The future of public health

By Seon Rockwell, managing director, Deloitte Consulting LLP, Alison Muckle Egizi, manager, Deloitte Services LP

In 2022, the American Public Health Association (APHA) celebrated its 150th anniversary. Next month, APHA will hold its 2023 annual conference in Atlanta.¹ The theme of this year’s event is “Overcoming social and ethical challenges.” Georges C. Benjamin, M.D., APHA’s executive director, says there are often social and ethical challenges to consider when making decisions about public health. During the first year of the COVID-19 pandemic, several studies indicated the disproportional impact the virus had on low-income populations and racially and ethnically diverse communities (see No one should be surprised that low-income populations are being hit harder by COVID-19). Focused attention and in-depth data analyses helped public health officials target certain populations to help address vaccine inequities. But we continue to face these challenges, Dr. Benjamin says. And now that the COVID-19 public health emergency has ended, some health disparities appear to be returning, possibly because there are fewer resources invested in vaccine outreach and access.

Dr. Benjamin has served as executive director of APHA since 2002. Prior to that, he was secretary of the Maryland Department of Health and Mental Hygiene. We recently had an opportunity to meet with Dr. Benjamin in person for a broad discussion about public health and its role. Here is an excerpt from that conversation:

Seon: Life expectancy in the United States is the lowest it has been in decades.² What role do you think public health can play in improving life expectancy going forward? (See Employers can spark healthy aging.)

Dr. Benjamin: The tragedy is that the U.S. spends twice as much as other industrialized nations, and we still have some of the worst health outcomes. While we've had a reduction in life expectancy, we understand a lot about why that occurred (see US health care can't afford health inequities). From a public health perspective, we need to fix the fundamentals. That means creating a system that works for everyone. Other nations seem to have come up with effective health systems, which means we can get there. We also need to fix issues around the fractionation of our health system. There are a lot of people involved and there are many moving parts, but our payment system is fractured, and our delivery system is fractured. It's a patchwork of things which are not built to serve the patient at all. We also need to place more emphasis on prevention, and we clearly need to address the social determinants of health. (See The future of public health.)

Seon: What do you see as the key lessons learned from public health’s response to the COVID-19 pandemic?

Dr. Benjamin: During the public health emergency, the United States had elements of a single-payer health system that provided free testing and treatment for COVID-19. People who were enrolled in Medicaid were able to stay on. Once the public health emergency was declared over, some people lost access to care and some of the improvements made to health equity went back to where they were. I think we demonstrated that the system we had in place during the public health emergency was far superior to the system we have. We have since returned to the usual way of delivering services, at least for COVID-19. We are back to working with a patchwork of programs to make sure that people who are uninsured don't fall through the cracks.

Seon: Federal public health is a patchwork of federally funded state, regional, territorial, and local offices. Do you think they can be tied together more effectively?

Dr. Benjamin: What happened with COVID-19, is a lot of money was appropriated and put out into the field. But a lot of that money went out without a roadmap and without a broad consensus on what to do with it. I’m concerned about that. That is something that definitely has to change. If we can't clearly document the return on the investment, people are going to see the funding as a waste of money. That will make future funding for public health even more challenging. We need national leadership for public health. We need a true Minister of Health who can come in and say we are going to fix the health of the nation. But again, it is a leadership issue. It is important to recognize that every system gives you exactly the outcomes that it is assigned to do. And our system is designed to allow people to fall through the cracks.

Seon: Interoperability has generally been a prominent strategy for public health. How do you think interoperability fits into addressing that patchwork you describe?

Dr. Benjamin: If we're going to be serious about building a health information highway, we need leadership to decide it wants it. When President [Dwight] Eisenhower decided to build the interstate highway system, there was an incentive. There were concerns about nuclear weapons and other emergencies and he wanted to be able to evacuate cities quickly. At the time, the U.S. was just a patchwork of roads.³ The federal government combined financial incentives and strong leadership to make it happen. That’s what we need now. We need strong leadership to say interoperability in health technology is a national priority. We have internet and Wi-Fi deserts. We need to think about this as both a national security and economic imperative.

Seon: What role do you think federal health agencies should play in the command structure during health emergencies?

Dr. Benjamin: When a disaster, such as a hurricane, occurs, federal agencies know their role. FEMA understands their coordination and leadership role and how to work with state organizations. States know how to talk to each other. But whenever there is a public health emergency, such as a new virus, it can be unclear which agency should take the lead. What is the role of the surgeon general? What is the role of the assistant secretary for preparedness and response? Even the role of the [Centers for Disease Control and Prevention]. Then the federal government names czars to manage a health crisis and they add more people. We generally don’t have functional and interoperable data systems to help make important command decisions when we need it. We have gotten better at being prepared for a pandemic, but we keep trying to reinvent the command structure. What I learned both in my time in the District of Columbia as health commissioner, and then in Maryland, is that if you have a good incident command structure, and a good emergency management entity, you have the core backbone for an effective response.

Alison: At the local level, some health departments formed rapid partnerships with communities and businesses out of necessity during the pandemic. Do you think that change is sustainable?

Dr. Benjamin: We ought to recognize that exchanging business cards in the middle of a disaster is a big mistake. Since the pandemic, agencies have invested much more in getting to know their communities. Some have sustained new partnerships while others have let them languish. To make these partnerships durable, we need to have enhanced and sustained engagement with the private sector to better understand our roles in improving health and how we can help each other. Every business owner should know the local health officer. And the health officer should meet with the local Chamber of Commerce regularly. Public health can and should play an enormous role in the economic development of communities.

Alison: Public health challenges often require partnering with health care organizations (see Teaming up to deliver whole health). Do you think the pandemic has catalyzed better relationships between the two fields?

Dr. Benjamin: We have a health care system more attuned to helping public health since the pandemic began, and major medical associations have shared public statements to support us. The tension is in finding ways for the health care system to bolster the existing public health system rather than reinvent public health. Community Health Needs Assessments [CHNAs] are a great example.⁴ The minute the Affordable Care Act passed, CHNAs became a fiscal issue of importance to the hospital C-suite. But some state health departments were already doing that work. That could have been an area to forge a stronger partnership between health departments and hospitals. In many communities, hospitals were doing it independent of each other when there was an opportunity to collaborate on the CHNAs. What many hospitals discovered through these assessments are things public health has known for a long time. Low-income people often face food insecurity or unstable housing, which can affect their health. And people who live in low-income communities tend to have higher rates of diabetes and more heart disease. CHNAs helped to bring social determinants of health into the conversation. Some hospitals are helping patients address food insecurity. Social Services groups have been doing that for years, but now hospitals are a part of that effort.

Alison: Since COVID-19 emerged, there has been an exodus of public health workers. What do you think have been the biggest lessons learned in generating workforce resiliency? What recruitment and retention strategies might demonstrate promise?

Dr. Benjamin: About 40% of public health workers in some communities have retired or left to pursue something different.⁵ In some cases, they were burned out. But public health over the past several years has become a popular choice for people going to school. We have seen phenomenal growth in undergraduate public health programs as well. There is a pretty good pipeline, but there are still things that could be done to make it better. We need to strengthen the public health system so that people have a good place to work and a stronger sense of purpose. Public health has enormous responsibilities and people like to know that they're going to a place where they believe in their work and where their work is valued. Public health leaders need to make sure that they create that welcoming environment for people. As older workers are replaced, I think we need to understand that younger people sometimes have different expectations and needs. They tend to think about the world differently. Everybody doesn't have to work 9 to 5 in an office. We also need a program to help us recapture public health workers who have left but might want to reengage. 

Seon: What gives you hope for the future?

Dr. Benjamin: My job is to give people hope around public health. I get up every morning, and I try to do that. We have the APHA Student Assembly, which is made up of about 7,000 public health students and young professionals. Seeing how energized they are about the work they are doing gives me hope for the future. They are incredibly well organized and are eager to make a difference. One of the benefits of being an emergency physician is you get to fix things and see your impact right away when people leave in better condition than they came in. In public health, there isn’t much immediate gratification. But occasionally, you get involved in a policy or a program and you know it is going to make a difference. It can be life altering.

Conclusion

The COVID-19 pandemic demanded so much of public health workers. At the same time, the pandemic, overall, led to the development of new— and strengthening of existing—partnerships. And it helped to catalyze new thinking about what the future of public health should look like. The key may be strong public health leadership and partnerships, a clear command structure, interoperable data systems, and a reinvention of what it means to be a public health worker. We have what it takes to achieve it, together.

Acknowledgments

James Howgate, David Betts

The executive’s participation in this article is solely for educational purposes based on their knowledge of the subject and the views expressed by them are solely their own. This article should not be deemed or construed to be for the purpose of soliciting business for any of the companies mentioned, nor does Deloitte advocate or endorse the services or products provided by these companies.

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Endnotes:

¹APHA 2023 Annual Meeting & Expo

²Falling behind: The growing gap in life expectancy, American Journal of Public Health, American Public Health Association, September 2024

³Interstate highway system, Dwight D. Eisenhower Presidential Library

⁴Community Health Needs Assessment, IRS.gov, July 13, 2023 [Community Health Needs Assessments, which were outlined in the Affordable Care Act (ACA), require hospitals and health systems to identify the perceived health issues in a community, conduct quantitative analyses of actual health issues, appraise existing efforts to address those issues, and formulate a plan for future action.]

⁵Workplace perceptions and experiences related to COVID-19, CDC, July 22, 2022

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