Blog Health Equity

Keeping the public healthy: Who will pay?

Written by Will Ross, MD, MPH, associate dean for diversity, professor of medicine in the School of Medicine and Institute for Public Health 2018 Annual Conference moderator

Will Ross
Office of Diversity

In 2002, The Institute of Medicine issued a report entitled, “Who Will Keep the Public Healthy?” The report concluded that “… public health professionals must have a framework for action and an understanding of the forces that impact on health, a model of health that emphasizes the linkages and relationships among multiple determinants affecting health. Such an ecological model is key to effectively addressing the challenges of the 21st century.”

A review of public health funding in the United States, before and after the release of the 2002 IOM report, does not project confidence in a country committed to reducing preventable deaths. Using the OECD model for public health funding, the U.S. allots approximately three percent of total national health spending for nonclinical health or “public health” improvement efforts. Matters deteriorate further at the state level; according to a 2016 report from the Trust for America’s Health, Missouri ranks 49th out of 50 states, with a per capita public health spending of $5.90 per person.

At the local level, the absence of a dedicated tax source for the City of St. Louis, and the dire conditions of a $10 million budget deficit for St. Louis City in fiscal 2018 do not argue for resource allocation to public health commensurate with the need to ameliorate long-standing health inequities (in St. Louis County, political divisions over public health funding, leading to the departure of the County Director of Health, does not place them in an enviable position relative to St. Louis City).

How do we effectively address the country’s, and the St. Louis region’s, public health needs in the face of stagnant, if not dwindling public health financing? A 2008 analysis by the New York Academy of Medicine and the Trust for America’s Health, a nonprofit, nonpartisan organization focused on public health, identified a $20 billion annual shortfall in public health funding. The creation of the Prevention and Public Health Fund in 2010, which provided $15 billion over its first 10 years, was a great first step in bridging that deficit. The fund would have provided base support for prevention, infrastructure and training (including community health workers) and public health research (Table 1), however the funding allocation came at a time of large federal budget deficits and pressures to spend money in other ways. Public health is invariably political, and the Public Health Trust Fund suffered and bled from a thousand political cuts.

In the interim, the country’s public health crisis has only worsened – since 2014 we have grappled with the elevated levels of lead in the Flint, Michigan water supply; the growing opioid and substance abuse epidemic; and gun violence claiming the lives of countless youths. In St. Louis, the disparity in infant mortality has not abated, and we should derive no solace knowing that in 2018, Montgomery, Alabama had the highest rates of sexually transmitted infections, knocking us out of the number one category to number two in the nation.

The answer to improving our region’s public health needs lies in mobilizing community partnerships, leveraging public health resources, and engaging in focused interventions. It lies in realigning public health efforts with academic medical centers, community health centers, and hospital networks. The nation’s divergent public health system – an academic track and an independent community-based health department track, is a is a relatively contemporary phenomenon from the early 20th century. The distinction between academic medical centers and public health practice emerged in the post-World War II era. Prior to 1940, many of the nation’s elite academic medical centers – founders of the most revered schools of public health in the country, prided themselves on alliance between basic science, clinical medicine, and preventive health. With the rapid expansion of biomedical research after World War II, epidemiology within academic medical schools fractured from the traditional epidemiology that was the mainstay of schools and departments of public health. That fracture was ostensibly due to allocation of research funds for “medical school-based epidemiology,” perceived as more scientifically valuable than epidemiology taught in schools of public health. In 1988 the Committee for the Study of the Future of Public Health issued a stern warning that the decades-long divide between academic medicine and public health was endangering the health of the country.

Many communities responded to the IOM criticism by embracing a collective impact approach, with academic medical centers working in tandem with State and local health departments, hospital partners, and grass roots community organizations to address the social and structural determinants of health.  A salient example was the apparent disappearance of the black-white infant mortality gap in Dane County, Wisconsin, between 1990-2007.  In an effort to reduce the African American infant mortality rate in Dane County, which was considered on par with many developing countries, the University of Wisconsin partnered with the Wisconsin Department of Health Services, local community health centers, local health foundations, and community non-profit organizations such as the Early Childhood Family Enhancement Center. The county rate subsequently declined 67%, from 19.4 per 1,000 live births for the period 1990-2001 to 6.4 for the period 2002-2007, and the racial disparity gap was essentially eliminated.

That same unity was on display in St. Louis last year as the St. Louis City and County Departments of Health aligned with local hospital partners including the BJC Hospital System, and nonprofit groups such as the St. Louis Regional Health Commission to complete the first ever region-wide community health assessment.  The next phase in restoring the historic relationship between academic medical centers and public health practitioners is to fully integrate public health pedagogy in medical school curricula; create a conceptual model that provides oversight and accountability for regional public health; and take bolder action to reduce barriers to health so that everyone in our community can reach their full health potential.  Creating a regional public health entity, a recommendation offered in the 2014 Better Together Public Health Report, continues to gain traction as a viable model for shared services, greater economies of scale, and more focused attention on the intractable public health issues in our community.  These practices, in concert with developing a region-wide community health improvement plan, will strengthen the ability of public health officials to fulfill their obligation to assess the public’s health, develop appropriate policies, and assure the public’s health is sustained.  And there is always hope we can restore the nation’s Prevention and Public Health Trust Fund and place it in a lock box, so the future of this country’s public health will remain sound and secure.