness. A year later, a scaled-back version of the legislation had $19.2 billion.

The omnibus spending legislation that funds the federal government through Sept. 30, 2022, includes a $582 million increase in funding for the CDC that is supposed to go toward public health infrastructure. Funding for global health programs increased by $634 million from the amounts allocated in 2021.

There are some differences of opinion about what public health infrastructure should entail, but improved surveillance and data collection and analysis seem to be on every list. “We need to invest a lot more in surveillance of potential candidates for yet another pandemic,” Vos says. “There are tools for that, and they are not dramatically expensive.”

Furthermore, Emanuel was a co-author of a JAMA opinion piece that, among other things, called for creation of a “digital, real-time integrated data infrastructure for public health” as part of national strategy for dealing with COVID-19. Marc Lipsitch, D.Phil., an epidemiologist at the Harvard T.H. Chan School of Public Health in Boston, who was on the STAT-ProPublica panel with Shah, mentioned that he was “on loan” to the CDC this year to set up a center for forecast and outbreak analysis.

Other proposals for updating public health include building in reverse capacity, so when pandemics hit, hospital beds are ready and vaccines can be produced quickly. In the same JAMA opinion piece, Emanuel and his co-authors propose the creation of a public health workforce that could be dispatched to deal with emergencies and community health workers that could provide services outside of normal conventional healthcare settings.

Cerdá is concerned that when the COVID-19 pandemic fades, memory and preparedness will follow, so when the next pandemic occurs, the world will again be taken by surprise. He likens the need for investment in public health to the Federal Reserve and other institutions and policies designed to tamp down the economy’s boom-and-bust cycle.

“Maybe that is what we should be thinking about with public health — that this (pandemic) isn’t an exception (and) it is not different. We (must) have an infrastructure to address this, and it (must) be global,” Cerdá says.

However, Wilson says most public health systems don’t currently operate at the global scale. He sees a mismatch that is partly reflective of how the focus of public health tends to be at state and local levels.

Until 2020, when the pandemic forced the federal government to swing into action, combined state and local government spending on public health exceeded the federal government’s public health expenditures. “Public health is usually associated with units that are the size of countries or even states and counties. But COVID-19 is global and rips across all those borders and couldn’t care less about who is from where,” Wilson says. “Our political systems are ill-designed for the global problems we’ve created.”

For example, say there is enough money and that this sturdier and smarter public health infrastructure came to be — and it was accompanied by the thorough data collection and dazzling analytics — would that be enough to cope with future pandemics and viral disease outbreaks? Well, maybe.

But Cerdá, Wilson and others say the loss of trust in government and science will have a corrosive effect on even the most robust public health systems and measures. “There was an almost unquestioned trust of the CDC before the events of 2020. The loss of that trust is a very important loss,” says Cerdá, adding that he believes the Trump administration deserves blame for that loss of trust.

When Vos’ colleagues analyzed the variation in COVID-19 infection and infection-fatality ratios among 177 countries, they surprisingly found that pandemic preparedness did not have an effect but measures of trust in government and trust in other people — and of government corruption — did. By their reckoning, if the trust in government levels in other countries matched those in Denmark, there would have been 13% fewer infections in the world, and if interpersonal trust was at Danish levels, there would have been 40% fewer infections.

Wilson sees the trust problem as extending well beyond the CDC and public health and as predating the Trump administration. He refers to the amount of money people are putting into cryptocurrency as an example. “The rise of cryptocurrency is not just because people are greedy and want to make money,” he says. “It’s also because a lot of people think it’s like private money.”

Wilson says when he teaches undergraduates at Brown, he tries to get across that healthcare systems are not separate and they reflect the values and beliefs of the societies they serve.

“(The U.S. has) a deeply divided society” he says. “Solving all these problems (must) be addressed at the same time. People aren’t going to take vaccinations just because we invest in public health.”

Peter Wehrwein is managing editor of Managed Healthcare Executive.®